INFORMATION FOR MEDICAL PROFESSIONALS

Our History and Services Provided

I established Illawarra Holter Monitoring in 1989 to provide the first public hospital-based Holter monitoring service in the Illawarra region. Some years prior to that (in 1980) I developed the first diagnostic treadmill stress testing service in the Illawarra at Wollongong Hospital and later established the first ambulatory blood pressure monitoring service in the Illawarra region.

In 1996 I felt that there was a need to provide these diagnostic services to the public outside the hospital setting and commenced my present practice located at 310 Crown Street.

Having established these cardiac services I have a keen interest in their quality and we aim for best practice in all our diagnostic procedures.

Our Quality Holter Recordings

We take particular pride in the accuracy of our Holter recordings in the detection of arrhythmias. A point of differentiation with our recordings is the comprehensive editing that is performed to ensure maximum accuracy. Failure to perform this time-consuming editing (which may on occasion take more than one hour for a single recording), particularly in the presence of significant artefact, means that many Holter printouts I have seen performed elsewhere are of such poor quality as to be diagnostically useless. Our extensive editing (which may include reviewing in excess of 100 ECG strips, including all hourly maximum and minimum HR strips) virtually guarantees that every significant arrhythmia during the recording period will be detected. Additionally all our Holter reports are reviewed by a senior Cardiologist.

The Value Of Ambulatory BP Monitoring

I would like to make a brief comment on Ambulatory BP monitoring, which represents one of the major advances in the management of hypertension in recent years. An ABP recording will typically measure BP half-hourly during waking hours and hourly during sleep, giving approximately forty (40) readings over a 24-hour period. It is a much more reliable indicator of a patient’s underlying BP compared to isolated clinic readings or random readings using home monitoring. I believe it is an investigation which is probably underutilised by some practitioners; those who use it as a routine tool in the management of their hypertensive patients (eg prior to commencing drug therapy or in the evaluation of treatment efficacy) consistently obtain clinically useful information which allows treatment to be optimised. Although the procedure does not attract a Medicare rebate it may be highly cost-effective in the long term by reducing unnecessary drug therapy and medication side-effects.

Educational Material

I propose to make available to interested referring Medical Practitioners clinical material on ECG interpretation, notes on Diagnostic Stress Testing and Ambulatory BP monitoring, interesting ECGs etc. These will be available here on the website on the Education Page (link below)

EDUCATION

Treadmill Exercise Testing Vs Stress Echo

A matter of concern has been the recent promotion of expensive stress echocardiography tests by some practitioners as an initial diagnostic investigation for chest pain (the same comment may apply to inappropriate expensive and time-consuming radionuclide stress tests) where a relatively inexpensive standard treadmill stress test would suffice. The promotion of such procedures where they are not clinically indicated is disingenuous. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines ‘explicitly state that echocardiography should not be routinely substituted for treadmill exercise testing when electrocardiographic analysis is expected to suffice’ (Braunwald’s Heart Disease 7th ed: GUIDELINES: Use of Echocardiography). More recent guidelines from the ACC are more complex, focusing on appropriate use criteria (AUC) for stress echocardiography. Test indications are scored on a scale of 1 to 9; tests with a score of 7-9 are classified A (appropriate); a score of 4-6 indicates uncertainty (U) regarding the appropriateness of the test and a score of 1-3 indicates the test is inappropriate (I) for that indication.
It should also be noted that it is not possible to obtain satisfactory image quality while the patient is exercising; the accuracy is reduced in the presence of left bundle branch block and image quality may be poor in the presence of obstructive lung disease. The ACC/AHA guidelines specifically state that echocardiography is not indicated where its results will have no impact on diagnosis or clinical decision making. As such we only perform standard treadmill tests and a positive test or an equivocal test with a high index of suspicion for coronary artery disease should generally be followed by coronary angiography following review by a Cardiologist.
As such we only perform standard treadmill tests at 310 Crown Street; stress echocardiography procedures are available where indicated at Associate Professor McKenzie's rooms at 30 Loftus Street.

Our Service Promise To You

We are committed to providing the highest possible quality for the services we provide; this includes notifying referring practitioners by phone of clinically significant test results (eg serious arrhythmias, positive stress tests confirming a diagnosis of coronary artery disease) and assisting in arranging early Specialist review if requested. I would hope we are able to offer the benefit of experience in our field; my Cardiac Technician has had some 35 years experience and I personally have performed some 35,000 diagnostic stress tests and more than 19,000 Holter analyses.
​Finally, although Medicare rebates do not reflect the cost of providing these services we do attempt to keep our fees as affordable as possible so the procedures are accessible to all members of the community.

I would like to thank our referring practitioners for their continued support (in some cases over many years); it is a privilege working with you to promote high quality patient care in the Illawarra.

Dr John McLeish
​Director, Illawarra Holter Monitoring