Medmastery_Holter Monitoring Essentials Handbook

HOLTER MONITORING
ESSENTIALS
HANDBOOK
Cara Mercer, BSc (Hons)

Table of contents
Abbreviation list 3
Planning a Holter monitor

Introducing Holter monitoring 5
Choosing between monitoring options 8
Recognizing the clinical indications 12
Taking a patient-centered approach 16
Requesting a Holter monitor 18
Putting it into practice (case examples) 20
Performing a Holter monitor

Explaining the Holter monitor to your patient 25
Optimizing the recording 28
Keeping a symptom diary 31
Returning the Holter monitor 34
Interpreting the results

Analyzing a Holter monitor recording 41
Reviewing the ECG 43
Making sense of common findings 52
Avoiding pitfalls 57
Writing a Holter monitor report 61
Appendix
Reference list 71
Become an expert at www.medmastery.com. 2

Abbreviation list
AF atrial fibrillation
AV atrioventricular
bpm beats per minute
ECG electrocardiogram
HCM hypertrophic cardiomyopathy
PAC premature atrial complexes or contractions
PAF paroxysmal atrial fibrillation
PVC premature ventricular complexes or contractions
VT ventricular tachycardia

Chapter 1
PLANNING A HOLTER
MONITOR
www.medmastery.com
Introducing Holter monitoring
The standard 12-lead electrocardiogram (ECG) is an invaluable diagnostic tool.
However, it does have its limitations:
• It can only provide a brief snapshot of the patient’s heart rhythm.
This means that for arrythmias that occur intermittently, patients will need a
monitor that can be used over a longer period of time.
• It requires patients to remain still in order to obtain a clear reading.
For patients who require continuous cardiac monitoring, a different type of

monitor is needed. This is where Holter monitoring can be particularly useful.
Parts of a Holter monitor

Typically, a Holter monitor has three principal components:
1. The main device itself

The main device contains all the electronics required to make the recording.
Historically, Holter monitors stored the ECG data on a cassette tape, so the test
is sometimes still referred to as a 24-hour tape. However, modern recorders use
solid-state hardware without any moving parts to store data on a memory card.
The main device usually has one or more buttons that allow the patient limited
interaction. For instance, there will likely be a button allowing patients to
highlight whenever they experience symptoms during the recording. The device
will also contain a power source such as rechargeable or changeable batteries.
2. Electrodes that attach the device to the patient

Most monitors will have three or four electrodes but the number can vary
depending upon the type.
3. Adhesive pads that attach the electrodes to the patient’s skin

Good attachment of the electrodes to the patient is essential for a high-quality
ECG recording, as suboptimal attachment is likely to introduce electrical noise
and cause artifacts. The sticky pads that attach the electrodes to the patient’s

skin are self-adhesive and generally hypo-allergenic because wearing the
monitor for a prolonged period can cause skin irritation.
Prepping the skin

Good skin preparation is important prior to attaching the self-adhesive pads.
Let’s go over the steps.
1. Remove chest hair

Start with removing any chest hair in the regions of electrode placement.
2. Clean and prepare the skin

Use an alcohol wipe to clean the skin, followed by a mildly abrasive pad to
optimize contact. The self-adhesive pads connect to the electrodes themselves,
so ensure that the attachment is secure.
Tracking activity
The electrodes are long enough to allow the patient to wear the Holter monitor
around their waist or neck while having sufficient flexibility for the patient to
continue with their usual activities.
It’s a common misconception that patients need to sit still and not perform any
activities while wearing the Holter monitor. In fact, we want patients to go about
their lives as normal to get an overview of how their heart rhythm behaves during
a typical day. It’s important to explain this to patients while they are having the
monitor fitted so that they understand what is expected of them.

It’s fine for patients to exercise, go to work, and undertake the rest of their usual
daily activities during the recording. However, when it comes to analyzing the
recording subsequently, it’s helpful to know what patients were doing during
the recording.
For instance, a sinus tachycardia will have different clinical implications

depending upon whether it occurred during exercise or while the patient was
resting. For this reason, a symptom diary is essential.
Symptom diary
As the name suggests, the symptom diary allows the patient to make a note
of any relevant symptoms that may occur during the recording and to note the
precise time at which the symptoms occurred. This allows the ECG findings to
be put into a clinical context during subsequent analysis.
The diary also allows patients to record their activities, such as exercising or
resting, and their waking and sleeping hours. This can be extremely helpful when
trying to interpret episodes of tachycardia or bradycardia, and when deciding
upon their likely clinical significance.
Analyzing the findings

Once a Holter recording has been returned by a patient, it needs to be analyzed
and a report written for the referring clinician.
Although Holter analysis software will automatically analyze the recording and
flag issues, it’s not perfect. Therefore, it is still important for the recordings to
be reviewed. This way, the findings can be categorized under a clinical context.
Based on the symptom diary, we can then decide on the urgency of the findings.
We will be discussing Holter monitor reports and all other aspects of Holter
monitoring in more detail in the remainder of the course.
Return to table of contents

Choosing between monitoring options
Although a 12-lead ECG can be invaluable for the diagnosis of arrhythmias, it will
only provide you with a diagnosis if the arrhythmia is present at the moment of
the recording. This isn’t a problem for persistent arrhythmias, such as persistent
atrial fibrillation. But it does pose a major challenge for intermittent arrhythmias,
such as paroxysmal atrial fibrillation (PAF).
Ambulatory recording of a patient’s ECG is often necessary to capture

intermittent arrythmias when they occur and to allow such arrythmias to be
correlated with the patient’s symptoms. In this lesson, we’ll learn about the
different options you have for recording.
How to choose the right monitor

There is no shortage of recording options available, each with its own set
of advantages and disadvantages. One of the key factors when choosing
the best form of ambulatory ECG monitoring is how frequently the patient’s
symptoms occur.
For example, a short-term monitor such as a 24-hour or 48-hour Holter

recording is much better suited to frequent symptoms than to infrequent events
that may only happen once in a month. If the patient’s symptoms only occur
once or twice over a month, either an event recorder or an invasive monitor such
as an insertable cardiac monitor would be more appropriate.
Let’s go through a few of the monitoring options.
Short-term Holter monitors

There are three key advantages to using a Holter monitor:
1. Non-invasive
2. Relatively simple and inexpensive to use
3. Provides continuous monitoring

Continuous monitoring is a great advantage. This way, even if the patient has
asymptomatic episodes, the monitor will still record the event.
Length of use
Although Holter monitors are typically worn for
24–48 hours, many can be worn for several days
if required. Anything beyond a week is likely to
be problematic due to both the limited storage
capacity of the device and some irritation the
patient might experience from the prolonged use
of the adhesive electrodes. < 1 week
(24–48 hours typically)
Patient event recorders

One benefit of patient event recorders is that they, like Holter monitors, are a
non-invasive option. However, they do have a list of cons:
1. Patient event recorders cannot record the ECG continuously

Instead, they allow the patient to make recordings on demand as symptoms
occur. While this is fine for most symptomatic arrythmias, it’s not an option
for detecting asymptomatic ones.
2. Their use may be impractical for some patients

Using an event recorder may be impractical for a patient with dementia, arthritis,
or a symptomatic arrythmia that causes incapacitation such as syncope.
3. Results may vary

The quality of the ECG recording also depends upon the patient’s use of the
event recorder, meaning the results may be varied.
Nonetheless, event recorders can be carried indefinitely, so they provide a useful

option for patients with infrequent symptomatic events.
Smartphone-compatible devices
Newer technologies include devices that work alongside smartphones, allowing
patients to record their ECG on demand. Like with event recorders, these can be

very effective for capturing infrequent symptomatic events, but they share the
disadvantages of event recorders that we have just discussed.
The Apple Watch is an example of a device that can be worn for a long period of
time, except for when it’s being charged. It can provide screening for asympto
matic events as well as facilitate the recording of an ECG rhythm strip on demand.
The caveat to these devices is that there can be false-positive detections and,
although useful in some scenarios, they need to be used with caution.
Insertable cardiac monitors

Insertable cardiac monitors provide an option for
long-term monitoring of up to 3 years or more. Let’s
go over a few of the pros:
1. They can detect significant arrhythmias and

automatically save a recording of them.
2. They offer patients the option to activate their 3 years
recordings during symptomatic events.

3. Monitoring of the device can be done remotely, so data
can be downloaded from the device without the need for an office visit.
However, these devices are implanted subcutaneously and, therefore, require

an invasive procedure for their insertion and subsequent removal. Be sure to
consider all the procedural risks that will accompany the use of these devices.
In summary, there are many factors to consider when choosing between ECG
monitoring options:
• The planned duration of recording

• Whether you are aiming to capture symptomatic events or screen for
asymptomatic ones
• Your patient’s mental and physical competency at using the device
• Whether the risks for an invasive option are warranted

Always pay attention to these factors to ensure that you select the best
monitoring option for your patient.

Recognizing the clinical indications
There are several indications for Holter monitoring:
1. Palpitations
2. Pre-syncope and syncope
3. Routine screening for arrhythmias
4. Assessment of known arrhythmias
Let’s go over these indications in more detail.
Palpitations
Of all the indications for Holter monitoring, the assessment of palpitations is
the most common. Palpitations may result from almost any type of arrhythmia,
ranging from premature atrial complexes or contractions (PAC) to episodes of
ventricular tachycardia (VT). It’s also possible that palpitations are unrelated to
any arrythmia at all.
PAC
VT
Unrelated

Holter monitoring can play an invaluable role in symptom-rhythm correlation. In
conjunction with a symptom diary, it can establish what rhythm was occurring at
the exact moment that a patient experienced a palpitation.
When patients are found to have more than one type of arrythmia during Holter
monitoring, it’s important to establish which arrhythmia(s) may be responsible
for their palpitations and which one(s) may be unrelated in order to ensure that
treatment is targeted appropriately.
Pre-syncope and syncope

Pre-syncope and syncope are other common reasons for Holter monitoring. It is
essential that patients precisely record their symptoms and the timing of them
in the symptom diary so that the relevant portions of the ECG can be scrutinized.
Pre-syncope and syncope can result from both bradycardia (e.g., complete heart
block or pauses) and some episodes of tachycardia (e.g., ventricular tachycardia).
Bradycardia
Tachycardia
Pre-syncope and syncope can also have non-arrhythmogenic origins such

as epilepsy or vasodepressor syncope. In such cases, it can be diagnostically
useful to confirm that the ECG is, in fact, normal during the symptomatic event.
Of course, in this case, non-arrhythmogenic causes need to be considered.

Routine screening for arrhythmias
Holter monitoring is used for screening purposes in certain asymptomatic
conditions such as hypertrophic cardiomyopathy (HCM). Patients with
HCM have an increased risk of experiencing both atrial fibrillation and
ventricular tachycardia.
Here are the key guidelines for arrhythmia screening in patients with HCM:
• 24–48 hour ambulatory ECG monitoring

• Every 1–2 years
Atrial fibrillation
Holter monitoring plays an important role in screening for episodes of atrial
fibrillation. It’s important to remember that it will only detect episodes that occur
during the recording period. This means there is a chance of missing paroxysmal
atrial fibrillation in patients where such events only occur infrequently.
Atrial fibrillation
Atrial fibrillation screening is important in patients who have suffered an embolic

stroke because it has important implications for decisions about anticoagulation.
Assessment of known arrhythmias

Holter monitoring can also be useful in the assessment of known arrhythmias.
For instance, it can help determine whether drug treatment is proving effective.
For example, the medication could be suppressing paroxysmal arrhythmias or
providing ventricular rate control in atrial fibrillation.

Holter monitoring can also show whether there has been a reduction in arrythmia
frequency following an electrophysiological ablation procedure.
In summary, there are many different indications for Holter monitoring. Therefore,
there are many ways this test can help you to make diagnoses and guide you in
treatment decisions.

Taking a patient-centered approach
In this lesson, we’ll discuss the patient factors you should consider when
adapting the monitoring test to suit the patient.
Listening to the patient’s symptoms

The most important factor to think about before deciding what type of monitoring
to consider is the patient’s symptoms:
• How often do the symptoms occur?

• How long do they last?
• Does the patient experience syncope with or without warning?
Initially, the answer to these questions should guide you toward determining the
length of time needed for the Holter recording or patient event recording.
Deciding upon the use of a patient diary

Let’s discuss the patient diary. The patient diary can cause patients unease and
confusion but it is an important tool, and we can use it to assess the patient’s
candidacy for the Holter device.

For example, consider the following when deciding whether to use a patient diary:
• Is the patient physically capable of writing in or reading the diary?

• Do they have physical limitations preventing them from doing either task?
• Is the problem cognitive in nature?
Most Holter monitors have a symptom activation button that can be pressed to
flag a symptomatic episode. This option could be preferable with patients who
are struggling to use the diary.
Assessing cognitive competency

It’s important to consider the patient’s cognitive competency. Do they
understand why they need to have the test? This information is valuable because
it establishes whether a patient advocate may be necessary.
For example, if a patient has dementia, they may need to be governed by an

advocate in order to use the device appropriately. Consider the following:
• Does dementia inhibit the patient from being able to articulate their
symptoms and frequency?
• Even with assistance, will they be able to keep the monitor on for a prolonged
period of time?
Each device will pose unique challenges for patients. However, every test can be
adapted to suit the patients’ individual needs. Once you have fully assessed your
patient, you will be able to successfully adapt the Holter recording to the patient
and their unique needs and abilities to maximize the efficacy of the test.

Requesting a Holter monitor
Once the patient has been assessed for symptoms, duration, and frequency and
we have decided what type of monitor and duration to use, we should consider
what information to include on the request form. We need to be concise about
what we’re looking for and hoping to achieve.
Here are four things to consider including on the request form:
1. Clinical question
Be clear and intentional about the answer you are seeking. For example, are
you ruling out atrial fibrillation or ectopic beats? What is the length of the
episodes? Are they brief or prolonged? What is your clinical suspicion, and
how can you adapt your assessment plan to cater to the specific condition
you are evaluating for?
2. Frequency of symptoms
How often is the patient experiencing symptoms? Is it daily, every couple of
days, or perhaps once a week? The answer to this question will establish the
duration of the monitoring period.
3. Medications
Medications are a commonly overlooked variable. Specifically cardiac
medications such as beta-blockers, calcium channel blockers, or digoxin.
These medications will affect the patient’s results.
If the technician analyzing the monitor isn’t privy to this information, they
might mistake normal results for concerning findings. For example, if a
patient is using beta-blockers, their resting heart rate will normally be slow.
But if the technician does not know they are using a medication, they might
report that the patient is abnormally bradycardic.
4. Special considerations
Every patient will have specific needs, so evaluate how those will influence
your plan of care. If the patient is hard of hearing, they will need a patient

advocate to help them understand the test. If the patient has allergies, they
may not be able to tolerate the electrodes.
Knowing these extra details will help the technician adapt the monitor to fit the
needs of the patient while still obtaining accurate recordings.
In summary, there are four pieces of information to include in your assessment

that will greatly benefit the technician in their analysis of the Holter exam: clinical
question, frequency of symptoms, medications, and special considerations. As
we have learned in this Medmastery course so far, these details are the key to
obtaining the best results from the test.

Putting it into practice (case examples)
Let’s see what we have learned in this chapter by looking at some typical cases.
Case 1: 46-year-old male with episodic palpitations

Our first case involves a 46-year-old male who presented with episodic
palpitations occurring about once a month. He describes the palpitations as fast
and irregular, and each episode lasts for 1–2 hours.
What do you think would be the most appropriate form of ECG monitoring to
obtain a diagnosis?
His physician has requested a 24-hour Holter monitor. Unsurprisingly, the

recording did not capture any symptomatic events. His physician then repeated
the Holter, and when that did not capture anything either, he repeated the Holter
a third time. The patient became frustrated without any diagnosis after having
several monitors.
For patients experiencing infrequent symptoms, a 24-hour Holter monitor is

ineffective. The probability of catching an event that only occurs once a month
is roughly 1 in 30. Therefore, a formal diagnosis is unlikely if you are using a
screening period where it’s unlikely you will record an episode.
This patient provides an opportunity to use a patient event recorder device such
as a cardiomemo recorder, which can be used for a month. This way the patient

could conveniently record episodes on demand so that we can capture an ECG
during a symptomatic episode.
After three fruitless Holter monitor recordings, our patient was eventually issued
a cardiomemo device and received a diagnosis of paroxysmal atrial fibrillation.
Paroxysmal atrial fibrillation
Case 2: 28-year-old male with hypertrophic

cardiomyopathy
Our next patient is a 28-year-old male who has been diagnosed with HCM after
family screening. He is entirely asymptomatic.
Is there any role for Holter monitoring in his case?
The answer is yes. There is an indication for Holter monitoring. Hypertrophic

cardiomyopathy is commonly associated with a risk of arrhythmias.
Atrial fibrillation, with its associated stroke risk, is the most common arrhythmia
seen in HCM, with an annual incidence of around 3%. In addition, asymptomatic
non-sustained ventricular tachycardia is also common, being detected in 25% of
adults with HCM.

The 2014 guidelines on HCM from the European Society of Cardiology
recommend a 48-hour ambulatory ECG in the initial clinical assessment. The
goal here is to detect atrial and ventricular arrhythmias and assess the risk of
stroke and / or sudden cardiac death. Holter monitoring is the most ideal way to
achieve this goal.
Atrial arrhythmia
Ventricular arrhythmia
It’s important to be aware of all the clinical indications for Holter monitoring,
which can include patients with no symptoms whatsoever.
Case 3: 65-year-old female with dizzy spells

This case involves a 65-year-old female who was referred for a Holter monitor to
investigate dizzy spells that were occurring daily.
This appeared to be a reasonable indication for Holter monitoring, so the monitor

was fitted and the patient went home.

Unfortunately, the patient returned early the following day with a skin rash
affecting much of her chest, especially where the ECG electrodes had been
applied. The patient had told her doctor about a previous allergy to adhesives,
but the doctor had not mentioned this in the request form. Therefore, the patient
was very unhappy about her allergic reaction.
This case illustrates how important it is to provide all the relevant clinical
information when filling out a request for a Holter monitor, including whether
the patient has any relevant allergies and whether they will need special
considerations or assistance in the use of their monitor.

Chapter 2
PERFORMING A
HOLTER MONITOR
www.medmastery.com
Explaining the Holter monitor to your patient
In order to maximize the chances of a high-quality diagnostic recording, patients
need to know how to use their Holter monitor. A few minutes spent with the
patient to explain the device’s key features is well worth the time and effort.
What the monitor does

To begin, explain to your patient that the Holter monitor is designed to take a
recording of their heart rhythm. If applicable, also explain that the monitor can
capture what their heart is doing at the time of any symptoms.
How long to wear it

Next, let your patient know how long they will need to wear the monitor, which is
typically 24 hours but sometimes longer. Emphasize the importance of keeping
the monitor on as much of that time as possible. If the monitor isn’t being worn,
it can’t capture the heart rhythm.
What to do if it needs to be removed

There may be periods when the Holter monitor needs to be removed (e.g., when
the patient wants to take a shower). If the monitor is only being worn for 24
hours, we would usually request that the patient refrain from showering for the
duration of the recording. For longer recordings, this is impractical, so the patient
is allowed to remove the monitor briefly. However, they will need to reattach it
once they’ve finished showering.
If patients do need to remove the monitor, or if one of the electrodes becomes

detached accidentally, then it’s important that they know how to reattach
the electrodes correctly. Be sure to explain this to your patient when you’re
attaching their monitor for the first time and make sure that they or a caregiver
understands what to do.

How to reattach the electrodes
It’s a good idea to provide clear, written instructions about how to reattach the
electrodes, as some patients may forget the instructions they were given. Make
sure you give the patient a supply of spare electrocardiogram (ECG) pads as well,
in case they need to replace the ones they were sent home wearing.
How to flag symptoms

Holter monitors require minimal interaction from patients, but they do usually
have a button that can be pressed whenever the patient experiences a relevant
symptom. This flags the timing of any such symptoms on the ECG recording
itself, making it easier to correlate symptoms with the rhythm during analysis.
Make sure your patient knows how to operate the symptom button and when it’s
appropriate to press it. This is also a good moment to explain how to fill out the
symptom diary. We’ll discuss this in more detail in lesson 3 of this chapter.
Adapting the instructions

Finally, it is sometimes necessary to adapt the explanation of the Holter monitor
for your patient (e.g., if they are hard of hearing or have a learning disability). It
may also be necessary for the patient to have an advocate present to help with
their understanding.

Always think about things from the patient’s viewpoint to make sure that the test
is truly patient-centered. Whenever possible, think about ideas for adaptations
to maximize the chance of a successful recording.

Optimizing the recording
In the previous lesson, we learned how to explain the test to your patient in order
to increase the chances of a diagnostic recording. There are also some steps
that you can take while fitting the monitor to the patient to ensure a high-quality
ECG recording.
Preparing the skin

Skin preparation is one of the most important elements of obtaining a good
quality recording. Let’s go over a few considerations for preparing the skin for
the application of electrodes:
1. Shave when possible

The skin must be free of hair whenever possible (except when prohibited by
cultural beliefs).
2. No oils or lotions
The skin needs to be free from oil or body lotion in the areas that the
electrodes are going to be applied. It is worth informing patients that they
shouldn’t apply cosmetic creams or oils to the chest area on the day of
attendance. This helps prevent the electrodes from moving and, therefore,
disrupting the recording.
3. Wipe with an alcohol wipe and a mildly abrasive pad

Before applying the sticky electrode pads, clean the skin with an alcohol
wipe and rub the surface of the skin with a mildly abrasive pad. This will
optimize electrical contact and improve the quality of the ECG recording.
4. Check the pads first

It is also important to check that the electrode pads themselves stick well to
the skin, and that their adhesive hasn’t dried during storage. Also, take the
opportunity to check the electrode cables for any signs of damage.

Optimizing electrode placement
Electrode placement is the second most important aspect of acquiring a good
recording. For optimum results, place the electrodes in the following manner:
• On the chest in areas that are unlikely to rub or catch on clothes

• Avoid sternotomy scars or irritated areas of skin
• If needed, place electrodes slightly off-center from where they are technically
supposed to be (e.g., to avoid scars or if the patient’s skin becomes slightly
irritated during the recording)
• On the rib cage rather than breast tissue in female patients to avoid artifact
and baseline wander on the recording (which can happen when breast tissue
moves and the electrodes move, such as when putting on a bra)
Avoiding electrode removal or device tampering

Patients should not try to remove the electrodes once fitted and should not
scratch around the area. The device should not be tampered with. As stated
previously, the patient should try to refrain from showering as the equipment is
not waterproof.
If a recording period of longer than 24 hours is required, then extra electrodes

may be provided so that the patient can shower and reattach the electrodes.
Below are ECG examples showing how the Holter recording can look due to
poor skin preparation or the patient interacting with the electrodes. There may

be excessive noise and the recording may be broken in areas, thus inhibiting
accurate analysis. When electrodes fall off altogether, the ECG can masquerade
as asystole. With careful preparation, this kind of artifact can be avoided.
Excessive noise
Electrodes falling off

Keeping a symptom diary
The symptom diary is an essential component of the Holter recording. It is very
important that patients use the diary to accurately record their activities and any
symptomatic episodes. Providing your patients with a clear explanation of how
to fill out their diary is the key to getting the best results from the test.
Types of symptoms to include

Generally, we are looking for symptoms such as palpitations, dizziness, or syncope.
In the case of syncope, the patient may not be able to fill in the diary. However,
they may be able to activate the device just before the episode. Keep this in mind
when requesting or issuing the Holter monitor so the instructions can be tailored
to your patient.
What we are looking for is the symptom-rhythm correlation, which may or may
not be associated with a cardiac arrhythmia. There are an array of symptoms
that could be unrelated to the original problem. So, the patient should receive an
explanation about the types of symptoms that are considered relevant when the
Holter monitor is issued.
One of the biggest problems when trying to analyze a Holter recording is the
overwhelming amount of detail in the patient diary. If not explained properly, the

diary can contain many symptoms that are unrelated to the original problem,
making it difficult to accurately assess symptom-rhythm correlation.
Cardiac medications
As mentioned previously, medication is also a key point in the symptom diary.
The patient must note any cardiac medication they take.
For instance, rate-limiting medications may cause bradycardia. Digoxin may

change the appearance of the ST segment, especially during exercise. It is
important that the medication is documented correctly. For example, it would be
optimal for the patient to write bisoprolol rather than the little white tablet.
Periods of rest and exercise

During the recording, patients are encouraged to go about their daily activities.
Some might have the misconception they must sit still and do nothing while
wearing the monitor. This is not the case. Patients are encouraged to do what
they would do normally including resting and exercising.
However, it is important to note that they should document when they are resting
and exercising. We would not normally expect someone to be tachycardic at rest.
However, if it happens during a period when they documented that they were
exercising, then it can be considered normal.
Sometimes, symptoms occur both on exertion and during day-to-day activities.

This is why it is important that the patient be encouraged to continue with
normal day-to-day tasks so that you can decipher the triggers of an episode.
Sleeping and waking hours

The diary also needs to include a record of the patient’s sleeping hours. This
entails what time they went to bed and what time they got up. Heart rate can
vary between waking and sleeping hours. Therefore, it is important for these to
be documented.

This documentation is especially important if the person works night shifts. If
the patient works overnight, their awake hours might be different than what you
would expect.
In summary, a good-quality patient diary is a crucial aspect of Holter monitoring.

Returning the Holter monitor
When you issue a patient with a Holter monitor, it’s important to think ahead
about the device’s return. The patient needs to know when to bring the device
back and where to return it to.
Some centers instruct the patient to attend the hospital again so that the monitor
can be removed by the technician. Others instruct the patient to remove the
Holter themselves and simply bring the device back to the department. Whatever
your preference, make sure your patient receives clear instructions about what
you want them to do.
As well as returning the Holter monitor, patients must also return their symptom
diary. Make sure they know to bring the diary back at the same time as the device.
Patients will understandably be anxious to hear the results of their Holter

recording. Therefore, it’s a good idea to let them know how long the analysis is
likely to take and how they will receive details of the results.
Cleaning and storing the monitor

Once the Holter monitor has been returned, it should be cleaned thoroughly
with a suitable disinfectant wipe, including both the unit and the cables. While
cleaning the device, check all the components carefully for any signs of damage
(e.g., the outer sheath of the electrodes splitting or fraying or any clear fracture
points along the cable).

The device’s data card and patient diary should be stored until the data is ready
to be downloaded and analyzed. Make sure that everything is clearly labeled
with the patient’s details to avoid errors.
The batteries should be removed and safely disposed of or recycled. Remember

that new batteries will be required before the device is issued to the next patient.
When the new batteries are inserted, the device clock should be checked to
ensure it is accurately set and ready for use.

So far in this chapter, we have learned about the importance of providing a
clear explanation of the Holter monitor to the patient, good skin preparation and
electrode placement, and the value of the symptom diary.
In the symptom diary there are important details you’ll want your patient to add:
• Accurate documentation of symptoms

• Medication details
• Exercise and resting periods
• Waking and sleeping hours
•
Let’s take a look at a couple of case examples to see how these things are
handled in practice.
Case 1: 40-year-old female with episodic dizzy spells

For this case, the patient is a 40-year-old female who presented with episodic
dizzy spells occurring several times each day. She describes the palpitations as
fast and irregular, and each episode lasts for 1–2 hours.
What do you think would be the most appropriate form of ECG monitoring to
obtain a diagnosis?

The patient documents frequent dizzy spells during the day with sinus
bradycardia noted throughout the recording. Episodes of nocturnal heart block
are noted intermittently.
Sinus bradycardia
Nocturnal heart block
The technician reported these findings to the doctor who then discussed the
results of the Holter recording with the pacing team. It was decided that the
patient would benefit from a pacemaker.
The patient was admitted for the procedure and her medication was checked. It
was discovered that the patient was on beta-blockers and had recently had the
dose increased. This medication had not been noted in the diary.
The procedure was canceled and the medication dose was reduced with a
resolution of the patient’s symptoms. The Holter monitor was repeated and
there were no episodes of bradycardia or heart block.
Why do you think this misunderstanding happened?
The symptom diary is a crucial component of a Holter recording and needs

to include not only the patient’s symptoms but also a record of the patient’s

activities, their bedtime and waking times, and, crucially in this case, a record of
all the medication they were taking at the time of the recording.
Case 2: 65-year-old male with palpitations

A Holter monitor is applied to a 65-year-old male who is suffering from palpitations.
A 12-lead ECG has already demonstrated sinus rhythm with isolated ventricular
ectopic beats.
Sinus rhythm with isolated ventricular ectopic beats
What we want to know from the Holter is:
1. Does the patient’s palpitations correspond to the ectopic beats, or is there

some other arrhythmia occurring?
2. How frequent are these ventricular ectopic beats?

Once the Holter monitor is returned, we discover that the recording is seriously
degraded by artifact. It is difficult to analyze accurately and it is not possible to
assess the frequency of ventricular ectopic beats.
In other words, the ECG during symptomatic episodes is uninterpretable. The

automated analysis software has erroneously flagged episodes of ventricular
tachycardia (VT), which on closer inspection are just artifact.
What has happened here is that skin preparation prior to the Holter application
was poor. The patient was not shaved and the electrodes were not making good
contact with the skin. The recording was marred with artifact.
It was almost impossible to tell what the ECG was showing when the patient
had symptoms, and the analyzer software provided a false detection of VT. The
Holter recording is essentially nondiagnostic, as it has failed to answer both of
the clinical questions that were asked.
The patient was understandably angry about this as the recording had been a
waste of time and needed to be repeated.
These examples show the importance of thoughtfully performing Holter

recordings, and in particular the value of a good symptom diary and the need
to optimize the quality of the ECG recording itself. By paying careful attention
to how your Holter recordings are performed, you can maximize the diagnostic
yield of the test and provide the best possible service for your patients.

Chapter 3
INTERPRETING THE
RESULTS
www.medmastery.com
Analyzing a Holter monitor recording
Performing a high-quality recording is only half the task of Holter monitoring. The
second half is analyzing the recording—reviewing the electrocardiogram (ECG)
and extracting relevant data to identify any clinically-relevant concerns as well
as providing an answer, where possible, for the clinical question posed by the
referring clinician.
Start by considering the clinical question

Every Holter recording begins with a clinical question. This might be a question
about the underlying diagnosis in a patient with episodic symptoms, such as
palpitations or syncope. Perhaps it is whether a patient who is at high risk of
arrhythmias (such as someone with hypertrophic cardiomyopathy) is actually
experiencing those arrhythmias. Or maybe it is whether a patient is responding to
treatment, such as a patient with atrial fibrillation (AF) who has been started on
rate-limiting medication.
Before you analyze the Holter recording, make sure you know what the original
clinical question was. That will guide you as to which aspects of the recording
you need to focus on.
In the subsequent lessons in this chapter, we’re going to look at how to review a
Holter recording with an analyzer, and how to do so in a structured manner. We’ll

also take a closer look at some of the arrhythmias you’ll encounter commonly
during Holter analysis, and we’ll discuss their clinical significance.
Holter analysis is prone to pitfalls. So, we’ll take a look at some of the common
issues you’re likely to encounter. We’ll discuss how to recognize pitfalls such as
artifact, and how to avoid them.
We’ll also take a look at how to write a high-quality Holter report. We’ll discuss
what information you need to include, and how to structure the report so that it’s
clear and concise. Finally, we’ll round things off by taking a look at some typical
case examples.
Are you ready? Then let’s get started with the next lesson!

Reviewing the ECG
When it comes to downloading and analyzing the ECG, it is best to take a
structured, step-by-step approach.
Many modern Holter analysis systems will auto-analyze the recording as it

is downloaded. They also have a variety of functions to help you review the
recording, such as start, stop, and pause functions. These allow you to play back
selected portions of the ECG.
You can also zoom in and zoom out on selected ECG strips and you can choose
to run the strip at different speeds. All of these functions are there to assist you;
however, ultimately you are the operator.
So where do we start? Firstly, we begin with the symptom diary.
Adding symptom events

Most analysis systems will let you add symptom events onto the recordings so
there is a clear time when the patient had a symptom. This is the first step.
Knowing a patient had a symptomatic episode is the most important factor

before we start reviewing the recording. Once you have entered any symptomatic
episodes, you are ready to start running the recording.

Holter software will often highlight beats which it thinks are abnormal.
Generally, a Holter system will decide beats are normal by assessing their
amplitude, width, and duration.
The software will create a normal template, and if a beat does not match the
normal template, the software will identify that beat as abnormal or an arrhythmia.

The single most important aspect when reviewing
the ECG is to note what the analyzer is showing
while looking at the ECG for yourself as it runs. The
analyzer is there to help guide you; it is not there to
report the recording on its own.
Pacemaker misinterpretation
Initial considerations
So, at the start of the Holter recording, consider the following:
1. What is the patient’s baseline rhythm that you see?

Is it normal sinus rhythm? Atrial fibrillation? Is there a bundle branch block
morphology or is the QRS width normal? It will be important as you review the
ECG to note any initial abnormalities.
Normal sinus rhythm

Atrial fibrillation
2. Do the waves and intervals have normal durations?

This is also important to identify at the start of the recording. Is the PR
interval normal? Are the QRS duration and the QT interval normal?
3. Are there any baseline abnormalities evident?

For example, do you see the delta wave and short PR interval of
Wolff‑Parkinson-White syndrome?

Analyzing episodes of tachycardia or bradycardia
Once we’ve established the initial baseline rhythm, we go on to look for any
episodes of tachycardia or bradycardia that we may want to assess in more detail.
Tachycardia
Bradycardia
During these episodes, examine the following:
1. Is the rhythm still sinus?

Or is there evidence of atrial or ventricular arrhythmias, or any evidence of
atrioventricular (AV) block?
Arrhythmia
AV block

2. What was the patient doing at the time?
Is the rhythm appropriate for the context, such as sinus tachycardia when
exercising or sinus bradycardia while sleeping?
Sinus tachycardia
Sinus bradycardia
3. Are there any pauses during review?

Did these pauses occur during daytime hours or nocturnally? Are they sinus
pauses or is there AV block?
Sinus pauses
4. Was the patient symptomatic to a pause and, if so, for how long?
Generally, most cardiac electrophysiologists consider 6 seconds as diagnostic
and in the context of AV block rather than sinus pauses. If it is a young patient,
you should consider that they might simply have a high vagal tone.
5. Do you see any premature complexes, either atrial or ventricular?

When you see premature beats, you need to identify whether they are coming
from the atria or the ventricles.

Atrial premature complex
Ventricular premature complex
As well as identifying the origin of premature complexes, we also want to

know how many there were during the recording, and whether the patient was
symptomatic to them. The analyzer software will normally count the total number
of premature complexes, both atrial and ventricular, and provide you with the
absolute number of each.
The software will also provide the proportion of total heartbeats that they account
for, expressed as a percentage. This is the overall burden. However, it’s important
to ensure that the software is identifying premature beats correctly, otherwise the
automated data will be misleading.
premature complexes
Overall burden = x 100
total heartbeats
6. Are the premature ventricular complexes unifocal or multifocal?

If a recording demonstrates frequent premature ventricular complexes or
contractions (PVCs), it is important that the reviewer states whether they are
unifocal or multifocal. Unifocal PVCs are coming from the same focus and if
the patient is symptomatic to these, ablation can be considered. Ablation is
technically more challenging when the PVCs are coming from different areas.
Unifocal
Multifocal
7. Are there any arrhythmias demonstrated such as supraventricular

tachycardia?
From a diagnostic perspective, it is important to state whether the tachycardia
is of abrupt or gradual onset, and also how the rhythm terminates.
8. How long do episodes of paroxysmal atrial arrhythmias last?
Supraventricular tachycardia
If there are episodes of paroxysmal atrial arrhythmias such as AF or atrial

flutter, how long do the episodes last?
Paroxysmal atrial arrhythmia
9. What is the overall AF burden?

The AF burden is expressed as the percentage of the recording which the
patient spends in AF. This is important when trying to decide whether a

patient may need anticoagulation and also in monitoring their response
to treatment.
minutes of AF (in total)

AF burden = x 100
minutes of recording
So, to summarize, we have established that reviewing a Holter requires structure.
1. Assess the symptom diary. If the patient had symptoms, ensure that the ECG
findings at the time of relevant symptoms are noted.
2. Check the rhythm and beat morphology at the start of the recording and
note any baseline abnormalities. Ask yourself if they are appropriate for the
context (for example during exercise, rest, or sleep).
3. Diagnose beat morphologies and check for pauses. Don’t forget to establish
whether they are intermittent or constant. And, as always, note the frequency,
onset, and offset of each individual event as they occur.

Making sense of common findings
When you analyze a Holter recording, there are some arrhythmias you’ll
encounter commonly. Let’s take a look at some of those now.
Atrial fibrillation
The most common sustained arrhythmia we see on Holter recordings is AF.
It’s identified by its irregularly irregular character and by the absence of any
discernible repeating P wave activity.
Atrial fibrillation
In persistent AF, Holter monitoring can provide valuable information about
ventricular rate. For instance, when we want to assess the effectiveness of rate-
controlling medication such as beta-blockers.

Atrial fibrillation can also be paroxysmal. By convention, and in accordance with
published guidelines, we only label an episode as a paroxysm of AF on Holter
monitoring if it has lasted for 30 seconds or longer.
It’s important to report on any such episodes of AF that you see because
paroxysmal AF is associated with an increased risk of stroke, even when it
is asymptomatic.

What if these episodes last less than 30 seconds?
What terminology should we use for episodes that look like AF but are shorter
than 30 seconds?
Well, there’s no consensus on this. One option is to refer to such an episode as an

atrial arrhythmia without P waves and with irregular ventricular response lasting
less than 30 seconds. This description is a little cumbersome, but it conveys the
key features of the event without applying the clinical label of atrial fibrillation.
Premature ventricular complexes or contractions

PVCs are also sometimes called ventricular ectopic beats, and these are another
common finding on Holter recordings.
Premature ventricular complexes

PVCs are identified as broad QRS complexes lasting more than 120 ms and
are also identified by their abnormal morphology which varies according to
their point of origin within the ventricles. They occur prematurely (i.e., earlier
than the next normal beat would have occurred) and are usually followed by a
compensatory pause.
Unifocal or multifocal PVCs

PVCs can be described as unifocal when they all originate from the same
location and share the same morphology. They can be labeled multifocal if they
originate from different locations. Therefore, their morphology varies.
Unifocal

Multifocal
Correspond with symptoms reported

You need to report any PVCs that are associated with symptoms such as
palpitation. Therefore, it’s important to check the patient’s symptom diary to see
whether any of the PVCs correspond to events that the patient has recorded.
Report the number and frequency of PVCs

You also need to report the number and frequency of palpitations, whether
symptomatic or not. I recommend reporting the total number of PVCs seen during
the recordings. Express that value as a percentage of the total heartbeats seen.
I also report the average frequency of PVCs per hour. It’s recognized that
patients with very frequent PVCs, such as 20 000 or more during a 24-hour
Holter recording, run a risk of PVC-induced cardiomyopathy. For this reason,
you always need to report on overall PVC numbers, whether the patient is
symptomatic or not.
Ventricular tachycardia
Ventricular tachycardia (VT), a regular tachycardia with wide QRS complexes, is
another relatively common arrhythmia on Holter monitoring, particularly as a
brief incidental finding.
Ventricular tachycardia

However, VT can be associated with serious symptoms such as syncope and
may indicate a risk of sudden cardiac death. You must, therefore, always report
any episodes of VT that you see whether the patient was symptomatic or not.
Sustained or non-sustained VT
We often categorize episodes of VT as sustained or non-sustained. If an episode
lasts more than 30 seconds, it’s sustained. If it lasts less than 30 seconds, it’s
non-sustained.
Monomorphic or polymorphic VT
VT can also be described as monomorphic when all the QRS complexes have the
same shape. It can be labeled polymorphic when the shape changes from one
beat to the next.
Monomorphic
Polymorphic
Pauses
The final common finding that I’d like to highlight are pauses. These can be
caused by sinus arrest or (in which case you will see evidence of atrial activity
but no ventricular activity).
Whether they are due to sinoatrial or atrioventricular block, pauses cause a

cessation of ventricular activity for a period of time and can be associated with
dizziness and syncope. As such, it’s important to comment on the presence of

any pauses that you see and to record whether they were symptomatic, and how
long they lasted.
It’s also important to try and identify whether the pauses were due to
atrioventricular block by looking for any evidence of background atrial activity.
All of these factors will help to determine whether or not a pacemaker may
be indicated.
Pauses
In summary, there are several arrhythmias that you will commonly encounter
during the analysis of Holter recordings. It’s important to include details of
these in your reports, not only because they may be the cause of the patient’s
symptoms, but also because they can carry risks and clinical implications for
the patient even when they are asymptomatic.

Avoiding pitfalls
There are various reasons why a Holter recording may be suboptimal. This may
be due to patient preparation or Holter software problems. In this lesson, we are
going to talk about the most common pitfalls and troubleshooting.
Mislabeled artifact
As discussed in an earlier lesson, Holter software will automatically attempt to
analyze a recording for you before you run the recording and review it. A lot of
common mistakes involve misinterpretation by the software. One of the most
common problems is mislabeling artifact as premature ventricular complexes or
as pacing spikes from a pacemaker.
In the example below, you can clearly see that there is artifact on the ECG strip,
which the software may interpret as either pacing spikes, PVCs, or an extremely
high heart rate greater than 300 beats per minute (bpm) because it does not fit
into the normal beat template criteria.
In the case of misinterpretation, it can inflate ectopic burdens and even annotate
episodes of AF where there are none. It is very important that you check on the
event screen on the Holter software that the label, if any, is correct.
Take a look at the next image. What do you think? Does it show episodes of non-
sustained ventricular tachycardia? Atrial flutter?

The image above simply shows artifact caused by excessive noise-producing
interference on the recording. However, the Holter analysis software labeled it as
showing both atrial flutter and episodes of non-sustained ventricular tachycardia.
This is incorrect, so taking the automated report at face value could have
subjected the patient to unnecessary investigation and treatment.
The type of artifact shown below is typically caused by the patient scratching
around the electrode sites. The artifact from scratching mimics atrial flutter
or ventricular ectopic activity as the baseline moves almost in time with
the scratching.
Artifact due to scratching
Often, we can see baseline artifact that mimics arrhythmias if a patient is

exercising vigorously and becomes sweaty. In this case, it is likely because the
electrodes have become loose. Patients who do a lot of exercise are advised to
replace electrodes after heavy exercise so that the rest of the recording can run
smoothly without further episodes of artifact.

Both of the ECG traces below show a loss of signal, which means that contact
through the electrode has been lost. This could either be that one or more of the
electrodes has come off entirely or an electrode is still attached but electrical
contact is poor.
Loss of signal
Deciphering between a loss of signal and asystole

A loss of signal can often mimic asystole and will be labeled as pauses or
asystole by the Holter software. A tip to recognize this is to look closely at it by
zooming in on the ECG if necessary. A loss of signal artifact looks very, very flat,
and very straight. In true asystole, there is normally some baseline drift and may
be evidence of some electrical activity such as small P waves.
Loss of signal
Asystole

In addition, take a look at the patient diary. Is there a relevant symptom at this
time? The diary may reveal if the patient was exercising heavily or had removed
the electrodes to bathe or shower.
Also note the duration. Does the pause last for seconds, minutes, or even hours?
If it is a true pause, anything over 6 seconds would probably make the patient
symptomatic. It is implausible that a patient could be asystolic for a prolonged
period and yet remain symptom-free.
Pitfalls with symptom diaries

Although I have emphasized the importance of symptom diaries throughout this
course, the symptom diary can also be a source of problems.
Some patients may write too much or too little in the diary, or their diary entries
can be difficult to interpret. Times may not be documented or there may be many
different, and likely irrelevant, symptoms documented. In these cases, it can be
difficult to interpret what the patient may or may not be feeling.
In these cases, it is best to note that there are symptoms in the diary and at
what times (if times are documented). Review the Holter recording as a whole
to ascertain if there are any abnormalities in general. If there are minor ECG
abnormalities as discussed earlier, then look at the diary again to see if the
timing of any of the symptoms matches these ECG abnormalities.
If the recording is normal as a whole, then it is safe to say that any symptoms
listed do not relate to any underlying arrhythmias, and this is a reassuring finding.
To avoid falling into the trap of making a diagnostic error, always remain aware
of potential pitfalls when analyzing a Holter recording. In particular, if a finding
is unexpected or seems to be out of context, be sure to double-check everything
carefully before you write your Holter report.

Writing a Holter monitor report
So far, we’ve discussed an approach to Holter analysis, the significance of some
common findings, and how to avoid pitfalls. Now it’s time to learn how to write a
Holter report.
In putting the report together, we need to determine which findings are relevant
and which are not. We want to establish whether this has been a useful recording
in providing a diagnosis for any of the patient’s symptoms and / or for identifying
any asymptomatic problems. The report needs to be concise, well-structured,
and clearly written.
Patient and Holter recording details

To begin with, the report must always contain appropriate identifying details
of the patient—their name, date of birth, gender, and any relevant healthcare ID
numbers. It’s also good practice to provide a summary of the test indication, as
provided by the requesting clinician.
Next, we need to provide details of the Holter recording itself:
• When was the recording performed?

• How long was the recording for? Was it 24 hours or longer?
• Was the full recording completed or was the monitor removed early for
various reasons?

Often, patients remove monitors early for reasons such as skin irritation
from electrodes.
Findings
Minimum, maximum, and mean heart rates
It is important to note down maximum and minimum daytime and nighttime
heart rates. A good way of looking at this as a whole is the heart rate curve.
Heart rate curve
The heart rate curve is useful for looking at diurnal variation and making a
note of any daytime bradycardias in certain circumstances. It is also useful for
shift workers.
It is also important to include the mean heart rate as this can be helpful in the
diagnosis of inappropriate sinus tachycardia.
Pauses
Are there any pauses of significance? This would be one of the first things to
be highlighted in your report as it could be indicative of a medical emergency.
Include the following:
• How long were the pauses?

• When did they occur?
• Was the patient symptomatic?

Additional findings
Now, on to the main body of the report. Answer the following questions:
• What was the main rhythm?

• Are there any significant bradycardias or tachycardias?
• Were these bradycardias or tachycardias appropriate relative to patient activity?
• Was there any ectopic activity or sustained arrhythmias greater than 30
seconds in duration?
• Were there any rhythm changes?
• Were these abnormalities of gradual or rapid onset?
• Did the patient have any symptoms associated with arrhythmias that could
potentially account for those symptoms?
Conclusion
Finally, you need to summarize your findings in a concise conclusion where you
do the following:
• Highlight the most relevant aspects of the recording

• Try to answer the diagnostic question that was asked by the referring clinician
Below is an example of how the structure of a typical report might look. This is a
sample report of a recording with occasional unifocal ventricular ectopic beats.
The patient documented symptoms in their diary and demonstrated ectopic

activity around the same times. This recording was conclusive in terms of showing
that the patient was suffering symptoms while experiencing ectopic beats.
It is important to note that printed ECG strips should also be included in the
reports to demonstrate symptomatic episodes and findings. A single ECG
example of each is useful.

A high-quality Holter report will highlight any clinically relevant ECG findings
and should endeavor, wherever possible, to provide an answer to the diagnostic
question posed by the referring clinician.

Here’s what we’ve covered so far in this chapter:
1. How to analyze a Holter recording.

2. How to take a structured approach to review a recording with a Holter analyzer.
3. How to make sense of some of the common Holter findings.
4. Common pitfalls that are likely to be encountered and how to recognize and
avoid them.
5. How to write a clear, concise, and well-structured Holter report.
Now, let’s take a look at some case examples to see how these things are
handled in practice.
Case 1: 65-year-old male with palpitations

Our first case involves a 65-year-old male who is suffering from palpitations.
The Holter recording has shown PVCs. What information do we need to consider
when analyzing the recording and writing our report?

Are the PVCs responsible for his symptoms?
First, we need to establish whether the PVCs are responsible for the
patient’s symptoms.
This can sometimes be tricky for frequent arrhythmias such as PVCs as

there may be hundreds or even thousands throughout the entire recording.
Nonetheless, checking the patient’s symptom diary and assessing the rhythm at
the time of any relevant symptoms may establish whether typical symptomatic
events coincide with any PVCs or with an increased frequency of PVCs during
the recording.
Overall burden of PVCs

Next, we want to determine what the overall burden of PVCs is as high burdens
can run a risk of PVC-induced cardiomyopathy. The automatic Holter analysis
will usually give you the total number of PVCs seen during the recording. You
can express the PVC burden either as the average number of PVCs / h or as a
percentage of the total number of heartbeats seen.
A PVC burden of greater than 20 000 in 24 hours starts to raise concerns about
the risk of developing cardiomyopathy.
Unifocal or multifocal?
It can also be helpful to describe whether the PVCs are unifocal (i.e., same
morphology) or multifocal (i.e., differing morphologies). A single focus is more
easily amenable to successful ablation in comparison to multiple foci. So, this
information can help guide clinicians in deciding upon the best treatment options.

In summary, for all arrhythmias seen during Holter monitoring, you should
determine how the arrhythmias relate to any symptoms, and then describe
relevant features of the arrhythmia that may assist with making treatment
decisions. In this way, you’ll be able to maximize the usefulness of your Holter
report for the referring clinician.
Case 2: 22-year-old female with episodes of syncope

Our second case involves a 22-year-old female with episodes of syncope. A
Holter monitor was performed and showed an episode of sinus tachycardia at
125 bpm. Is this relevant?
Check the symptom diary

The first thing we should do is check the symptom diary to see whether the
patient had any relevant symptoms during the recording. It would be unusual for
a mild sinus tachycardia to cause syncope.
Indeed, her symptom diary showed that she was asymptomatic during the Holter
recording. She didn’t experience syncope or any other symptoms. However, her
diary also included a record of her activities during the Holter recording. It shows
that during the episode of sinus tachycardia, the patient was exercising at the
gym. The sinus tachycardia is therefore entirely appropriate, and not of any
clinical concern.

The symptom diary can help provide a context for the patient’s heart rhythm and
can help you determine whether changes in the rhythm are appropriate or not.
This is why it is helpful if patients record periods of activity in the diary and also
the time that they go to bed and when they get up.
This activity record helps you to decide whether the rhythm is appropriate
(e.g., sinus tachycardia while exercising or sinus bradycardia while asleep) or
inappropriate, and this can then be reflected in your Holter report.
Case 3: 75-year-old male being screened for

paroxysmal atrial fibrillation
Our last patient is a male aged 75 who had a Holter monitor as a screen for
paroxysmal AF. When the recording was analyzed, the automated analyzer
highlighted a 20 second pause that occurred at 6:00 pm.
Whenever the software reports a potential arrhythmia, it’s important to check

whether the patient’s symptom diary shows any symptomatic episodes at
the relevant time. This patient’s diary showed that he was asymptomatic.
This is implausible for a genuine 20 second pause as this would undoubtedly
cause syncope.
Closer inspection of the ECG reveals that there is a completely flat line during the
detected episode of asystole. This is also unusual as the ECG would normally be
expected to show a degree of baseline drift even during genuine asystole. Taking

these factors together, it’s much more likely that this is pseudo asystole caused
by loss of the ECG signal due to a period of poor connection of one or more
ECG electrodes.
It’s essential to distinguish between genuine arrhythmias and artifactual ones

and to describe your conclusions clearly in your Holter report. Do this to avoid a
misdiagnosis and unnecessary further testing or treatment for the patient.
Genuine arrhythmia
Artifactual arrhythmia
With this case, we’ve now reached the end of our course on Holter monitoring. I
hope you’ve found it useful and that you’ll now put all your learning into practice!

References
APPENDIX
www.medmastery.com
Reference list
Brignole, M, Moya, A, de Lange, FJ, et al. 2018. 2018 ESC Guidelines for the diagnosis
and management of syncope. Kardiol Pol. 76: 1119–1198. PMID: 30117520
Crawford, MH, Bernstein, SJ, Deedwania, PC, et al. 1999. ACC/AHA Guidelines for
Ambulatory Electrocardiography. A report of the American College of Cardiology/
American Heart Association Task Force on practice guidelines (committee to revise
the guidelines for ambulatory electrocardiography). Developed in collaboration with
the North American Society for Pacing and Electrophysiology. J Am Coll Cardiol. 34:
912–948. PMID: 10483977
Hindricks, G, Potpara, T, Dagres, N, et al. 2021. 2020 ESC Guidelines for the diagnosis
and management of atrial fibrillation developed in collaboration with the European
Association for Cardio-Thoracic Surgery (EACTS): The task force for the diagnosis
and management of atrial fibrillation of the European Society of Cardiology (ESC).
Developed with the special contribution of the European Heart Rhythm Association
(EHRA) of the ESC. Eur Heart J. 42: 373–498. PMID: 32860505
Khalil, CA, Haddad, F, and Al Suwaidi, J. 2017. Investigating palpitations: The role of
Holter monitoring and loop recorders. BMJ. 358: j3123. PMID: 28751495
Mittal, S, Movsowitz, C, and Steinberg, JS. 2011. Ambulatory external

electrocardiographic monitoring: Focus on atrial fibrillation. J Am Coll Cardiol.
58: 1741–1749. PMID: 21996384
National Institute for Health and Care Excellence contributors. 2014. Transient loss of
consciousness (‘blackouts’) in over 16s. NICE | The National Institute for Health and
Care Excellence. www.nice.org.uk. Published October 2, 2014.
Accessed November 11, 2021.
Steinberg, JS, Varma, N, Cygankiewicz, I, et al. 2017. 2017 ISHNE-HRS expert

consensus statement on ambulatory ECG and external cardiac monitoring/telemetry.
Heart Rhythm. 14: e55–e96. PMID: 28495301

Become an expert by learning the most important clinical skills at www.medmastery.com.

Medmastery_Holter Monitoring Essentials Handbook

Uploaded by

Copyright:

Available Formats

You might also like

Medmastery_Holter Monitoring Essentials Handbook

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Medmastery_Holter Monitoring Essentials Handbook

Uploaded by

Copyright:

Available Formats

HOLTER MONITORING

Cara Mercer, BSc (Hons)

Planning a Holter monitor

Performing a Holter monitor

Interpreting the results

Become an expert at www.medmastery.com. 2

Become an expert at www.medmastery.com. 3

For patients who require continuous cardiac monitoring, a different type of

Parts of a Holter monitor

1. The main device itself

2. Electrodes that attach the device to the patient

3. Adhesive pads that attach the electrodes to the patient’s skin

Become an expert at www.medmastery.com. 5

Prepping the skin

1. Remove chest hair

2. Clean and prepare the skin

Become an expert at www.medmastery.com. 6

For instance, a sinus tachycardia will have different clinical implications

Analyzing the findings

Return to table of contents

Become an expert at www.medmastery.com. 7

Ambulatory recording of a patient’s ECG is often necessary to capture

How to choose the right monitor

For example, a short-term monitor such as a 24-hour or 48-hour Holter

Let’s go through a few of the monitoring options.

Short-term Holter monitors

Become an expert at www.medmastery.com. 8

Patient event recorders

1. Patient event recorders cannot record the ECG continuously

2. Their use may be impractical for some patients

3. Results may vary

Nonetheless, event recorders can be carried indefinitely, so they provide a useful

Become an expert at www.medmastery.com. 9

Insertable cardiac monitors

1. They can detect significant arrhythmias and

recordings during symptomatic events.

However, these devices are implanted subcutaneously and, therefore, require

• The planned duration of recording

Become an expert at www.medmastery.com. 10

Return to table of contents

Become an expert at www.medmastery.com. 11

Let’s go over these indications in more detail.

Become an expert at www.medmastery.com. 12

Pre-syncope and syncope

Pre-syncope and syncope can also have non-arrhythmogenic origins such

Become an expert at www.medmastery.com. 13

• 24–48 hour ambulatory ECG monitoring

Atrial fibrillation screening is important in patients who have suffered an embolic

Assessment of known arrhythmias

Become an expert at www.medmastery.com. 14

Return to table of contents

Become an expert at www.medmastery.com. 15

Listening to the patient’s symptoms

• How often do the symptoms occur?

Deciding upon the use of a patient diary

Become an expert at www.medmastery.com. 16

• Is the patient physically capable of writing in or reading the diary?

Assessing cognitive competency

For example, if a patient has dementia, they may need to be governed by an