Holter monitoring involves using a portable electrocardiography device to record a patient's heart rhythm over a period of 24 to 72 hours. The device uses electrodes attached to the skin to track the heart's electrical activity. A Holter monitor can detect abnormal heart rhythms and help diagnose conditions like unexplained palpitations, syncope, or evaluate pacemaker function. The report provides summaries of heart rate, arrhythmias detected, heart rate variability, and 24-hour trends to help clinicians identify abnormal rhythms and understand their clinical significance. Holter monitoring can play a role in evaluating patients with known heart disease, suspected ischemia, cryptogenic stroke, and pacemaker function.

1. Holter Monitoring
Dr. KAZI ALAM NOWAZ
MD FINAL PART STUDENT CARDIOLOGY
NHFH & RI

2. 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

3. • Dr. Norman Holter introduced portable
devices to record the ECG in 1957
THE EVOLUTION OF OUTPATIENT
AMBULATORY CARDIAC MONITORING

4. Different types of ambulatory
electrocardiogram monitoring
• Holter monitors
• Event monitors
• Ambulatory real-time cardiac monitors
• Adhesive patch electrocardiographic monitors
• Implantable loop recorders

5. 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

6. 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.

7. 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

8. 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.
HOLTER MONITOR

9. 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.

10. 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

11. * DM Software 11
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.

12. * DM Software 12
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.

13. 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.

14. 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

15. 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.

16. 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

17. 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

18. 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.

19. THANKS TO ALL