Holter Monitoring
Dr. KAZI ALAM NOWAZ
MD FINAL PART STUDENT CARDIOLOGY
NHFH & RI
WHAT IS HOLTER
MONITOR?
• A Holter monitor is a small, wearable device
that keeps track of heart rhythm.
• A Holter monitor uses electrodes and a
recording device to track heart's rhythm for
24 to 72 hours.
• Holter monitor testing is also sometimes
called ambulatory electrocardiograph
THE EVOLUTION OF OUTPATIENT
AMBULATORY CARDIAC MONITORING
• Dr. Norman Holter introduced portable
devices to record the ECG in 1957
Different types of ambulatory
electrocardiogram monitoring
• Holter monitors
• Event monitors
• Ambulatory real-time cardiac monitors
• Adhesive patch electrocardiographic monitors
• Implantable loop recorders
ACC/AHA Guidelines for
Ambulatory Electrocardiography
CLASS I
• Patients with unexplained syncope, near syncope,
or episodic dizziness in whom the cause is not
obvious
• Patients with unexplained recurrent palpitations
• To assess antiarrhythmic drug response in
individuals with well-characterized arrhythmias
• To aid in the evaluation of pacemaker and ICD
function and guide pharmacologic therapy in
patients receiving frequent ICD therapy
HOW HOLTER MONITOR WORKS?
• The Holter monitor is small. It’s
slightly larger than a deck of
playing cards.
• Several leads, or wires, are
attached to the monitor. The
leads connect to electrodes
that are placed on the skin of
chest with a glue-like gel.
• The metal electrodes conduct
heart’s activity through the
wires and into the Holter
monitor, where it’s recorded.
HOLTER MONITOR
Uses:
– Patients experiencing daily symptoms
– Precise quantification of arrhythmias
Advantages:
– 24-48 hours full disclosure available
– Heart rate and AF burden graphs
– Arrhythmia counts (ex., 10 PVCs per
hour)
HOLTER MONITOR
Disadvantages:
– 24 -48 hour-short duration
– Artifact may not be discovered until test
analyzed
Diagnostic yields:
– Yields low for intermittent symptoms or
syncope: <5% to 13%. Chest 1980;78:456-461.
Patient preparation
• Prepare Skin for the Electrodes: Proper preparation of the areas of
the chest where the electrodes will attach is essential for good ECG
recordings.
• Always Wear the Monitor: Patient have to wear the monitor and
keep it turned on 24 hours a day, every day, for the entire length of
prescribed procedure, during all normal daily activities except those
that involve water. Do not get any part of the monitor wet.
• Record Activities in a Diary: This will help to understand the
activities surrounding the arrhythmia, which can lead to a diagnosis
on what causes them.
• Avoid Things that Create Interference: This includes magnets,
microwaves, electric blankets, cell phones, and MP3 players.
• Follow Instructions: It’s very important to follow the instructions
provided in the monitor ’s user guide.
Findings we look
• Heart rate histogram
• Bradycardia events
• Ectopic beat / episode counter:
narrow complex, broad complex premature beats,
couplets, triplets, VT, SVT episodes, Pauses
• ST T changes
• QTc QT analysis
• Heart rate variability
• Rhythm strips
• Sleep apnea 24 hour trend
Holter ECG Report Summary
■ It has six (6) boxes of data summaries. The
first box is Heart Rate data.
■ The 2nd box is for ventricular ectopic (VE)
beats. VE beats in excess of 10 per hour, VE
Pair, V-Runs, and R on T beats are worrisome.
■ The 3rd box is for Heart Rate Variability (HRV).
An SDNN of 50 or less is cause for concern.
■ Next is ST. Delta ST depressions of 1mm or
more are worrisome.
■ Next are SVE’s (atrial ectopics). SV-Runs and
A-Fib are worrisome.
■ Next are Bradycardia events. Pauses in
excess of 2.5 seconds are problems. This is
followed by QT summaries. QTc in excess of
460 ms can lead to problems.
■ Mini-ECG strips give a general impression.
* DM Software 11
24-Hour Trends Report
■ This is the 2nd page to the basic Holter ECG
Report. It shows 24-hour trends of Heart Rate,
ST, HRV-SDNN, HRV-Power, VE beats, and SVE
beats.
■ The bottom half shows the hourly counts for heart
rate, arrhythmias, pauses, and ST.
■ The top HR graph shows the max-avg-min HR for
each minute during the 24-hour Holter ECG. The
max and min HR ECG is shown to the right.
■ The next trend is the ST segment. If an ST was
more than 1mm, the max ST is shown to the right.
■ The next 2 trends are Heart Rate Variability
trends. They are SDNN and Total Power. The
SDNN should be above 50, and the Power should
be above 800.
■ The next 2 trends are VE and SVE arrhythmias
per hour. VE beats in excess of 10/hour, VE
Pairs, and V-Runs may warrant action. The same
may apply to SV-Runs and A-Fib minutes.
* DM Software 12
Arrhythmias that are not necessarily
pathologic.
• Sinus bradycardia during rest or sleep
• Sinus arrhythmia with pauses less than 2.5
seconds
• Sinoatrial exit block
• Wenckebach atrioventricular (AV) block
• Wandering atrial pacemaker
• Junctional escape complexes
• Premature atrial or ventricular complexes.
Arrhythmias that are warning
• Frequent and complex atrial and ventricular
rhythm disturbances
• Second-degree AV block type II
• Third-degree AV block
• Sinus pauses longer than 2.5 seconds
• Marked bradycardia during waking hours
• Tachyarrhythmias
What is the role of holter monitoring
in patients with
known ischemic heart disease?
• In the post–myocardial infarction patient, the
occurrence of frequent PVCs (more than 10
per hour) and nonsustained ventricular
tachycardia (VT) by 24-hour monitoring is
associated with a 1.5- to 2.0-fold increase in
death during the 2- to 5-year follow-up
independent of LV function.
Diagnosis of suspected ischemic heart
disease?
• Transient ST-segment depression 0.1 mV or
greater for more than 30 seconds is rare in
normal subjects and correlates strongly with
myocardial perfusion scans that show regional
ischemia.
• Although some monitors can detect and
quantify ST-segment changes
Role of holter monitoring in stroke
• Approximately 25% of stroke remains
unexplained after a thorough clinical
evaluation and is labeled as cryptogenic
• Occult atrial fibrillation is identified by
ambulatory monitoring in approximately, 3%
to 8% of patients with cryptogenic stroke
Pacemaker
• The Pacemaker report shows the
following:
* Paced Beat Total
* Intrinsic Beat Total
* % Paced
* % Intrinsic
Pacemaker Failures:
* Failures to Capture
* Failures to Sense
* Beats < Lower HR Limit
* Beats > Upper HR Limit
* R-R Intervals > 1.5 seconds
Arrhythmia analysis for VE and SVE beats
is performed on Intrinsic (normal) beats.
The arrhythmia analysis includes VE Pairs,
V-Runs, and SV-Runs.
All reported “Pacemaker Failures” should
be immediately evaluated by a
cardiologist.
THANKS TO ALL
