U.S. patent application number 12/901428 was filed with the patent office on 2012-04-12 for ambulatory electrocardiographic monitor for providing ease of use in women and method of use.
Invention is credited to Gust H. Bardy, Jon Mikalson Bishay, Jason Felix.
Application Number | 20120089000 12/901428 |
Document ID | / |
Family ID | 44903086 |
Filed Date | 2012-04-12 |
United States Patent
Application |
20120089000 |
Kind Code |
A1 |
Bishay; Jon Mikalson ; et
al. |
April 12, 2012 |
Ambulatory Electrocardiographic Monitor For Providing Ease Of Use
In Women And Method Of Use
Abstract
A method for performing ambulatory electrocardiographic
monitoring on an adult female is provided. An ambulatory ECG
monitor, that includes a plurality of sensing electrodes coupled to
self-powered sensing circuitry, is provisioned. A monitoring site
is located on the surface of a patient's chest at midline and above
the body of the sternum adjacent to the fourth and fifth
intercostal spaces between the breasts in the upper portion of the
intermammary cleft. The electrodes are aligned and placed along the
midline. Interference from breast tissue with placement of the
ambulatory monitor at the monitoring site is evaluated. The
ambulatory ECG monitor is removably adhered to the monitoring site
clear of any breast tissue interference for the duration of
monitoring. ECG data is sensed through the sensing electrodes at
the monitoring site and the sensed ECG data is recorded into the
sensing circuitry.
Inventors: |
Bishay; Jon Mikalson;
(Seattle, WA) ; Bardy; Gust H.; (Carnation,
WA) ; Felix; Jason; (Vashon Island, WA) |
Family ID: |
44903086 |
Appl. No.: |
12/901428 |
Filed: |
October 8, 2010 |
Current U.S.
Class: |
600/391 |
Current CPC
Class: |
A61B 5/301 20210101;
A61B 2560/0406 20130101; A61B 5/7207 20130101; A61B 2560/0412
20130101; A61B 5/335 20210101; A61B 5/332 20210101; A61B 2560/0468
20130101; A61B 5/02438 20130101; A61B 5/6833 20130101; A61B 2503/00
20130101 |
Class at
Publication: |
600/391 |
International
Class: |
A61B 5/0408 20060101
A61B005/0408 |
Claims
1. A method for performing ambulatory electrocardiographic (ECG)
monitoring on an adult female, comprising: provisioning an
ambulatory ECG monitor comprising a plurality of sensing electrodes
coupled to self-powered sensing circuitry; locating a monitoring
site on the surface of a patient's chest at midline and above the
body of the sternum adjacent to the fourth and fifth intercostal
spaces between the breasts in the upper portion of the intermammary
cleft; aligning and placing the electrodes along the midline;
evaluating interference from breast tissue with placement of the
ambulatory monitor at the monitoring site; removably adhering the
ambulatory ECG monitor to the monitoring site clear of any breast
tissue interference for the duration of monitoring; and sensing ECG
data through the sensing electrodes at the monitoring site and
recording the sensed ECG data into the sensing circuitry.
2. A method according to claim 1, further comprising: selecting a
circuit board exhibiting axial and lateral flexibility;
provisioning the sensing circuitry on the selected circuit board
and enclosing the sensing circuitry within a housing; and
conformably flexing the circuit board within the housing along the
contours of the chest's surface.
3. A method according to claim 1, further comprising: enclosing the
sensing circuitry within a housing; selecting a layer of skin
adhesive and a set of standoffs comprised of non-uniform heights
with the standoffs comprised of greater height located closer to
the xiphoid process of the patient than the standoffs comprised of
lesser height; attaching the skin adhesive layer to a bottom
surface of the housing separated by the set of standoffs; and
conformably adhering the skin adhesive layer to the chest's surface
with the housing separated from the chest's surface by a gap formed
by the heights of the set of standoffs.
4. A method according to claim 3, further comprising one of
defining the skin adhesive layer in a shape comparable to the shape
of the bottom of the housing; and defining the skin adhesive layer
in a shape differing from the shape of the bottom of the
housing.
5. A method according to claim 1, further comprising: fashioning a
housing comprised of an elongated triangular shape with rounded
vertices; and enclosing the sensing circuitry within a housing,
wherein the housing is removably adhered to the monitoring site
with the narrowest part of the triangular shape facing towards the
patient's feet.
6. A method for performing ambulatory electrocardiographic (ECG)
monitoring at a midline sternum-centered location of an adult
female, comprising: provisioning an ambulatory ECG monitor
comprising a plurality of sensing electrodes coupled to
self-powered sensing circuitry and enclosed in a flexible housing;
independently suspending a layer of skin adhesive from a bottom of
the flexible housing; locating a monitoring site on the surface of
a patient's chest at midline and above the body of the sternum
adjacent to the fourth and fifth intercostal spaces between the
breasts in the upper portion of the intermammary cleft; evaluating
interference from breast tissue with placement of the ambulatory
monitor at the monitoring site; conformably placing the ambulatory
ECG monitor, comprising: aligning and placing the electrodes along
the midline; removably adhering the skin adhesive to the monitoring
site for the duration of monitoring; positioning the housing to
avoid the breast tissue interference; and bending the housing
axially and laterally along the contours of the monitoring site;
and sensing ECG data through the sensing electrodes at the
monitoring site and recording the sensed ECG data into the sensing
circuitry.
7. A method according to claim 6, further comprising: identifying
the breast tissue interference by evaluating each of width, length,
depth, and relative location of the adult female patient's
intermammary cleft based on one or more of breast size, shape,
position, symmetry, overall body physique, posture, type and fit of
brassiere worn, and presence of artificial breast implants relative
to the size of the flexible housing.
8. A method according to claim 6, further comprising: providing a
set of standoffs between the skin adhesive layer and the bottom
surface of the housing, the standoffs comprised of non-uniform
heights with the standoffs comprised of greater height affixed at
opposite ends of the bottom surface of the housing than the
standoffs comprised of lesser height; and permitting the skin
adhesive layer to flex and stretch in conformity with the patient's
skin at the monitoring site.
9. A method according to claim 6, further comprising one of:
defining the skin adhesive layer in a shape comparable to the shape
of the bottom of the housing; and defining the skin adhesive layer
in a shape differing from the shape of the bottom of the
housing.
10. An ambulatory electrocardiographic (ECG) monitor for an adult
woman, comprising: self-powered ECG sensing circuitry; a plurality
of sensing electrodes coupled to the sensing circuitry; a housing
enclosing the sensing circuitry; and a skin adhesive layer facing a
contact surface and independently suspended from the housing with a
set of standoffs having non-uniform heights affixed to and defining
an increasingly wide gap between the skin adhesive layer and a
bottom surface of the housing.
11. A monitor according to claim 10, further comprising: a circuit
board exhibiting axial and lateral flexibility and upon which the
sensing circuitry is comprised.
12. A monitor according to claim 10, wherein one or more cutouts
are defined around the periphery of the skin adhesive.
13. A monitor according to claim 10, wherein the skin adhesive
layer comprises adhesive fabric, cloth, foam, and latex.
14. A monitor according to claim 10, wherein the skin adhesive
layer is defined in a shape comparable to one of the shape of the
bottom of the housing and a shape differing from the shape of the
bottom of the housing.
15. A monitor according to claim 10, wherein the sensing circuitry
compensates for gaps in recording of ECG data resulting from
disconnection and reconnection of the sensing electrodes.
16. A monitor according to claim 10, wherein the housing is
unshielded.
17. An ambulatory electrocardiographic (ECG) monitor with conformal
shape and independent suspension for an adult woman, comprising: a
flexible ECG circuitry body, comprising: self-powered ECG sensing
circuitry comprising a processor, memory, and finite power supply;
a circuit board exhibiting axial and lateral flexibility and upon
which the sensing circuitry is comprised; and a housing enclosing
the circuit board; a plurality of sensing electrodes coupled to the
processor, which processes and stores sensed ECG data into the
memory; and a skin adhesion assembly, comprising: a layer of skin
adhesive facing a contact surface; and a set of standoffs having
non-uniform heights affixed to and defining an increasingly wide
gap between the skin adhesive layer and a bottom surface of the
housing of the circuitry body.
18. A monitor according to claim 17, further comprising: a hole
defined through a center of each of the standoffs, wherein the
sensing electrodes are positioned in each of the holes facing the
contact surface.
19. A monitor according to claim 17, wherein one or more cutouts
are defined around the periphery of the skin adhesive.
20. A monitor according to claim 17, further comprising: a radio
frequency identification tag comprised with the flexible ECG
circuitry body and providing a unique identifier.
21. A monitor according to claim 17, further comprising: an
actimetry sensor coupled with the sensing circuitry and storing
gross motor activity data into the memory.
22. A monitor according to claim 17, wherein at least one of the
memory and the finite power supply are comprised on the skin
adhesive layer instead of the circuitry body.
23. A monitor according to claim 17, the skin adhesive layer
comprises adhesive fabric, cloth, foam, and latex.
24. A monitor according to claim 17, wherein the skin adhesive
layer is defined in a shape comparable to one of the shape of the
bottom of the housing and a shape differing from the shape of the
bottom of the housing.
25. A monitor according to claim 17, wherein the plurality of
electrodes are spaced less than 6 cm apart.
26. A monitor according to claim 17, wherein the monitor weighs not
more than 28 g (1.0 oz).
Description
FIELD
[0001] This application relates in general to ambulatory
electrocardiography and, in particular, to an ambulatory
electrocardiographic monitor for providing ease of use in women and
method of use.
BACKGROUND
[0002] The cardiac electrical signal begins in the cells of the
sinoatrial node in the right atrium. These cells spontaneously
depolarize and create a cardiac action potential of electrical
impulses that rapidly propagates outward across the right atrium
and then the left atrium. The cardiac action potential in turn
stimulates muscle cells of the atrial myocardium to depolarize and
contract to push blood into the ventricles. Shortly thereafter,
this atrial action potential encounters the atrioventricular node
located at the juncture of the atria and ventricles near the center
of the heart. The atrioventricular node slightly delays cardiac
action potential propagation into the ventricles to ensure complete
drainage of blood from the atria. Thereafter, the muscle cells of
the ventricular myocardium are activated by the electrical wave
front and are stimulated into systolic contraction. After a rest
and reset period, the complete the heart beat cycle repeats. Any
disruption in this process, which can include heart block, sinus
bradycardia, atrial fibrillation, and ventricular tachycardia, can
lead to the symptoms ranging from dizziness to a sensation of heart
fluttering or palpitations, loss of consciousness or even death.
Being able to record the electrical signal of the heart is a
fundamental diagnostic tool of every physician.
[0003] Identifying abnormal rhythms depends upon the manner in
which and the amplitude of the depolarization signal of the muscle
cells of the atrial and ventricular myocardium that in turn act as
sequential voltage sources, which generate a current flow across
the thoracic region of the body and result in a characteristic
signal on the body surface. In a typical electrocardiographic (ECG)
monitor, cardiac action potentials occur between 0.05 Hz to 150 Hz
with a signal strength of around 3mVp-p (peak-to-peak). Although
miniscule, the current flow can be measured to characterize the
electrical activity of the heart using an ECG monitor or similar
device. Voltage differentials from pairings of the electrodes are
filtered, amplified, and combined into P, QRS, and T complexes.
[0004] Conventionally, cardiac action potentials are detected
through electrodes attached to the skin on the chest and limbs
based on the American Heart Association's classic 12-lead placement
model, such as P. Libby et al., "Braunwald's Heart Disease--A
Textbook of Cardiovascular Medicine," Chs. 11 and 12 (8.sup.th ed.
2008), the disclosure of which is incorporated by reference. Both
traditional in-clinic and ambulatory Holter-style ECG monitors
follow the standard 12-lead model with variations on numbers and
placement of leads. Generally, limb lead electrodes are placed on
each arm and on the left leg, while precordial lead electrodes are
placed on the left upper chest region over the heart in close
proximity to the heart and at a location of strongest cardiac
action potential signal strength. In turn, the monitoring circuitry
relies on the superior signal strength from over-the-heart
electrode placement and the relatively long signal vector length
that is afforded by lead placement over a wider physical expanse of
the body. For instance, based upon the large inter-electrode
distances, signal amplification assumes a signal strength of around
3mVp-p (peak-to-peak). The limb leads can be re-positioned as
necessary to compensate for variability in patient anatomy due to
tissue and bone density and heart position.
[0005] The 12-lead placement model, however, is poorly suited to
long-term ambulatory monitoring both from the perspective of
comfort and from the perspective of reliability, particularly in
adult women, as well as on other patients with large-girthed,
fatty, or well-developed upper chest regions. The latter concern
simply relates to how standard monitoring electrodes fall off with
modest movement, as well as how signal quality diminishes when
electrodes are placed over breast tissue, as is unavoidable in some
women. In-clinic ECG monitoring, for instance, assumes that the
patient will remain relatively stationary and that the limb leads
can be repositioned as necessary to provide sufficient electrode
separation for recording a signal of reasonable amplitude and to
compensate for variability in patient anatomy. In contrast, during
ambulatory monitoring, a woman's body is in continual motion, even
during sleep, albeit to a lesser degree. Electrodes are apt to
detach and signal quality degrades or is absent altogether.
Additionally, in women, changes in body position, for instance,
lying down, stretching, or bending over, can displace the
positioning of the breasts and the corresponding changes in tissue
and bone density can deleteriously affect any electrodes placed
thereon. Breasts also exhibit pendulous motion in proportion to
overall size in response to motor activities, such as walking,
running, biking, or exercise. Such recurrent motion can act to
progressively detach items adhered to the soft tissues, like the
breasts, and are likely to irritate the skin when motion leads to
electrode patch tension. Moreover, breast tissue can increases the
distance between sensing electrodes placed and the underlying
heart. Breast tissue may also force placement of the electrode in a
suboptimal location for recording the cardiac signal to remain
comfortable, especially during long-term monitoring. The trade-off
in women, especially active or large breasted, buxom women, can
account for poor ECG signal quality.
[0006] Holter and other forms of ambulatory ECG monitors generally
rely on electrodes placed close to the heart as suggested by the
12-lead placement model. For instance, U.S. Pat. No. 3,215,136
issued Nov. 2, 1965 to Holter et al. discloses an
electrocardiographic recording and playback means. Episodes of
ventricular tachycardia, asystolic intervals, and ectopic heart
activities are sensed by electrodes disposed on the patient's skin
in a suitable location, with sufficient inter-electrode separation.
These signals are ordinarily recorded via a compact recorder worn
by the patient that records an electrocardiogram (ECG) while he
engages in activities of daily living, which subsequently allows a
cardiac specialist to temporally correlate patient symptoms and
cardiac abnormalities with activities. A cardiac rhythm disorder,
as well as the absence of a rhythm disorder during symptoms, can
sometimes be identified by having the patient record those symptoms
during the use of the Holter monitor.
[0007] U.S. Pat. No. 6,117,077 issued Sep. 12, 2000 to Del Mar et
al. discloses a long-term ambulatory physiological recorder
provided in a relatively planar and triangular-shaped recorder
housing with three adhesive electrode pads. The recorder is fully
self-contained and mounted immediately adjacent to the organ system
that is to be monitored. Electrode pads are adhesively and
conductively attached to the patient's left chest in a position
generally over the heart with positive and negative terminals in a
relative vertical position from the top to the bottom of the heart.
Additional electrode leads can also be connected to an input port
on the recorder and placed over adjacent areas of the upper
chest.
[0008] U.S. Pat. No. 6,456,872 issued Sep. 24, 2002 to Faisandier
discloses a Holter-type apparatus for recording physiological
signals indicative of cardiac activity. A base unit is formed of a
flexible sheet carrying electrodes and a recording case that
carries a battery and flexible printed circuit material. The base
unit is disposable and can be changed with each new patient
examination. The recorder case is fixed in position on the
patient's thorax through a plurality of electrodes affixed either
through adhesion or through depression using suction cups.
Alternatively, the base unit can be carried by a thoracic belt or a
hanging strap collar. The recording case includes electronic
circuits for the collection and processing of ECG signals and a
data transmission port is provided for by-directional exchange of
data, control parameters, and information.
[0009] U.S. Pat. No. 7,257,438 issued Aug. 14, 2007 to Kinast
discloses a patient-worn medical monitoring device that includes a
lanyard and electronics package supported in the manner of a
pendant. A lanyard includes integral electrodes or other sensors
for making physiological measurements, which may be stored in a
monitor for later readout or transmitted, before or after
processing, to a remote location. The device can locally process
and analyze a patient's signals and transmit only summary data or
analyzed results to a remote device.
[0010] Finally, U.S. Patent application, Publication No.
2007/0255153, filed Nov. 1, 2007, to Kumar et al.; U.S. Patent
application, Publication No. 2007/0225611, filed Feb. 6, 2007, to
Kumar et al.; and U.S. Patent application, Publication No.
2007/0249946, filed Feb. 6, 2007, to Kumar et al. disclose
discloses a non-invasive cardiac monitor and methods of using
continuously recorded cardiac data. A heart monitor suitable for
use in primary care includes a self-contained and sealed housing.
The housing encloses an electronic memory connected to electrodes
on the upper left chest to detect an ECG. A thin, flexible, and
tapered rim or lip is provided around the edges of the electronics
portion of the monitor to increase the surface area available for
adhesion. Continuously recorded cardiac monitoring is provided
through a sequence of simple detect-store-offload operations that
are performed by a state machine. The housing is adapted to remain
affixed to a patient for at least seven days. The heart monitor can
include an activation or event notation button, the actuation of
which increases the fidelity of the ECG information stored in the
memory. The stored information can be retrieved and analyzed
offline to identify both normal and abnormal ECG events. The
monitor is specifically intended to provide monitoring continuously
and without interruption over an extended period. Despite the
improvement in size and case of use of such a system, neither this
device or any of the above described systems defines a device
capable of extremely simple and reliable application for any body
habitus and by any individual regardless of training. The
application of this monitor is especially problematic for large
breasted, buxom women.
[0011] Finally, U.S. Patent application, Publication No.
2008/0284599, filed Apr. 28, 2006, to Zdeblick et al. and U.S.
Patent application, Publication No. 2008/0306359, filed Dec. 11,
2008, to Zdeblick et al., disclose a pharma-informatics system for
detecting the actual physical delivery of a pharmaceutical agent
into a body. An integrated circuit is surrounded by
pharmacologically active or inert materials to form a pill, which
dissolve in the stomach through a combination of mechanical action
and stomach fluids. As the pill dissolves, areas of the integrated
circuit become exposed and power is supplied to the circuit, which
begins to operate and transmit a signal that may indicate the type.
A signal detection receiver can be positioned as an external device
worn outside the body with one or more electrodes attached to the
skin at different locations. The receiver can include the
capability to provide both pharmaceutical ingestion reporting and
psychological sensing in a form that can be transmitted to a remote
location, such as a clinician or central monitoring agency.
[0012] Therefore, a need remains for an ambulatory ECG monitoring
device and method of use adapted to long term monitoring that
resists body movement while providing ease and discreteness of use
and patient comfort regardless of patient knowledge and regardless
of patient body habitus.
SUMMARY
[0013] A small and anatomically adaptive ambulatory
electrocardiogram monitor includes a disposable ECG monitor that is
applied in-clinic by a primary care provider, by the patient at
home, or by other healthcare or lay individuals to record ECG data
over an extended time period while the patient engages in
activities of daily living. The shape of the ECG monitor is adapted
to placement on women and large-chested individuals. The patient's
upper thoracic region is evaluated, including determining what
affect breast physiology will have on extended placement of the ECG
monitor. The ECG monitor is placed on the patient's chest at
midline in the upper portion of the intermammary cleft, covering
the center third of the sternum and centered between the manubrium
and the xiphoid process on the inferior border of the sternum. This
unique location for ECG monitor application and the monitor's small
size allow for a uniformity of applicability by minimally trained
physicians or even lay individuals. Upon completion of monitoring,
the patient delivers the disposable monitor to a reading service,
along with encoded patient medical information and a diary
recording the patient's subjective impressions contemporaneous to
the monitoring, such as described in commonly-assigned U.S. patent
application, entitled "Computer-Implemented System And Method For
Evaluating Ambulatory Electrocardiographic Monitoring of Cardiac
Rhythm Disorders," Ser. No. ______, filed Oct. 8, 2010, pending,
the disclosure of which is incorporated by reference. A unique
identifier assigned to the disposable monitor is also provided with
the sealable envelope. The reading service interprets the ECG data
and patient medical information and, where indications of a cardiac
rhythm disorder or other health concern arise, an automated
referral to a cardiac specialist, or other healthcare specialist,
is made. The patient and his primary care provider are also
informed.
[0014] One embodiment provides a method for performing ambulatory
electrocardiographic monitoring on an adult female is provided. An
ambulatory ECG monitor, that includes a plurality of sensing
electrodes coupled to self-powered sensing circuitry, is
provisioned. A monitoring site is located on the surface of a
patient's chest at the sternal midline adjacent to the fourth and
fifth intercostal spaces between the breasts in the upper portion
of the intermammary cleft. The electrodes are aligned and placed
along the midline. Interference from breast tissue with placement
of the ambulatory monitor at the monitoring site is evaluated. The
ambulatory ECG monitor is removably adhered to the monitoring site
clear of any breast tissue interference for the duration of
monitoring. ECG data is sensed through the sensing electrodes at
the monitoring site and the sensed ECG data is recorded into the
sensing circuitry.
[0015] A further embodiment provides a method for performing
ambulatory ECG monitoring at a midline sternum-centered location of
an adult female. An ambulatory ECG monitor, that includes a
plurality of sensing electrodes coupled to self-powered sensing
circuitry and enclosed in a flexible housing, is provisioned. The
flexibility of the housing is integral to the design to comfortably
adhere to the sternal surface. The sternal surface is non-planar,
even in men, and the surface of the skin over the sternum has a
subtle three-dimensional topography. A proper understanding of this
topography is critical to device design, as provided through the
shape and flexibility of the housing, to ensure that ECGs can be
recorded from the sternal location in women. A layer of skin
adhesive is independently suspended from a bottom of the flexible
housing. A monitoring site is located on the surface of a patient's
chest at midline and adjacent to the fourth and fifth intercostal
spaces between the breasts in the upper portion of the intermammary
cleft, a location ideal for recording both atrial and ventricular
cardiac signals. Interference from breast tissue with placement of
the ambulatory monitor at the monitoring site is evaluated. The
ambulatory ECG monitor, due to its specific tapered and elongated
triangulated shape with rounded edges, is conformably placed in
this location, even in the face of significant cleavage. The
electrodes are aligned and placed along the midline. The skin
adhesive is removably adhered to the monitoring site to avoid the
breast tissue interference. The housing is axially and laterally
bendable along the non-planar contours of the monitoring site. ECG
data is sensed through the sensing electrodes at the monitoring
site and the sensed ECG data is recorded into the sensing
circuitry.
[0016] A still further embodiment provides a ambulatory
electrocardiographic (ECG) monitor for an adult woman. Self-powered
ECG sensing circuitry is provided. A plurality of sensing
electrodes are coupled to the sensing circuitry. A housing encloses
the sensing circuitry. A skin adhesive layer facing a contact
surface and independently suspended from the housing with a set of
standoffs having non-uniform heights is affixed to and defines an
increasingly wide gap between the skin adhesive layer and a bottom
surface of the housing.
[0017] A yet even further embodiment provides ambulatory
electrocardiographic (ECG) monitor with conformal shape and
independent suspension for an adult woman. A flexible ECG circuitry
body includes self-powered ECG sensing circuitry including a
processor, memory, and finite power supply, a circuit board
exhibiting axial and lateral flexibility and upon which the sensing
circuitry is included, and a housing enclosing the circuit board. A
plurality of sensing electrodes are coupled to the processor, which
processes and stores sensed ECG data into the memory. A skin
adhesion assembly includes a layer of skin adhesive facing a
contact surface, and a set of standoffs having non-uniform heights
affixed to and defining an increasingly wide gap between the skin
adhesive layer and a bottom surface of the housing of the circuitry
body.
[0018] An ambulatory ECG monitor in accordance with foregoing
embodiments can be built at low cost, size and weight with a bill
of materials of about one fifth of the cost of a conventional
ambulatory ECG monitor. Low cost enables clinics and hospitals to
maintain amble inventory at all times, thereby facilitating the ebb
and flow of patients in need of ambulatory ECG monitoring who will
not need to wait on monitor availability or laboratory staffing for
use and overread.
[0019] Additionally a single-use ECG monitor in the form of an
adhesive patch in accordance with foregoing embodiments can be
constructed with a weight of less than two ounces and
inter-electrode spacing of less than 6 cm, which presents three
advantages. First, costs for shipping the monitors to clinics,
hospitals, pharmacies, and other locations are reduced, especially
when large quantities must be mailed around the world. Second,
small size and weight ambulatory ECG monitors can be easily carried
in the pockets of health care providers and therefore applied upon
demand without the need to either retrieve the monitors from a
special location or to send the patient to a separate laboratory.
Third, small, lightweight ambulatory ECG monitors reduce shear
forces on the skin, which further ensures good signal acquisition
and long-term ECG recording by facilitating adherence to the skin
and comfort for the patient.
[0020] Still other embodiments will become readily apparent to
those skilled in the art from the following detailed description,
wherein are described embodiments by way of illustrating the best
mode contemplated. As will be realized, other and different
embodiments are possible and the embodiments' several details are
capable of modifications in various obvious respects, all without
departing from their spirit and the scope. Accordingly, the
drawings and detailed description are to be regarded as
illustrative in nature and not as restrictive.
BRIEF DESCRIPTION OF THE DRAWINGS
[0021] FIG. 1 is a front anatomical diagram showing placement of an
ambulatory electrocardiographic monitor on a female patient.
[0022] FIG. 2 is a cutaway anatomical diagram showing placement of
the ambulatory electrocardiographic monitor of FIG. 1.
[0023] FIG. 3 is an exploded perspective view of an ambulatory
electrocardiographic monitor in accordance with one embodiment.
[0024] FIG. 4 is a side view of the ambulatory electrocardiographic
monitor of FIG. 3.
[0025] FIG. 5 is a bottom view of the ambulatory
electrocardiographic monitor of FIG. 3.
[0026] FIG. 6 is an exploded side view of the ambulatory
electrocardiographic monitor of FIG. 3.
[0027] FIG. 7 is a functional block diagram showing the groups of
electronic component of the ambulatory electrocardiographic monitor
of FIG. 3.
DETAILED DESCRIPTION
[0028] Ambulatory ECG monitoring can be improved by locating the
lead electrodes to body positions better adapted to minimize
artifacts due to body movement. FIG. 1 is a front anatomical
diagram 10 showing placement of an ambulatory electrocardiographic
(ECG) monitor 11 on an adult female patient 12. Placement of the
monitor 11 on an adult female patient 12 can require additional
considerations to ensure safety, comfort, and long-term adhesion
over the course of the monitoring period. The same considerations
may apply on non-adult female patients with large-girthed, fatty,
or well-developed breasts to whom the present discussion is
primarily focused. For clarity, the term "female" will apply to
individuals in this entire class of patients without regard to age
or gender or other physical characteristics or traits not germane
to the selection of the monitoring site and placement of a monitor
11 on the patient's chest.
[0029] For these kinds of patients, the monitor 11 is placed
between the breasts 14a, 14b in the upper portion of the
intermammary cleft 15. The breast size, shape, position, symmetry,
overall body physique, posture, and other factors, such as the type
of brassiere worn and its fit or the presence of artificial
implants are carefully evaluated relative to the size of the
monitor 11 for ensuring that the monitor 11 does not overlap with,
sit or press upon, and otherwise significantly interfere with the
natural movement and positioning of the breasts 14a, 14b. The
placement of the monitor 11 depends upon the width, length, depth,
and relative location of the intermammary cleft 15. A skin adhesion
layer of the monitor 11 is firmly adhered within the upper
intermammary cleft 15 with the assembly housing the ECG recording
circuitry bending in conformity to the shape of the sternum and
being independently suspended above the skin adhesion layer to
resist torsional body movement, as further described infra.
[0030] The monitor 11 may be applied in-clinic by a primary care
provider, or by the patient herself, for instance, under a
physician's orders after first obtaining the monitor 11 from a
pharmacy or other authorized dispensary, such as described in
commonly-assigned U.S. patent application, entitled
"Computer-Implemented System and Method for Mediating
Patient-Initiated Physiological Monitoring under Consolidated
Physician Supervision," Ser. No. ______, filed Oct. 8, 2010,
pending, the disclosure of which is incorporated by reference. The
monitor 11 is typically used over a 24-48 hour period, but the
monitoring period could be extended from seven days up to 30 days
through use of a series of monitors. During monitoring, the patient
12 engages in activities of daily living, while the monitor 11
unobtrusively monitors and collects ECG data. Recording commences
upon physical application of the monitor 11 and ends when the
monitor 11 is removed, typically by the patient 12. Along with the
monitor 11, the patient 12 receives instructions for having the
monitor 11 processed post-monitoring, which can be performed by a
reading service, such as described in commonly-assigned U.S. patent
application, entitled "Computer-Implemented System And Method For
Evaluating Ambulatory Electrocardiographic Monitoring of Cardiac
Rhythm Disorders," cited supra. As appropriate, the patient 12 is
referred to a medical specialist for follow up care, such as
described in commonly-assigned U.S. patent application, entitled
"Computer-Implemented System and Method for Facilitating Patient
Advocacy through Online Healthcare Provisioning," Ser. No. ______,
filed Oct. 8, 2010, pending, the disclosure of which is
incorporated by reference.
[0031] Proper placement of the monitor 11 is critical to recording
high quality ECG data. FIG. 2 is a cutaway anatomical diagram 20
showing placement of the ambulatory electrocardiographic monitor 11
of FIG. 1. The ambulatory monitor 11 is removably adhered onto the
skin on the patient's chest 21 at midline, covering the center
third of the chest 21 over the sternum 26, roughly between the
third and fifth ribs 25a, 25b and approximately centered between
the suprasternal notch 23 on the superior border of the manubrium
and the xiphoid process 24 on the inferior border of the sternum
26.
[0032] The midline sternum-centered monitoring site enables high
P-wave and QRS-wave acquisition and provides several additional
benefits over other more typical cutaneous monitoring locations
like those locations over the left upper chest or in the left
inframammary crease. First, electrical current originating from the
atria and ventricles flow directly underneath the sternum 26
providing excellent P waves and QRS waves necessary for cardiac
rhythm diagnosis. Signal quality is further improved by minimizing
the depth of tissue, and noise thus generated by moving tissue,
between the monitor's electrodes and the heart. Tissue depth is
fairly consistent at the sternal midline where variations in the
patient's weight and physical topology least interfere with ECG
signal pickup. The midline sternum-centered location enables the
monitor's electrodes to record an ECG of optimal signal quality
from a location immediately above the strongest signal-generating
aspects of the heart. Further, the surface of the skin located over
the midline sternum-centered location remains relatively
stationary, despite body motion or movement of underlying breast
tissue 29, as well as muscle or other body tissue. Movement of the
skin surfaces of the upper thoracic region can be of significant
moment, particularly on obese patients or women with large or heavy
breasts. Adhering the monitor 11 to a body position of minimal
movement helps ensure that the monitor 11 remains adhered to the
patient 12 throughout the entire monitoring period, as further
described infra.
[0033] The ambulatory ECG monitor is constructed to provide low
cost widespread use, with a particular emphasis in improving
patient care at the primary care medical practice level, especially
for women. FIG. 3 is an exploded perspective view 40 of an
ambulatory electrocardiographic monitor 41 in accordance with one
embodiment. Physically, when viewed from above, the monitor 41 has
an elongated triangular shape with rounded vertices, such as
described in commonly-assigned U.S. Design Patent application,
entitled "Ambulatory Electrocardiographic Monitor," Ser. No.
______, filed Oct. 8, 2010, pending; the disclosure of which is
incorporated by reference, with dimension's of approximately 3.8 cm
(1.5 in) wide and 7.6 cm (3.0 in) long with a pair of electrodes 48
spaced less than 6 cm apart. The monitor 41 weighs about 14.2 g
(0.5 oz) when assembled with electrodes 48 and a waterproof housing
for the ECG recording circuitry, although a weight of up to 28 g
(1.0 oz) would be acceptable. In one embodiment, the pair of
electrodes 48 have an approximately 5.33 cm spacing, although other
electrode spacing, generally less than 6 cm, and combinations of
three or more electrodes could also be used. When adhered onto a
patient's sternum, the narrowest part of the monitor 41 faces
downwards towards the patient's feet. On a female patient, the
narrow part fits partway into the upper intermammary cleft 15. The
small and narrow size, as well as the taper, allow the monitor 41
to fit comfortably between the breasts.
[0034] The monitor 41 is constructed in a modular fashion and
includes a flexible housing and standoff-separated skin adhesion
assembly. The housing includes a cover 42, printed circuit board
(PCB) 43, and cover base 44, and the skin adhesion assembly
includes a set of standoffs 45a, 45b, a layer of skin adhesive 46,
and a set of electrodes 48. The housing protects the electronic
components for sensing and recording ECG data, as further described
below with reference to FIG. 7, which are affixed to the PCB 43.
The cover 42 conformably fits against the edges of the cover base
44. The cover 42 and cover base 44 form a water resistant enclosure
that fully enclose the PCB 43. In a further embodiment, the housing
61 is vented, which allows the cover 42 to slightly "give" when
pressed. A button 47 is formed on the top surface of the cover 42
that engages a switch on the PCB 43, which the patient can press
during monitoring to mark an event occurrence, such as onset of
dyspnea. An indicator light 49, such as a light emitting diode,
visually signals the patient 12 that the monitor 11 is working. A
steady light signifies normal operation, while a blinking light
indicates a problem.
[0035] The outer materials are selected for extended term use. The
cover 42 and cover base 44 are both constructed from flexible
bio-safe materials, such as plastic, silicon, or foam, and can be
vacuum-formed, extruded, or die cut. The adhesive layer 46 is
constructed using an adhesive fabric or cloth, which can be woven,
as well as latex, foam, and other materials that sufficiently
resist the twisting and torquing of the skin's surface. In a
further embodiment, darts are cut into the periphery of the
adhesive layer 46 to more closely conform the adhesive layer 46 to
an uneven or contoured skin surface. Other materials and methods of
manufacture are possible.
[0036] The housing and skin adhesion assembly facilitate long term
monitoring. Continuous and uninterrupted wear of the monitor 41
over the entire course of monitoring may be impracticable for every
patient. Skin sensitivities, allergies, irritation, and similar
factors have an effect on a patient's ability to tolerate the
wearing of the monitor 41 for an extended period. Similarly, oil on
the skin's surface, perspiration, and overall physical hygiene can
affect monitor adhesion. As a result, the housing can be separated
from the skin adhesion assembly to allow the patient 12 to
reposition or replace the skin adhesion assembly. The set of
electrodes 48 fit within set of standoffs 45a, 45b and a set of
holes or "gel wells," in the skin adhesive layer 46. In turn, the
skin adhesive layer 46 is affixed to the cover base 44 through a
combination of a pair of snap-on or similar form of removable
connectors facing downwardly from the PCB 44 and adhesive applied
to the upward facing surfaces of the standoffs 45a, 45b.
[0037] To facilitate overall long term monitoring through a series
of short term monitoring periods, the housing can be separated from
the skin adhesion layer and either a new skin adhesion layer can be
applied, or the existing skin adhesion layer can be repositioned.
Either the same housing or a new housing can be used during
successive periods of monitoring. When the same housing is reused,
the recording circuitry compensates for disconnection and
reconnection of the sensing electrodes by stopping recording of ECG
data during the gap in monitoring, as sensed by disconnection from
the set of electrodes 48. The recording circuitry thereafter
resumes recording upon being reconnected to a set of electrodes 48.
If necessary, the patient 12 may choose to take a break and allow
her skin to "breathe" between applications of the skin adhesion
layer.
[0038] In one embodiment, the monitoring circuit for ECG recording
used by the monitor 10 operates under microprogrammed control on a
single channel of analog input signals. The signals originate as
cardiac action potentials sensed from the skin's surface by a
single sensing electrode pair, although multiple sensing electrode
pairs could be employed with modifications to the monitoring
circuit to factor in multiple input signal channels. The analog
input signals are converted into digitized form and encoded for
efficient compressed data storage in non-volatile memory. The
monitoring circuit injects a reference feedback signal into both
the analog input signal path and the patient's body. Thus, noise
generated by the electronics is integrated into the input signals,
rather than being filtered or rejected. The monitoring circuit is
thereby able to operate unshielded, with no filtering, and through
minimal power filtering components, which thereby eliminates the
need for either the cover 42 or cover base 44 to include physical
noise shielding is eliminated through unique printed circuit board
design and layout, as well as careful selection of electronic
components that naturally dampen received noise. As well, the
digitization and compression of the original low noise analog
signal requires less memory to store long term ECG data.
[0039] Referring back to FIG. 2, the body's surface over the
sternum 26 is inherently uneven, even in children, due to the
underlying bone structure of the body of the sternum 26 and ribs
28, as well as the muscle, fat, skin, and various tissue that cover
the sternum 26 and adjacent regions. The front surface of the body
of the sternum 26 is slightly convex in the east-west directions
and the sternum's front surface angles in towards the thoracic
cavity from around the fourth intercostal space 27 down to the
xiphoid process 24 in the north-south directions. In the elderly,
particularly in older males, the east-west convexity can become
increasingly pronounced with age, resulting in a so-called
"pigeon-chested" appearance.
[0040] Conforming fit and secure adhesion to this inherently uneven
surface are provided through two interconnected structures: a
flexible housing and standoff-separated skin adhesion assembly.
FIGS. 4 and 5 are respectively side and bottom views 60, 65 of the
ambulatory electrocardiographic monitor 41 of FIG. 3. The monitor
41 must adhere to the sternum 26 during the monitoring period. The
cover 42 and cover base 44 provide a housing 61 for the monitor's
electronic components. In one embodiment, the PCB 43 is about
0.02'' thick, which allows the PCB 43 to conform to the east-west
convexity of the sternum 26 and to the natural north-sound inward
curve towards the xiphoid process 24.
[0041] Objects adhered to the sternum 26 need to be able to both
conform statically to the shape of the chest 21 and to accommodate
dynamic torsional movement, as occurs during stretching, sleeping,
and other body movement. The PCB 43 can bend axially and laterally,
but the PCB's ability to stretch is limited by physical constraints
on electronics packaging. To provide stretch, the monitor 41
utilizes a form of independent suspension that enables the skin
adhesive layer 46 to stretch, as well as flex, independently of the
housing 61. The monitor 41 is adhered to the patient's skin through
a layer of skin adhesive 46 that is affixed to the bottom surface
of the cover base 44 around the set of standoffs 45a, 45b. The skin
adhesive layer 46 is slightly larger than the bottom of the cover
base 44 by about 0.125 in, although other shapes, sizes, and
dimensions could be used, including shapes that differ
significantly from the top profile of the cover base 44. The set of
electrodes 48 are removably affixed to a pair of snap-on connectors
facing downwardly from the PCB 44 and are electronically connected
to the PCB's circuitry. Other types of connectors that allow the
set of electrodes 48 to be removably affixed could also be used.
The set of electrodes 48 fit within openings formed in the set of
standoffs 45a, 45b and a set of holes 66a, 66b, or "gel wells," in
the skin adhesive layer 46. The electrodes 48 are coated with a
conductive gel that also assists with adhering the monitor 41 to
the patient's chest 21. The independent suspension is provided
through the set of two or more standoffs 46a, 46b that create a gap
62 of about 2.5 mm (0.1 in) to about 6.3 mm (0.25 in) between the
bottom surface of the cover base 44 and the top surface of the skin
adhesive layer 46. The heights of each of the standoffs 45a, 45b
define an increasingly wide gap between the bottom of the housing
61 and the adhesive layer 46, which permits the monitor 41 to stay
securely attached to the patient 12 during torsional movement, such
as occurs when stretching or rolling over in bed. The standoffs
45a, 45b have non-uniform heights to compensate for the unevenness
of the female anatomy, as further described below with reference to
FIG. 6. The gap 62 allows the housing 61 to "float" above the skin
contact surface, while the skin adhesive layer 46 can flex and
stretch along with the skin's surface on the patient's sternum
chest 21. The single-point contact of each of the standoffs 45a,
45b thus allows the monitor 41 to accommodate the patient's
twisting and turning movements and remain affixed without danger of
peeling off.
[0042] Breast tissue 29 (shown in FIG. 2) can increases the
distance between sensing electrodes 48 placed and the underlying
heart. FIG. 6 is an exploded side view 68 of the ambulatory
electrocardiographic monitor 41 of FIG. 3. The degree of inward
curvature of the sternum's front surface towards the thoracic
cavity is more pronounced in women than in men. The PCB 43 permits
north-south flex of housing 61, but the amount of inward flex may
be insufficient to securely adhere the monitor 41 to an adult
female's chest 21. To help compensate for the inward angle of the
body of the sternum past the fourth intercostal space 27,
especially in women, the standoffs 45b located on the narrowest
part of the monitor 41 have slightly greater heights. In one
embodiment, the shorter standoffs 45a have a height of about 2.5 mm
(0.1 in) and the taller standoffs 45b have a height of about 6.3 mm
(0.25 in).
[0043] The electronics package of each monitor facilitates low-cost
extended wear use. FIG. 7 is a functional block diagram 70 showing
the groups of electronic components 71 of the ambulatory
electrocardiographic monitor 41 of FIG. 3. The monitor 41 is
self-contained and operates under microprogrammed control, such as
described in commonly-assigned U.S. patent application, entitled
"Microcontrolled Electrocardiographic Monitoring Circuit with
Feedback Control," Ser. No. ______filed ______, pending, and U.S.
patent application, entitled "Microcontrolled Electrocardiographic
Monitoring Circuit with Differential Voltage Encoding," Ser. No.
______, filed Oct. 8, 2010, pending, the disclosures of which are
incorporated by reference. Digitally-controlled ECG monitoring
circuits provide the ability to handle the wide dynamic range
occasioned by the short signal vector and low signal strength
afforded by a midline sternum-centered ambulatory monitoring
location.
[0044] In a functional sense, the electronic components 71 can be
grouped into circuitry for a processor 72, memory 73, power supply
or battery 74, data interface 75, and radio frequency
identification (RFID) tag 77. The processor 72 is a discrete ECG
recording circuit that operates under microprogrammed control on a
single channel of analog input signals. To sense ECG data, the
processor 72 interfaces to a set of external electrodes 76 through
amplifiers and filters (not shown). Signals originate as action
potentials sensed on the skin's surface by at least one of the
electrodes 76 and a feedback signal is output through the other
electrode 76. The sensed ECG data is processed into a stream of
discrete digital values and encoded in the persistent non-volatile
memory 73, which can be implemented as electrically-erasable
programmable read-only memory (EEPROM) or "flash" memory. The data
interface 75 enables the processor 71 to download recorded ECG data
from the memory 73 and receive programming instructions. The
processor 71, memory 72, and data interface 74 can be a single
discrete integrated circuit or a set of individual components
interconnected through data channels. The battery 74 is a
conventional power cell or capacitor that provides power to the
recording circuitry sufficient to enable extended operation.
[0045] In a further embodiment, either or both of the memory 73 and
the battery 74 can be separately provided on the skin adhesion
layer 46 to facilitate long term monitoring through use of a series
of short term monitoring periods. Space for storing recorded ECG
data and power for operating the recording circuitry are
continually depleted. Providing the memory 73 and the battery 74 on
the skin adhesion layer 46 enables those resources to be
replenished, while enabling use of the same physical recording
circuitry throughout the entire monitoring period.
[0046] The RFID tag 77 contains a unique identifier for the monitor
that is either included on the PCB 43 with the other electronic
components, or is embedded into the housing 61, such as within a
foam-constructed cover 42. The RFID tag 77 is used during
monitoring to pair a monitor 41 to a tracking number that can be
used by the patient 12, referral center, and physician or staff to
track the physical whereabouts of the monitor 41 and to determine
the post-monitoring status of diagnosis and follow up care. The
RFID tag 77 is self-powered or can be powered through the battery
74. The RFID tag 77 is accessed using standard RFID transmitter and
receiver units. Other components in addition to or in lieu of the
electronic components 71 are possible, such as used to record
additional types of patient physiometry or to provide further
onboard capabilities.
[0047] In a further embodiment, the electronic components 71 also
include an actimetry sensor 78 to measure gross motor activity
undertaken by the patient, such as through walking, running,
changing posture or sleep position, and other body motions. For
instance, the actimetry sensor 78 may record movement, which
indicates that the patient was climbing stairs at the same time
that an increase in heart rate was recorded by the monitor 11.
Particularly, when actigraphy is combined with the patient's
subjective impressions as contemporaneously recorded in his diary,
the physician can confirm or better understand hemodynamic changes
and other aspects of cardiac physiology as reflected in the
recorded ECG data.
[0048] The monitor 41 may be fully or partially disposable. For
instance, the electronic components 71 on the PCB 43 may be
refurbished and recycled for multiple uses, while the housing 61
and skin adhesive 46 would be disposed after a single use. During
refurbishment, the battery 74 would be replaced and the memory 73
wiped clean. Alternatively, the entire monitor 41 may be used only
once, followed by appropriate disposal.
[0049] While the invention has been particularly shown and
described as referenced to the embodiments thereof, those skilled
in the art will understand that the foregoing and other changes in
form and detail may be made therein without departing from the
spirit and scope.
* * * * *