GPAC: Guidelines and Protocols Advisory Committee

Ambulatory ECG Monitoring (Holter Monitor and Patient-Activated Event Recorder)

Effective Date: July 1, 2004

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope

1. Patients suitable for ambulatory ECG monitoring

2. Choice of ambulatory ECG monitor

3. Ambulatory ECG monitoring for complex cardiac conditions

4. Patients not recommended for ambulatory ECG monitoring

Rationale

References

Sponsors

Scope

This guideline applies to the use of ambulatory ECG monitors for patients aged 13 years and older. It reflects changing technology and appropriate application of Holter monitors and patient-activated event recorders (loop recorders).

RECOMMENDATION 1: Patients suitable for ambulatory ECG monitoring

Ambulatory ECG monitoring is suitable for patients with symptoms which may be caused by arrhythmia, such as palpitations, light-headedness or syncope. Patients should be able to record symptoms in a diary or have symptoms recorded for them.

RECOMMENDATION 2: Choice of ambulatory ECG monitor

Patients with symptoms occurring daily or almost daily or those who have syncope without warning may be evaluated with a 24-hour Holter monitor. Patients with symptoms occurring less frequently may be better evaluated using a patient-activated event recorder.

RECOMMENDATION 3: Ambulatory ECG monitoring for complex cardiac conditions

Ambulatory ECG monitoring is often useful in more complex cardiac conditions. Selection of patients and choice of ambulatory monitor are best discussed with a specialist/cardiologist. The following categories of patients may benefit from ambulatory ECG monitoring:

• Patients with clinical suspicion of pacemaker malfunction when this cannot be determined by routine ECG and analysis by the manufacturer’s programmer.
• Patients with frequent, reproducible cardiac arrhythmias who are using antiarrhythmic drugs and who need to undergo serial monitoring to assess response or adverse reactions to drug therapy.
• Patients being assessed for trends in heart rate, e.g., drug therapy in atrial fibrillation, relative bradycardia.

RECOMMENDATION 4: Patients not recommended for ambulatory ECG monitoring

The following categories of patients are not recommended for ambulatory ECG monitoring:

• Patients with organic heart disease who are at immediate risk of life threatening arrhythmia, injury, or sudden death, or patients with arrhythmias causing ischemic chest pain, pulmonary edema, etc. These patients require emergency assessment.
• Patients with symptoms such as chest pain which may be due solely to coronary artery disease. Other investigations such as stress testing are more reliable for diagnosing coronary artery disease.
• Asymptomatic patients with recent myocardial infarction.

Rationale

The strengths of 24-hour Holter monitoring include its simplicity and the lack of need for patient activation. The continuous monitoring allows capture of asymptomatic arrhythmias or arrhythmias associated with loss of consciousness as well as documentation of circadian variation in arrhythmia occurrence. However, the continuous recording and saving of data limit the period of monitoring to a very short window that is often inadequate to diagnose the cause of symptoms.

A major strength of patient-activated event recorders (loop recorders) is the extended duration of possible monitoring compared with Holter monitors. These devices are routinely carried or worn for up to two weeks depending on the indication. Another advantage is the high degree of specificity achieved by requiring the patient to activate the monitor at the time of perceived symptoms.

Ambulatory electrocardiography can detect atrial fibrillation not found on the initial electrocardiogram in 1% to 5.4% of people with stroke. There is insufficient evidence to recommend for or against the use of ambulatory ECG for the detection of paroxysmal atrial fibrillation in this setting.

Because the role of treatment of ventricular ectopy for mortality reduction post-MI is still unclear, the use of Holter monitoring for routine risk stratification post-MI is not recommended at this time.

References

1. Bell C, Kapral M, with The Canadian Task Force on Preventive Health Care. Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke. Can J Neurol Sci 2000; 27(1):25-31.
2. Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A Jr, et al. 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 1999; 34(3):912-48.
3. Green MS, Ricci J, Wolfe K. The appropriate evaluation of the patient at risk for sudden death from ventricular arrhythmias. In: Prevention of sudden death from ventricular arrhythmia. Canadian Cardiovascular Society 1999 consensus conference. Can J Cardiol 2000; 16 Suppl C:1C-94C.
4. Zimetbaum PJ, Josephson ME. The evolving role of ambulatory arrhythmia monitoring in general clinical practice. Ann Intern Med 1999; 130(10):848-56.
5. Zimetbaum PJ, Kim KY, Josephson ME, Goldberger AL, Cohen DJ. Diagnostic yield and optimal duration of continuous-loop event monitoring for the diagnosis of palpitations. A cost-effectiveness analysis. Ann Intern Med 1998; 128(11):890-5.

Sponsors

This guideline, revised by the Guidelines and Protocols Advisory Committee, supersedes the guideline Ambulatory ECG Monitoring (Holter Monitor and Patient-Activated Event Recorder Monitor) revised in 2001. The revision was approved by the British Columbia Medical Association and adopted by the Medical Services Commission. Funding for this guideline was provided in full or part through the Primary Health Care Transition Fund.

Revised Date: April 1, 2007

This guideline is based on scientific evidence current as of the effective date.

Disclaimer

The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.

PDF Format

Some documents on this Web site are in PDF format and require a PDF reader. If you do not have Adobe Acrobat Reader Version 7.0 or the most recent version of another PDF reader, you can download Adobe Acrobat Reader by clicking on the 'Get Acrobat Reader' icon.