From sensation to action: expectation, appraisal, and decision-making in patient-triggered cardiac monitoring

This study examined whether objective physiological arousal predicts patient-triggered recordings (PTRs) in patients with an implantable loop recorder (ILR), to clarify how normative autonomic activation and clinically meaningful rhythm disturbances relate to symptom-triggered monitoring behavior during long-term surveillance. Data were drawn from 2,266 ILR patients enrolled in the CERTITUDE registry between 2019 and 2025; analyses were restricted to the 878 individuals who used the PTR function at least once. Day-level ILR data from the first 12 months following implantation were analyzed. Daily physical activity percent per day (PA), weekly variability in PA, and counts of device-detected atrial fibrillation, bradycardia, and asystole were modeled as predictors of daily PTR counts using within-person repeated-measures correlations and linear mixed-effects models. Subgroup analyses were conducted by primary clinical indication. Daily PA showed near-zero within-person associations with PTR behavior (overall r = - .018), and mixed-effects models yielded very small coefficients. Weekly PA variability was not associated with PTR activation. Device-detected arrhythmic events accounted for only marginal additional variance in PTR counts, and asystole was not associated with PTR use. Patterns were consistent across ILR indications. Overall, objective physiological arousal explained little of the observed variation in PTR behavior. PTR behavior during long-term ILR monitoring appears to be shaped largely by interpretive and decisional processes, rather than by direct detection of physiological events alone. Conceptualizing PTRs as behavioral responses to ambiguity in bodily sensations highlights the importance of patient education, contextualized physiological feedback, and attention to symptom appraisal in the clinical management of ILR patients.