Holter Monitoring and Loop Recorders: From Research to Clinical Practice

Holter monitors are tools of proven efficacy in diagnosing and monitoring cardiac arrhythmias. Despite the fact their use is widely prescribed by general practitioners, little is known about their evolving role in the management of patients with cryptogenic stroke, paroxysmal atrial fibrillation, unexplained recurrent syncope and risk stratification in implantable cardioverter defibrillator or pacemaker candidates. New Holter monitoring technologies and loop recorders allow prolonged monitoring of heart rhythm for periods from a few days to several months, making it possible to detect infrequent arrhythmias in patients of all ages. This review discusses the advances in this area of arrhythmology and how Holter monitors have improved the clinical management of patients with suspected cardiac rhythm diseases.

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Abstract P624: High Detection of Atrial Fibrillation by 90 Days Textil Holter Monitoring in Patients With Cryptogenic Stroke

Stroke ◽

10.1161/str.52.suppl_1.p624 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Jorge Pagola ◽

Jesus Juega ◽

Jaume Francisco ◽

Maite Rodriguez ◽

Juan Antonio Cabezas ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cumulative Incidence ◽

Left Atrial ◽

Cryptogenic Stroke ◽

Left Atrial Volume ◽

Holter Monitoring ◽

Cardiac Monitoring ◽

Atrial Volume ◽

Monitoring Time ◽

Number Of Patients

Introduction: External recorders allow for low-cost, non-invasive 1 to 4 weeks monitoring. However, the first 3 months of monitoring duration are the most effective to detect atrial fibrillation (AF). We show the results of the Thunder registry of patients monitored to detect AF during 90 days from the stroke. Methods: A prospective observational study was conducted with consecutive inclusion of patients with cryptogenic stroke after work up (neuroimaging, echocardiography and 24-hour cardiac monitoring) in 5 Comprenhensive Stroke Centers. Patients were continuously monitored for 90 days with a wearable Holter (Nuubo®) after the first 24 hours of the stroke onset. We analyzed the percentage of AF detection in each period (percentage of AF among those monitored), the quality of the monitoring (monitoring time), the percentage of AF by intention to monitor (detection of AF among patient included). Demographic, clinical and echocardiographic predictors of AF detection beyond one week of cardiac monitoring were assessed. Results: A total of 254 patients were included. The cumulative incidence of AF detection at 90 days was 34.84%. The monitoring time was similar among the 3 months (30 days: 544.9 hours Vs 60 days: 505.9 hours Vs 90 days: 591.25 hours) (p=0.512). The number of patients who abandoned monitoring was 7% (18/254). The cumulative percentage of intention to detect AF was 30.88% (Figure). Patients who completed monitoring beyond 30 days had higher score on the NIHSS basal scale (NIHSS 9 IQR 2-17) VS (NIHSS 3 IQR 1-9) (p=0.024). Patients with left atrial volume greater than 28.5ml/m2 had higher risk of cumulative incidence of AF according to the Kaplan Meyer curve beyond the first week of monitoring OR 2.72 (Log-rank (Mantel-Cox test) (p<0.001). Conclusions: In conclusion, intensive 90-day- Holter monitoring with textile Holter was feasible and detected high percentage of AF. Enlarged left atrial volume predicted AF beyond the first week of monitoring.

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Abstract WP232: Biomarkers of Atrial Cardiopathy and Atrial Fibrillation Detection on Mobile Continuous Outpatient Telemetry After Cryptogenic Stroke

Stroke ◽

10.1161/str.48.suppl_1.wp232 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Denise Sebasigari ◽

Alexander Merkler ◽

Guo Yang ◽

Benjamin Kummer ◽

Gino Gialdini ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Cryptogenic Stroke ◽

Heart Rhythm ◽

Population Based ◽

Embolic Stroke ◽

P Wave ◽

Left Atrial Diameter ◽

New Diagnosis ◽

Rhythm Monitoring

Background: In population-based studies, biomarkers of atrial dysfunction or “cardiopathy” have been shown to be associated with embolic stroke risk. However, it is unclear if this risk is mediated by undiagnosed paroxysmal atrial fibrillation or flutter (AF). We aim to determine whether atrial cardiopathy biomarkers predict atrial fibrillation on continuous heart-rhythm monitoring after embolic stroke of undetermined source (ESUS). Methods: This was a single-center retrospective study including all patients who met consensus criteria for ESUS and who underwent 30 days of ambulatory heart-rhythm monitoring looking for AF between Jan 1 st , 2013 and Dec 31 st , 2015. We reviewed medical records for clinical, radiographic, and cardiac variables. The primary outcome was new diagnosis of AF detected during heart-rhythm monitoring. The primary predictors were atrial biomarkers: left atrial diameter on echocardiography, P-wave terminal force in ECG lead V1 , and PR interval on ECG. Multiple logistic regression was used to assess the relationship between atrial biomarkers and AF detection. Results: Among 196 eligible patients, 23 (11.7%) were diagnosed with AF. In unadjusted analyses, patients with AF were older (72.4 vs. 61.4 years, p < 0.001) and had larger left atrial diameter (39.2 vs. 35.7 mm, p = 0.03). In a multivariable model including variables significant on univariate analyses, the only predictor of AF was age ≥ 60 years (odds ratio, 3.0; 95% CI, 1.06-8.5; p = 0.04). Atrial biomarkers were not associated with AF detection. Conclusion: Atrial biomarkers were not associated with AF after ESUS. This suggests that previously reported associations between these markers and stroke may reflect independent cardiac pathways leading to stroke. Prospective studies are needed to investigate these mechanisms and study anticoagulation versus antiplatelet treatment for secondary stroke prevention in patients with ESUS and atrial cardiopathy.

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Prevalence of paroxysmal atrial fibrillation in patients with cerebrovascular stroke of undetermined etiology

QJM ◽

10.1093/qjmed/hcab090.026 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Mohammed Elnwagy ◽

Hossam Shokery ◽

Emad Effat ◽

Hayam El Damnhory

Keyword(s):

Atrial Fibrillation ◽

Paroxysmal Atrial Fibrillation ◽

Left Atrial ◽

Cryptogenic Stroke ◽

Holter Monitoring ◽

Ectopic Beat ◽

Unknown Etiology ◽

P Value ◽

Undetermined Etiology ◽

Cerebrovascular Stroke

Abstract Background cerebrovascular stroke is major cause of morbidity and disability. Many causes may contribute to its presence, however. Some patients have none of the identified risk factors, yet face the consequences of stroke or transit ischemic attack. This type of stroke known to be stroke of undetermined source or etiology. It has a high rate of recurrence due to the persistence of the unknown etiology. Paroxysmal atrial fibrillation remains the hidden bottom of an iceberg representing a major part of the causes of ischemic cerebrovascular stroke of undetermined etiology . Aim and Objectives: to determine the prevalence of subclinical atrial fibrillation in patients with ischemic cerebrovascular stroke of undetermined etiology in a population in Egypt by 48h holter monitoring. Patients and Methods Patients diagnosed with acute cerebrovascular stroke of undetermined etiology at the neurology department of Ain Shams university hospitals underwent 48 hours holter monitoring within the first week of the insulting event. Results This study included 50 patients with cryptogenic stroke (CS) who underwent 48 hours holter monitoring. The patients' ages ranged between 22 and 77 years old (mean age 48.46 ± 12.74years). This study included 34 males and 16 females. Their body mass index BMI ranges from 21-35 kg/m2, with mean BMI of 24.78 ± 2.99 kg/m2. Their left atrial diameter ranges from 26-47mm, with mean diameter of 36.08 ± 5.23mm .Eight out of fifty patients newly diagnosed with subclinical atrial fibrillation with prevalence of 16%. There was statistically significant association between the atrial fibrillation (AF) and both age (p value, 009) and left atrial (LA) diameter (p value, 001) .There was an associated finding that need further investigation about the significant association between the ventricular ectopic beat VEB burden and the presence of AF or stroke. Conclusion The prevalence of paroxysmal atrial fibrillation among the population of ischemic stroke of undetermined etiology in a population in Egypt is close to worldwide percentage and the recent met analysis studies of 11%.

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Cardiac Rhythm and Conduction Disturbances

Mayo Clinic Critical and Neurocritical Care Board Review ◽

10.1093/med/9780190862923.003.0029 ◽

2019 ◽

pp. 197-206

Author(s):

Yahaira Ortiz Gonzalez ◽

Fred Kusumoto

Keyword(s):

Atrial Fibrillation ◽

Intensive Care Unit ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Cardiac Arrhythmias ◽

Cardiac Rhythm ◽

Hemodynamic Instability ◽

Conduction Disturbances ◽

Ventricular Tachycardias

Patients in the intensive care unit (ICU) are exposed to several physiologic stressors that may trigger cardiac arrhythmias and lead to hemodynamic instability. Prompt recognition and initiation of appropriate therapies for arrhythmias is important because critically ill patients with arrhythmias (compared to patients without arrhythmias) have longer hospitalizations and higher mortality (30.8% vs 21.2%). Arrhythmias are classified as tachyarrhythmias or bradyarrhythmias. The most common sustained arrhythmias are supraventricular; atrial fibrillation is the most prevalent. Among the ventricular arrhythmias, up to 50% are monomorphic ventricular tachycardias.

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Rates of Cardiac Rhythm Abnormalities in Patients with CKD and Diabetes

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.09420818 ◽

2019 ◽

Vol 14 (4) ◽

pp. 549-556 ◽

Cited By ~ 4

Author(s):

Nazem Akoum ◽

Leila R. Zelnick ◽

Ian H. de Boer ◽

Irl B. Hirsch ◽

Dace Trence ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Arrhythmias ◽

Ventricular Arrhythmias ◽

Cardiac Rhythm ◽

Cardiac Monitoring ◽

Premature Ventricular Contractions ◽

Mortality And Morbidity ◽

Conduction Abnormalities ◽

Patients With Diabetes ◽

New Diagnosis

Background and objectivesCardiac arrhythmias increase mortality and morbidity in CKD. We evaluated the rates of subclinical arrhythmias in a population with type 2 diabetes and patients with moderate to severe CKD who were not on dialysis.Design, setting, participants & measurementsThis is a prospective observational study, using continuous ambulatory cardiac monitors to determine the rate of atrial and ventricular arrhythmias, as well as conduction abnormalities in this group.ResultsA total of 38 patients (34% women), with mean eGFR of 38±13 ml/min per 1.73 m2, underwent ambulatory cardiac monitoring for 11.2±3.9 days. The overall mean rate of any cardiac arrhythmia was 88.8 (95% confidence interval [95% CI], 27.1 to 184.6) episodes per person-year (PY). A history of cardiovascular disease was associated with a higher rate of detected arrhythmia (rate ratio, 5.87; 95% CI, 1.37 to 25.21; P<0.001). The most common arrhythmia was atrial fibrillation, which was observed in two participants with known atrial fibrillation and was a new diagnosis in four patients (11%), none of whom experienced symptoms. Overall, atrial fibrillation episodes occurred at a rate of 37.6 (95% CI, 2.4 to 112.3) per PY. Conduction abnormalities were found in eight patients (21%), a rate of 26.5 (95% CI, 4.2 to 65.5) per PY. Rates of ventricular arrhythmias were low (14.5 per PY; 95% CI, 4.3 to 32.0) and driven by premature ventricular contractions.ConclusionsCardiac rhythm abnormalities are common in patients with diabetes with moderate to severe CKD not requiring dialysis. Rates of atrial fibrillation are high and episodes are asymptomatic. Future studies are needed to determine the role of screening and upstream therapy of cardiac arrhythmias in this group.

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HEART RATE TURBULENCE INDICATORS IN CLINICAL PRACTICE

The Bulletin of Contemporary Clinical Medicine ◽

10.20969/vskm.2021.14(5).62-67 ◽

2021 ◽

Vol 14 (5) ◽

pp. 62-67

Author(s):

GRIGORIY A. FADEEV ◽

◽

NIKOLAY A. TSIBULKIN ◽

OLGA YU. MIKHOPAROVA ◽

GRIGORIY G. BATYRSHIN ◽

...

Keyword(s):

Heart Rate ◽

Nervous System ◽

Autonomic Nervous System ◽

Sinus Rhythm ◽

Cardiac Rhythm ◽

Heart Rhythm ◽

Holter Monitoring ◽

Left Ventricular ◽

Heart Rate Turbulence ◽

Autonomic Nervous

Background. Heart disease is the leading cause of death in developed countries. Approximately half of these fatalities are due to sudden cardiac death. Electrocardiogram recording from the body surface allows stratification of patients according to the risk of cardiac arrest without the use of invasive methods. Arrhythmias, particularly ventricular extrasystole, can affect the sinus rhythm pattern. The change in sinus rhythm that occurs after an extrasystole is defined as heart rate turbulence. This phenomenon is not pathological, but some variants are associated with a risk of fatal arrhythmias. Aim. To analyze the indices and clinical significance of cardiac rhythm turbulence according to Holter monitoring in patients with various cardiological abnormalities at the hospital profile department. Material and methods. The study included 54 patients who were routinely treated in a cardiac hospital. Cardiac rhythm turbulence indices were obtained by Holter monitoring. Patients in severe and moderately severe clinical condition were not included in the study. Concomitant and past somatic diseases affecting the state of heart and cardiovascular system were considered. Results and discussion. Deviations in heart rhythm turbulence indices can be detected both in life- threatening arrhythmias and in benign extrasystoles. They are associated with the influence of the autonomic nervous system, but probably have different mechanisms. Deviations of heart rhythm turbulence indices were associated with left ventricular myocardial hypertrophy of concentric remodeling type and with an increased number of low-risk ventricular extrasystoles. To identify patients with arrhythmias of different risk, various threshold values of cardiac rhythm turbulence indices can be used. Conclusion. Factors likely to affect the indices of cardiac rhythm turbulence such as left ventricular myocardial remodeling and hypertrophy were revealed, as well as changes in autonomic nervous system regulatory function, including those associated with the constitutional features of the patient.

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Atrial fibrillation and Ventricular Tachyarrhythmias: Advancements for better outcomes

Cardiovascular & Haematological Disorders - Drug Targets ◽

10.2174/1871529x20666201001143907 ◽

2020 ◽

Vol 20 ◽

Author(s):

Alireza Gheini ◽

Afsoun Pourya ◽

Ali Pooria

Keyword(s):

Atrial Fibrillation ◽

Cardiac Arrhythmias ◽

Ventricular Arrhythmias ◽

Medical Condition ◽

Pharmacological Therapy ◽

Medical Attention ◽

Cardiac Diseases ◽

Cardioverter Defibrillator ◽

Rhythm Disorder ◽

Atrial Fibrillation And Flutter

: Cardiac arrhythmias are associated with several cardiac diseases and are prevalent in people with or without structural and valvular abnormalities. Ventricular arrhythmias (VA) can be life threating and its onset requires immediate medical attention. Similarly, atrial fibrillation and flutter lead to stroke, heart failure and even death. Optimal treatment of VA is very variable and depends on the medical condition associated with the rhythm disorder (which includes reversible causes such as myocardial ischemia or pro-arrhythmic drugs). While an implanted cardioverter defibrillator is often indicated in secondary prevention of VA. This review highlights newest advancements in these techniques and management of ventricular and atrial tachyarrhythmias, along with pharmacological therapy.

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Abstract 4307: New Insights into Surgical Atrial Fibrillation Ablation Therapy: Initial Experience with a Novel Permanently Implantable Heart Rhythm Monitor Device

Circulation ◽

10.1161/circ.118.suppl_18.s_864 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Thorsten Hanke ◽

Antje Karlub ◽

Efstratios Charitos ◽

Axel Hagemann ◽

Bernhard Graf ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Rhythm ◽

Holter Monitoring ◽

Ecg Monitoring ◽

Time Intervals ◽

Ablation Therapy ◽

Implantable Monitor ◽

Monitor Device ◽

Rhythm Monitoring ◽

Af Recurrence

Introduction: Surgical atrial fibrillation (AF) therapy is gaining widespread acceptance among cardiothoracic surgeons. However, assessment of therapy success is until now solely based on short time -“snapshot”-rhythm surveillance often at irregular time intervals. In order to evaluate the ablation’s success we intraindividually compared two different types of follow-up strategies: conventional 24h-Holter monitoring and direct long time rhythm surveillance achieved by a new implantable monitor device (IRMD). Methods: 20 cardiac surgical patients (male 16, mean age 69±9y) with a mean AF of 30±48m (paroxysmal n=7, persistent n=9, long standing persistent n=4) were treated intraoperatively with epicardial high intensity focus ultrasound (HIFU) ablation (+CABG n=10, +AVR n=5, +AVR/CABG n=2, +valve preserving ascending aorta replacement n=2, +endoaneurymoraphy n=1, lone atrial fibrillation n=1). Postoperative heart rhythm monitoring was accomplished in all patients with a 24h-Holter-monitor at prescheduled time intervals and additionally with a new implantable monitor device (Reveal XT, Medtronic®, MN, USA). A more than 0.5% of “time in AF” as reported by the IRMD was considered as recurrence of AF. Telemetry of the IRMD was performed simultaneously after completion of 24h-Holter monitoring. Results: During a mean FU of 8.7±1.4m a total of 29 24 h-Holter-monitors were obtained. Sinus rhythm was documented in 21, the IMRD however revealed AF recurrence in 11 of these cases. Thus, conventional 24 h ECG monitoring failed to identify AF recurrence in 59% of cases (p<0.027). Success rate after surgical ablation therapy (defined as freedom from AF recurrence of more than 0.5% of observational period) was 72% with 24h Holter monitoring, but only 35% using continuous ECG monitoring with IRMD. Conclusion: In order to evaluate better “real life” outcomes after atrial fibrillation ablation therapy, long term continuous heart rhythm surveillance instead of -“snapshot” - heart rhythm monitoring is mandatory. This is particularly important for the decision to alter medical therapies, e.g. oral anticoagulation or antiarrhythmic treatment.

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Abstract 25: Paroxysmal Atrial Fibrillation is Common in Patients With Defined Etiology for Stroke: Prolonged Monitoring of Cardiac Rhythm for Detection of Atrial Fibrillation After a Cerebral Ischemic Event (PEAACE) Study

Stroke ◽

10.1161/str.45.suppl_1.25 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Esseddeeg M Ghrooda ◽

Peter Dobrowolski ◽

Ghazala Basir ◽

Ibrahim Yaseen ◽

Nazim khan ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Cardiac Rhythm ◽

Previous History ◽

Cryptogenic Stroke ◽

Predictive Score ◽

Stroke Patients ◽

Similar Frequency ◽

Stroke Team ◽

Rhythm Monitoring

Introduction: Atrial fibrillation (AF) related cardioembolic stroke accounts for over 20% of ischemic stroke. Recent reports using prolonged cardiac rhythm monitoring (PCRM) in cryptogenic stroke reveal paroxysmal AF (PAF) in an additional 20% of patients. We report our findings with PCRM in patients with and without cryptogenic stroke patients in whom an initial 24-h Holter was negative. Methods: Patients admitted to the stroke service with no previous history of AF and no AF on Holter monitoring were enrolled for 3 weeks of PCRM. We used a PAF predictive score to determine the risk of the arrhythmia. All studies were interpreted by the stroke team prior to final review by the cardiologist. Results: Between Sept 2012 and June 2013, 96 patients were evaluated. Over all PAF was diagnoses in 37.5 % of patients. PAF was diagnosed in 32% of patients with cryptogenic stroke and 36 % of patients where an additional etiology may account for the stroke diagnosis. The AF prediction score was not useful in the recognition of patients that were more likely to be at risk for AF. 96 of 98 recordings were correctly identified by the stroke team prior to final diagnosis by the cardiologist. Interpretation: PAF is more common in stroke patients than was previously suspected. It occurs with similar frequency in patients with and without cryptogenic stroke. Our data strongly supports the need for prolonged cardiac rhythm monitoring in all stroke patients to diagnose this important preventable cause of ischemic stroke.

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Abstract WP222: Comparison of Two Methods of External Prolonged Cardiac Monitoring for the Detection of Atrial Fibrillation: Cardiophone - satellite Real Time Device vs Sorin (Automated Software) for the Peaace Study

Stroke ◽

10.1161/str.47.suppl_1.wp222 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Herbert Manosalva ◽

Saad Hasan ◽

Arif Pervez ◽

Askar Mohammad ◽

Dulara Hussain ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Real Time ◽

Heart Rhythm ◽

Cardiac Monitoring ◽

Real Time Monitoring ◽

Prolonged Monitoring ◽

Stroke Type ◽

Automated Software

Introduction: Recent evidence has shown that prolonged cardiac monitoring is superior to 24 hour Holter for detection of atrial fibrillation (AF). We compared two methods of prolonged monitoring in patients with acute ischemic stroke and TIAs. Objective: Comparison of the Cardiophone and Sorin monitor for detection of AF. Method: In the first part of the study (PEAACE I; 2011-2013), we used the spiderflash (Sorin, Italy) for up to 21 days of monitoring. In the second part (PEAACE II; 2013-2015), Cardiophone with real time monitoring of the heart rhythm for 14 days was used. Results: 102 patients in PEAACE I, (Mean age 72 +/-, 48.8% male) were compared to 120 patients in PEAACE II (Mean age 73 +/-, 70% male). Stroke type was “undetermined (cryptogenic) 92% and 91% in the two studies respectively. In PEAACE I, AF was detected in 43 out of 102 subjects (42%) (72% <30 seconds, 28% >30 seconds) with detection of 75% in the first week, 23% in the second, and 2% in the last week. In PEAACE II, 20 out of 120 subjects (17%) (70% <30 seconds, 30% >30 seconds) had AF, with 55% of detection in the first week, 45% in the second one (χ2 p=0.001). In PEAACE II, the results were available faster, within 2 days compared to 21 days in PEAACE I (χ2 p<0.0005). In PEAACE II, 90% of the patients received anticoagulation (93% of participants with A Fib <30 seconds, 83% with >30 seconds) compared to 77% in PEAACE I (68% with AF <30 seconds and 100% with AF >30 seconds) (χ2 p=0.021). Conclusion: There were significant differences noted in the rates of detection with the two techniques. Real-time monitoring resulted in recording of fewer events but lead to earlier initiation of treatment. All patients with >30 seconds of AF were anticoagulated whereas fewer patients with less than 30 seconds of AF were anticoagulated.

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