What are the next steps for a patient with no abnormalities on telemetry (electrocardiogram) but experiencing cardiac symptoms?

Next Steps After Normal Telemetry in a Patient with Cardiac Symptoms

For patients with cardiac symptoms but normal telemetry findings, further diagnostic evaluation is necessary, including extended cardiac monitoring, risk stratification, and additional cardiac testing based on symptom characteristics and risk factors.

Risk Stratification

• For patients with chest pain and normal telemetry, risk stratification should be performed using evidence-based tools such as the Goldman risk assessment, which evaluates: suspected MI or ischemia on ECG, systolic blood pressure ≤110 mmHg, bilateral rales, and history of unstable ischemic heart disease 1
• Patients with any evidence-based risk factors (low systolic blood pressure, pulmonary rales, or exacerbation of ischemic heart disease) should continue ECG monitoring for 12-24 hours until acute MI is ruled out by negative biomarkers 1
• Low-risk patients (Goldman score <8%, normal initial troponin and CK-MB) have extremely low rates of life-threatening arrhythmias (0%, 95% CI 0-0.3%) and may not require continued telemetry monitoring 2

Extended Monitoring Options

• For patients with intermittent symptoms not captured during initial telemetry, extended electrocardiographic monitoring (>24 hours) or event recording is recommended and should continue until symptoms occur while wearing the monitor 1
• Options for extended monitoring include:
  • 24-48 hour Holter monitoring for frequent symptoms 1
  • 7-14 day event monitors or patch monitors for less frequent symptoms 1
  • Implantable loop recorders for very infrequent symptoms 1
• Remote outpatient cardiac telemetry (ROCT) systems may be considered, which allow patients to self-apply adhesive chest patches at home and transmit continuous ECG data to cloud-based systems 3

Additional Diagnostic Testing

• If chest pain is the presenting symptom and telemetry is normal, ST-segment monitoring should be considered, as transient myocardial ischemia occurs in approximately 17% of patients with chest pain syndromes and is associated with serious in-hospital consequences 1
• Patients with transient myocardial ischemia are 8.5 times more likely to experience complications compared to those without ischemia, even with normal telemetry 1
• Serial cardiac enzymes and ECGs should be obtained to rule out acute coronary syndrome 1
• Exercise stress testing or other functional testing should be considered for patients with intermediate risk and normal initial evaluations 1

Special Considerations

• For patients with palpitations and normal telemetry:

  • Extended monitoring is particularly important as arrhythmias may be paroxysmal 1
  • Consider monitoring for specific high-risk arrhythmias such as supraventricular tachycardia, premature ventricular contractions, or atrial fibrillation 3

• For patients with syncope and normal telemetry:

  • Extended monitoring is recommended for hospitalized patients with suspected cardiac etiology 1
  • Risk stratification tools should be used to determine the need for extended monitoring 1

Common Pitfalls to Avoid

• Relying solely on telemetry to rule out cardiac causes of symptoms, as many arrhythmias are paroxysmal and may not be captured during limited monitoring periods 1
• Failing to consider ST-segment monitoring in addition to arrhythmia monitoring, as many ischemic events are clinically silent (71% in telemetry units) 1
• Unnecessarily prolonging telemetry monitoring in very low-risk patients, which increases healthcare costs without clear benefit 4, 2, 5
• Not extending monitoring duration for patients with concerning symptoms despite normal initial telemetry 1