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ECG Holter: Guide to Electrocardiographic Interpretation / Edition 1

Barbara J Aehlert. Atlas of Forensic Histopathology. Peter M. Pocket Guide to Echocardiography. Andro G. Breast Imaging and Pathologic Correlations. Dianne Georgian-Smith. Morton J. Interestingly, silent myocardial ischemia did not correlate with significant coronary heart disease and was thought to be due to microvascular disease and coronary spasm. Green et al. Poulikakos et al. Patients receiving peritoneal dialysis showed significantly fewer episodes of AF.

AF onset was more frequent on the days of the hemodialysis procedure, and during the dialysis procedure itself. Therefore, AECG monitoring during dialysis could help with the earlier diagnosis of AF in asymptomatic patients, which may prompt appropriate AF management including anticoagulant therapy. Reduced HRV is generally associated with an elevated sympathetic tone or reduced parasympathetic activity.

A strong link between epilepsy and cardiac arrhythmias has been described. Recordings during seizures report that sinus tachycardia just prior to the seizure is common, with both atrial and ventricular ectopy also observed. It is possible that the same cellular mechanisms triggering cardiac arrhythmias may be responsible for cerebral epilepsy. A variety of bradyarrhythmias have been observed, including sinus node dysfunction, bundle branch block, and the entire spectrum of AV blocks. Patients may also experience AF and sustained VT. Sudden death is reportedly due to asystole and ventricular fibrillation, and some patients may benefit from pacemaker or ICD.

AECG may be used to detect arrhythmias to guide device and medical management, but there is little published data to guide its specific use in this clinical context. Recent studies have shown that cardiac arrhythmias and conduction disorders are common in patients with sleep apnea Hersi, ; Todd et al. The mechanisms of this association include autonomic imbalance, systemic and pulmonary hypertension, intermittent hypoxia, and inflammation. All these conditions facilitate structural and electrical remodeling, which is considered to be the electrical substrate for a variety of arrhythmias Baranchuk, Because polysomnography is not universally available and can be logistically cumbersome, screening larger populations at risk would be advantaged by simpler and less expensive diagnostic tests.

It has been proposed that the Holter monitor may fill this role. Additional information beyond what is typical for Holter recordings include a description from the patient about hours of sleep. More validation of these techniques is needed. Arrhythmia monitoring of the athlete is, in some ways, distinct from utilization of monitoring in other circumstances.

For the athlete, symptoms suspicious of an arrhythmia, rarely, can be a premonitory sign of SCD and may indicate an otherwise potentially serious but treatable condition or arrhythmia. On the other hand, undue restriction for suspicious but benign symptoms may be unwarranted.

ECG Holter: Guide to Electrocardiographic Interpretation

A stepwise approach to evaluating the athlete should be considered. First, it is important to understand historical features of the symptoms involved and if they are related to specific competitive or physical activities. Second, it is important to rule out important cardiovascular disease that may be present concomitantly or be the initiator of the arrhythmia. An ECG and other noninvasive tests are performed to determine the presence of any underlying structural process that could be involved and require restriction from athletics.

On the ECG, there may be obvious features that point to a specific arrhythmogenic substrate. However, for many competitive athletes, the sport itself is required to initiate the symptom and potentially the arrhythmia. Thus, the AECG is one of several subsequent steps in evaluating the patient depending on the sport, the athlete, the circumstances of the symptoms, and the presence of comorbidities as well as family history. Ambulatory ECG monitoring for the athlete is specifically useful when 1 the athlete is not already restricted due to a diagnosed cardiovascular condition; 2 there is no other way to secure a diagnosis or cause for the symptoms with any certainty; and 3 participation in athletics causes the symptoms and may facilitate the arrhythmia diagnosis.

ECG monitoring can be used to secure an initial diagnosis or as a surveillance tool to ascertain that an arrhythmia is eliminated by therapy. AECG should be considered to correlate symptoms e. In addition, some known heart conditions e. The type of monitoring depends on symptom frequency, severity, duration, and type of circumstances surrounding the symptoms. In addition, the type of monitoring depends on the type of athletic participation and the arrhythmia and symptom being assessed.

There is no one best monitoring technique, and individualized decisions are needed. Rhythm disturbances, by themselves, do not necessarily elicit symptoms, and some rhythm disturbances can occur with or without symptoms. On the other hand, patients may have multiple rhythm disturbances and recording an asymptomatic rhythm disturbance does not necessarily imply high risk. Candidate selection for ICD therapy could be improved.

Accounting for the multifactorial pathogenesis of SCD including structural substrate, autonomic dysfunction, and repolarization abnormalities may improve specificity. Measurement of HRV is performed in the frequency and time domains as well as by nonlinear techniques. Nonlinear HRV analysis is believed to be less dependent on preprocessing and to express better the complexity of RR changes Perkiomaki et al. In heart failure patients, decreased HRV has been documented as a potent marker of heart failure progression and identified patients in need of heart transplantation or with elevated risk for death due to pump failure.

Patients with impaired HRV at enrollment were more likely to die from heart failure progression than from arrhythmic causes. QT variability QTV measures variations in the length rather than in the morphology of the QT interval to assess duration of repolarization. There are approximately 15 different QTV measures. QTV studies are performed at constant heart rates to avoid the need for heart rate correction.

Importantly standardization is lacking including technical requirements, recording duration, most suitable leads, and means to deal with effects of the autonomic nervous system, respiration, circadian influences, and medications. Important limitations include the facts that 1 normative QTV values have not been established; 2 there are no agreed cutpoints indicating elevated risk; and 3 QTV studies do not provide evidence of its capacity to guide therapy. Some of these methods have been implemented on commercial Holter systems, and they are becoming available for routine clinical use.

However, efforts to improve this continue, since sudden death occurs largely in subjects in whom left ventricular ejection fraction has proven insufficient for risk stratification. A recurring theme is that the use of the multiparameter approach incorporating indicators of autonomic tone and repolarization abnormality holds the greatest promise. The absence of randomized clinical trials to assess the capacity of these parameters to guide therapeutic interventions to prevent SCD is a major deficiency. AECG may be analyzed for relationship between ventricular arrhythmia and preceding heart rate and repolarization changes e.

Most antiarrhythmic drugs also exert negative chronotropic and dromotropic effects. Significant bradycardia in patients requiring heart rate lowering drugs may warrant pacemaker implantation. Catheter ablation of ventricular arrhythmias has become a widely used therapeutic approach. The efficacy of catheter ablation for ventricular arrhythmia is assessed immediately during and shortly after a procedure.

In clinical practice, this severe definition may give way to one that also takes account of AF frequency, duration, and symptom status. Duration and frequency of events vary greatly among patients with AF. These devices are particularly useful to capture ECG recordings during symptomatic events and clarify the arrhythmic basis for unexplained or ambiguous symptoms, especially if infrequent. Although these monitors can detect the onset of an arrhythmia such as AF, their algorithms are not designed to include the offset of the arrhythmia. Thus, information about the burden of AF cannot be consistently ascertained.

Reliance on symptoms alone by patient or physician may be misleading—both over and underestimating the presence of AF Charitos et al. As most patients do not have an implanted device, extended AECG facilitates accurate AF quantification and associated ventricular rates. AF and associated thrombus formation is the most common cardioembolic source of ischemic stroke Liao et al.

Possible complications e. The goal of a rhythm control strategy is to suppress or reduce the prevalence of AF associated with symptoms. Therefore, it may be reasonable to perform AECG to confirm the presence or absence of AF, particularly if residual symptoms are ambiguous or resting ECGs have been inconclusive. Outpatient monitoring with AECG may be used when starting antiarrhythmic drugs that do not require hospitalization for initiation.

Class 1C drugs e. Class III antiarrhythmic drugs risk torsade de pointes, which may be presaged by increasing QT intervals particularly postpause , prominent U waves, TWA, and greater prevalence of ventricular ectopy. If outpatient initiation has been selected not permitted by FDA for dofetilide, but not prohibited for sotalol , then AECG recording during dose initiation and titration may be reasonable Zimetbaum, Many antiarrhythmic drugs e. Monitoring postprocedure is mandatory to assess success and determine future management.

Complete absence of AF is considered a very favorable finding. Heightened surveillance during the early weeks following ablation may help manage patient expectations, provide reassurance regarding underlying rhythms when patients experience subtle or ambiguous symptoms, and aid in decision making for discontinuation of antiarrhythmic drug when the blanking period concludes.

Medications representing numerous classes of drugs have been shown to cause QT prolongation, usually via the mechanism of blocking IKr potassium current. The vast majority of older patients take several drugs, so an interaction of two or more drugs might increase the risk of QT prolongation and proarrhythmia. Development of new compounds by the pharmaceutical industry requires assessment of potential proarrhythmic effect at early stages of preclinical and clinical investigations.

Phase I and phase II clinical studies if properly designed with ECG monitoring incorporated provide an opportunity to identify the effect of the tested drug on QT duration.

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In many cases, the thorough QT study International Conference on Harmonisation, is required, which consists of careful monitoring of ECG parameters on therapeutic and supratherapeutic doses of a tested drug and during administration of moxifloxacin, an antibiotic with known QT prolonging effect considered as the positive control. Recent data from five thorough QT studies Ferber et al.

This approach could be further enhanced by drug exposure to QT response analysis empowered by continuous Holter monitoring Darpo et al. AECG monitoring plays an essential role in establishing indications for pacemaker implantation. In some cases, it is useful for evaluation of already implanted patients although current era implantable electronic devices pacers, ICDs, and CRTs have sophisticated remote monitoring capabilities that are able to evaluate electrical properties of the device itself and also arrhythmias Andrikopoulos et al.

Nevertheless, AECG may be helpful for arrhythmia analyses needed for correct device programming to deliver appropriate therapy, to avoid inappropriate intervention, or to detect device malfunction. In patients with AF scheduled for CRT implantation, careful analysis of ventricular rate response is required prior to implantation to ensure future efficiency of biventricular pacing treatment. AECG monitoring may provide valuable advice regarding the type of implanted device in terms of single versus dual chamber.

DDD pacing with minimal ventricular pacing algorithms is preferred in sick sinus syndrome. Advances in technology and clinical experience acquired over the past decades indicate that routine ECG monitoring after implantation is not necessary. However, AECG may be useful to correlate symptoms suggestive of arrhythmias or device malfunctioning. For example, AECG may also be helpful in patients with devices to assess upper rate pacemaker behavior with exercise, that is Wenckebach or AV block, and the device could be reprogrammed accordingly.

AECG monitoring can be performed in patients with symptoms suggestive of device malfunctioning such as intermittent loss of capture or sensing abnormalities that may lead to clinically significant pauses or tachyarrhythmias in patients in whom routine interrogation does not reveal the reason for corresponding clinical symptoms. Notably, other causes of syncopal episodes are frequently observed in patients with pacemakers. In one report, only 4. Evaluation of atrial and ventricular arrhythmia by device software and retrieved diagnostics may not always be complete Kumor et al.

Atrial arrhythmias may be characterized and quantified by AECG to guide proper treatment.

Arrhythmia Holter Training 1

Furthermore, slow VT episodes below detection threshold can only be assessed externally. AECG should be recommended to evaluate the presence of pacing fusion and pseudofusion beats. The need for reimplantation has to be established even before explantation, and therefore, monitoring of symptoms and ECG with a device programmed at a pacing rate below the patient's intrinsic rate is recommended. Hardwired continuous cardiac rhythm monitoring systems involve connections to monitoring equipment by cable using either digital or analog signals for data transfer.

These are utilized within intensive care units with immobilized critically ill patients. Cardiac telemetry refers to remote monitoring with wireless data transfers using a radiofrequency signal, typically applied on medical or surgical hospital wards to allow patient ambulation. Competency is required in both the afferent and efferent communication limbs of continuous cardiac rhythm monitoring. Attention to skin preparation, electrode placement, and equipment connections represents a critical first step.

Arrhythmia recognition requires both dutiful attention to the clinical alarms and also sufficient knowledge to delineate true arrhythmia events from noise artifact. False positives may lead to inappropriate medical interventions Knight et al.


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Nominal alarm default settings are designed to be highly sensitive so as to not miss a clinically important event, but can also demonstrate poor specificity. True events may be missed when a large volume of false alarms systematically desensitizes responders. Deliberate but dangerous reactions include rendering clinical alarms inaudible, inappropriate use of alarm suspension features and adjustments of alarm parameters to indiscriminately silence alarms.

In recognition, a national patient safety goal was issued by the Joint Commission requiring hospitals to establish effective alarm management policies by The Joint Commission, Addressing alarm fatigue may improve clinical outcomes. Patient selection may be important. For example, arrhythmia yield was only 1. Importantly, cardiac event rates stratified by telemetry indication have not yet been reported, leaving institutions to wonder about the relative yield within each category. Future research is needed to provide event rates stratified by telemetry indication and outcomes associated with standardization.

Automated electronic alarms hold promise; however, heavy reliance on these has generated alarm fatigue. Advantages include less distraction from normal hospital activity, centralization of staffing and monitoring resources, and access to and standardization of monitoring practice across multiple hospitals. Lead technicians i. Communication with nursing staff via direct mobile phone or use of a Crisis Phone for emergencies prevents delays in notification of an alarm or change, with direct communication with rapid response teams when needed.

Monitoring technician educational backgrounds commonly include cardiac arrhythmia recognition training as a Certified Cardiographic Technician or Certified Rhythm Analysis Technician. While promising, central monitoring outcomes and feasibility have not yet been published. This can reduce frequency of unnecessary transfers and thus decrease hospital cost. Immediate response to emergencies can be facilitated, for example, when a physician is not at the bedside. The decentralized version is a more personal way of being connected to the remote computers via an outside Internet connection.

For example, a patient in circulatory shock can receive immediate interpretation of bedside telemetry and echocardiogram. In addition, no worrying signs or symptoms were observed during training, nor it was necessary to stop rehabilitation urgently in any patient. If you have a hairy chest, he or she may shave some hair off to attach the electrodes firmly.


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Once the electrodes are in place, the technician helps you put the Holter monitor on and explains how to take care of it. You can carry the monitor in a pocket or pouch, slung across your shoulders and neck like a purse or camera, or attach it to your waist. Stay away from high-voltage areas, metal detectors or large magnets. The technician will show you how to keep a diary of your activities and symptoms during the test. If you feel symptoms such as chest pain, shortness of breath, uneven heartbeats or dizziness, note in your diary the time of day they began and what you were doing.

Your diary will be compared to the changes in your ECG recorded by the Holter monitor. What happens after wearing a Holter monitor? How can I learn more about Holter monitors? Talk with your doctor. Here are some good questions to ask: How long do I need to wear the monitor? What will the results tell you about my heart? What other tests or treatments might I need when this test is over? Last Reviewed: Jul 31,