Choosing between ECG monitoring devices—Holter or no Holter? That is the question!

If your patient suffers from atrial fibrillation, syncope, or other kinds of arrhythmia, you have a plethora of options for ambulatory ECG monitoring. Holter monitors are the most popular choice, but they also have their disadvantages. Would an event recorder, a smartwatch, or even an implantable device be a better fit for your patient?

Holter monitoring is an essential tool in every clinician’s kit. This course will give you the confidence to select the best type of ECG monitor for your patient’s clinical indication, maximize diagnostic yield, and identify and troubleshoot the most common problems. You’ll learn how to correlate your patient’s symptoms with the rhythm strip and confidently report your findings. Become a master in Holter monitoring and confidently analyze and report monitoring results with this course.

Although a 12 lead ECG can be invaluable for the diagnosis of arrhythmias, it'll 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. Ambulatory recording of a patient's ECG is often necessary to capture intermittent arrhythmias when they occur, and to allow such arrhythmias to be correlated with the patient's symptoms.

In this Medmastery course, we will learn about the different options you have for recording. 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.

A short term monitor such as a 24-hour or 48-hour Holter recording is much better suited to frequent symptoms until infrequent events that may only happen once a month. If the patient's symptoms only occur once or twice a month, either an event recorder or an invasive monitor, such as an insertable cardiac monitor would be more appropriate. key advantages of using a Holter monitor is that it is non-invasive, relatively simple and inexpensive to use, and can provide continuous monitoring.

This way, even if a patient has asymptomatic episodes, the monitor will still record the event. Although Holter monitors are typically worn for 24 to 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 irritation the patient might experience from prolonged use of the adhesive electrodes. Patient event recorders have their own list of pros and cons.

One benefit is that they, like Holter monitors are the non-invasive option. However, they cannot record the ECG continuously. They allow the patient to make recordings on demand as symptoms occur. Whilst this is fine for most symptomatic arrhythmias, it clearly isn't an option for detecting asymptomatic ones. Another concern is whether the patient is able to use the event recorder. It might be impractical for a patient with dementia, arthritis or a symptomatic arrhythmia that causes incapacitation such as syncope.

The quality of the ECG recording also depends upon the patient's use of the event recorder, meaning the results may be variable. Nonetheless, event recorders can be carried indefinitely, so they can provide a useful option for patients with infrequent symptomatic events. 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've just discussed.

The Apple Watch is an example of a device that can be worn for long periods of time, except for when it's being charged. It can provide screening for asymptomatic 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 such as Maytronics Reveal Linq device provide an option for very long term monitoring of up to around three years or so.

They can detect significant arrhythmias and automatically save a recording of them, as well as offering patients the option to activate their own recordings during symptomatic events. Monitoring of the device can be done remotely, so data can be downloaded from the device without the need for an office visit. These devices are implanted subcutaneously and therefore require an invasive procedure for the insertion and subsequent removal. Be sure to consider all the procedural risks that these devices will come with.

In summary, there are many factors to take into account when choosing between ECG monitoring options - The plans duration of recording whether you are aiming to capture symptomatic episodes or screen for asymptomatic ones, your patient's mental and physical competency at using the device and if 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 patients.