How

to Interprete
Ambulatory Electrocardiogram (AECG)
or Holter Monitoring

Erika Maharani
Faculty of Medicine University of Gadjah Mada/
Sardjito General Hospital
Yogyakarta
All arrhythmias STRAIGHTEN
themselves out in
THE END
 Outline

Holter Processing
Basic Rhythm
Sinus Node Function
Chronotropic Incompetence
Atrioventricular Node Function
Supraventricle or Ventricle Extrasistole
ST-T segmen Analysis
Final Report
Holter Processing
The Process
 Number of Channels
5 leads, 3 channels 5 leads, 7 channels 10 leads, 12 channels
 How Holter Finds Arrhythmias
Once you have beat labels its easy:

SEQUENCE Based Arrhythmias

Iso VE (Isolated Ventricular Ectopy): NNNNVNNNN
Couplet: NNNNVVNNNN
Ventricular Run: NNNNVVVVVNNN (#Vs > 3)
Bigeminy: NNNNNVNVNNNNN
Trigeminy: NNNNVNNVNNNNN
Quadrigeminy: NNNNVNNNVNNNNN
 How Holter Finds Arrhythmias

RATE Based Arrhythmias

Sinus Bradycardia: Sinus rhythm with the rate less than 60 bpm

Sinus Tachycardia: Sinus rhythm with the rate more than 100 bpm

Ventricular Tachycardia (V-Tach): Ventricular Run with the rate

more than 120 bpm

Idioventricular: Ventricular Run with the rate less than 40 bpm

 How Holter Finds Arrhythmias

TIME Based Arrhythmias

R-R Pause: when the R-R interval is more than 2000 ms
N-N Pause: when the N-N interval is more than 2000 ms
N-N Delay: when the N-N interval is 10% longer than the average of last
4 N-N intervals. (110%)
R on T: when the next complex comes early on top of the current T wave.
(380 ms)
Rhythm Template
 Signal Quality

Signal quality is a keystone to Holter monitoring. Without a sufficient

signal quality, the diagnostic algorithms often fail and thus the holter
sotware produces a lot of diagnostic errors.

Example:
Such signal cant be
successfully automatically
analyzed by the computer
software, it may require
physicians special attention.
 Good Signal Quality

ECG signal at rest:

ECG signal at rapid movement (patient running quickly)

 Artefacts

Artefacts Associated with the Recording

Sweating as a result of physical activity is a major enemy of the

electrodes.

The care taken to place the electrodes with perfect skin preparation
and careful fixing of the cable.

Thorax muscle contractions are often the source of artefacts, fix the
electrodes on the bony structures (ribs, sternum) to prevent artefacts
from muscle activity.
 Artefacts

Artefacts Associated with to the Recording Device

The tape recording can be influenced by artefacts owing to a rotation

problem with the tape or by the tape itself battery

Artefacts can also be due to an incompletely erased tape, reused after

a previous recording.

Fortunately, this is no longer a problem with digital recordings

The signal disappears completely on the first and second tracing. On the third
tracing, the T waves persist and thus provide the clue for an artefact
 Voice Recording

Each Holter unit is equiped with a microphone and can record the
physicians or patients notes.
This can be used to identify the patient (physician records the patient
name at the beginning of the examination) or as a patients diary.
 Record Duration

Holter offers up to 7 days of ECG monitoring. Such long monitoring

period is useful when subtle arrhytmias are expected to occur and
when classic 24-hour monitoring is not enough.

The Duration of Holter Monitoring in Patients With Syncope

Is 24 Hours Enough?
Eric B. Bass, MD, MPH; Edward I. Curtiss, MD; Vincent C. Arena, PhD; Barbara H. Hanusa, PhD; Alfred Cecchetti; Michael Karpf, MD; Wishwa N.
Kapoor, MD, MPH
Arch Intern Med. 1990;150(5):1073-1078.

These results suggest that 24 hours of Holter monitoring is not enough to identify all potentially important
arrhythmias in patients with syncope. Monitoring may need to be extended to 48 hours if the first 24-hour Holter recording
is normal.
 Holter ECG Report

Ventricular ectopic
(VE); VE beats in excess of Heart Rate Variability
Heart Rate data 10 per hour, VE Pair, V- (HRV); an SDNN of 50 or
Runs, and R on T beats less is cause for concern
are worrisome

ST segmen; delta ST Atrial ectopic; SV-Runs Bradycardia events;

depressions of 1mm or pauses in excess of 2.5
and A-Fib are worrisome.
more are worrisome seconds are problems

This is followed by QT summaries; QTc in excess of 460 ms

can lead to problems
Basic Rhythm
 Basic Rhythm

The sinus rhythm may alternate with one or different arrhythmias, or a

specific arrhythmia may be the basic rhythm.
Sinus Rhythm
Atrial Fibrillation
Atrial Flutter
Atrial Tachycardia

Ventricle Tachycardia

Alternation particularity (day, night, during bradycardia or tachycardia)

Cardiac frequency: maximal and minimal heart rate in correlation with

the physical activities of the patient
Basic Rhythm - Full Disclosure

It starts with Full Disclosure

This is your quality control that
the report is accurate. You see
100% of the 24-hour data, so we
have to report accurately
As shown to the left, all VE, SVE,
and Pause beats are clearly
shown
We then provide you with
summaries, multi-parameter
trends, and ECG strips
 Significant ECG Events

Mini-ECG strips give a general impression .

Strip Pages
Bradycardia - Tachycardia
Atrial fibrillation is
complicated by a
ventricular
tachycardia
Sinus Node Function
 Sinus Pause

Pauses as an expression of sinus dysfunction usually appear at

the end of atrial tachycardias, especially at the end of atrial
fibrillation.
Sinus block
Significant sinus pause:
> 3000 ms if symptomatic
> 6000 ms if asymptomatic

Noted in the Patient Diary

On the left of the tracing we see an atrial fibrillation which suddenly stops, followed by
a pause of nearly 3 sec
On the left of the tracing we see atrial fibrillation followed by the 2 sec pause. Only one
sinus complex appears, following the pause, but the fibrillatory activity reappears in
its repolarisation phase
Bradycardia falsely induced by a blocked atrial bigeminism
Chronotropic Incompetence
 Chronotropic Incompetence

Chronotropic incompetence (CI), broadly defined as the inability of

the heart to increase its rate commensurate with increased activity or
demand

It is common in patients with cardiovascular disease, produces

exercise intolerance which impairs quality-of-life

Independent predictor of major adverse cardiovascular events and

overall mortality
 Chronotropic Incompetence

CI has been most commonly diagnosed when HR fails to reach an

arbitrary percentage (either 85%, 80% or less commonly, 70%) of
the age-predicated maximal HR (usually based on 220-age equation
described earlier) obtained during an incremental dynamic exercise

The diagnosis of CI should take into account the confounding effects of

aging, physical condition, and medications.
 Graph of Patients Activity

The violet color represents patients movement (physical activity)

and blue color means patient was at rest.
This strip can be then correlated with other graphs such as HR or
event dispersion graphs.

Patients activity Heart rate trend

graph (strip)
Patients Event Monitoring

?
Atrioventricular Node Function
 AV Node Conduction

First-Degree Atrioventricular Block

Second-Degree Atrioventricular Block

Type 1 (Mobitz 1) - a Wenckebach phenomenon

Type 2 (Mobitz 2)

Third-Degree Atrioventricular Block

Probable sinoatrial block 2:1, first-degree atrioventricular block with a Wenckebach
phenomenon
Advanced atrioventricular block responsible for a ventricular pause of 2.6 sec
Supraventricle or Ventricle Extrasistole
 Supraventricular Extrasistole
Question
QRS complex has a normal If the QRS looks the same
as normal, how the
morphology but P wave is unusual computer distinguishes and
labels Supraventricular?
 Ventricular Extrasistole

Unusual shape and

morphology of QRS

Normal Conduction Path

Example of Ventricular Conduction

Supraventricular Ventricular
Extrasystolies Extrasystolies

State the number in words State the number in words

Sporadic
Sporadic
Rare (14 extrasystolies/hr)
Rare (14 extrasystolies/hr) Frequent (440 extrasystolies/hr)
Frequent (440 extrasystolies/hr) > 10.000/24 hr
> 10.000/24 hr
State the connections
State the connections Isolated
Isolated In doublets
In doublets Interpolated
Interpolated Bi-, tri-, quadrigeminism
Bi-, tri-, quadrigeminism
Morphology
Blocked
Monomorphic
Bi-, polymorphic
State the origin
Atrial
Junctional
With intraventricular aberration
 Summary Screen

The Summary screen gives a clear overview of all important cardiac

events that were detected in the signal.
The Summary table
contains the list of cardiac
events and their
Summary corresponding value
screen (count).

Use the Navigation buttons

to browse the events and
correct the invalid values if
necessary.
Summary
Screen
ST-T segmen Analysis
 ST Analysis

The ST segment, by definition, goes

from the end of the QRS (usually the

end of the S waves) to the beginning

HR
of the T wave. The end of the S wave
J point
ST Level
is also called the J point.
 ST Analysis

ST Segment

Appreciation

Specificity for the ischemia

Number of episodes

Episode duration

An ST Episode is when both the J-point and ST are depressed by 1 mm

or more for a time period of 1-minute or longer.
Myocardial ischemia with ST segment descent
Myocardial ischemia with ST segment descent, a premature atrial beat which
remains blocked
 QT, QTc, and QTd
All QT events are converted to QTc. This is QT corrected (c=corrected) for heart rate.
A QTc in excess of 450 ms can be a problem.
A QTc in excess of 490 ms should be looked at very seriously.

10/6/16 DM Software 51
 Poincar Graph
A complete record in one sight --- R-R interval
Fast search of Atrial Fibrillation/Flutter, extrasystoles, pauses, noisy areas etc.
Hence, such as the Relief, it is a tool that quickly helps to verify the automatic
diagnostics.
Poincar
Graph

Ventricular extrasystoles Pauses

Low HRV Atrial Fibrilation

Final Report
Title Page
Final Report
 Final Report
Basic rhythm
Is there any significant sinus pause?
Chronotropic competence
AV conduction
Any atrial premature contraction?
Any ventricle premature contraction?
Any ST-T changes?

General Impression
Thank You