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Ambulatory ECG Monitoring

Editor: Intisar Ahmed Updated: 11/2/2023 1:03:52 AM


Cardiovascular diseases substantially contribute to the burden of morbidity and mortality worldwide.[1] Arrhythmias significantly contribute to cardiovascular morbidity; most cardiac arrests and sudden cardiac deaths are secondary to arrhythmias.[2] The rapid, accurate diagnosis of dysrhythmias is essential to effectively treat patients, prevent complications, and optimize patient outcomes. Electrocardiography (ECG) is a foundational diagnostic tool offering valuable insight into the function of the cardiac conduction system. However, traditional ECG recordings in clinical settings provide only a snapshot of cardiac activity, limiting their ability to capture intermittent or subtle abnormalities.[3]

Ambulatory ECG monitoring enables continuous and prolonged surveillance of a patient's cardiac rhythm in their natural environment.[4] Ambulatory ECG monitoring employs portable devices to record and analyze cardiac electrical activity over extended periods. Continuous, prolonged monitoring is more likely to detect transient or infrequent cardiac events that may go unnoticed during short-term recordings. The prototype of ambulatory ECG monitoring is the Holter monitor, invented in 1961.[5] Ambulatory ECG monitoring has continually advanced; multiple devices are now available to improve diagnostic yield.[6] Prolonged ambulatory ECG monitoring is uniquely poised to capture elusive arrhythmias, evaluate the efficacy of antiarrhythmic therapies, and assess overall cardiovascular health.[7] 

This activity reviews the various ambulatory ECG monitoring devices currently in clinical use and the indications, critical findings, and clinical significance of this testing modality.


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Various ambulatory ECG monitoring systems are in regular clinical use. These systems include but are not limited to the Holter monitor, different event recorders, patch monitors, mobile outpatient cardiac telemetry, and various implantable devices. Additionally, several consumer devices are available for monitoring the cardiac conduction system.

Continuous ECG Monitor

Continuous ECG monitors, or Holter monitors, are the most commonly utilized ambulatory ECG monitoring devices. Holter monitors permit the continuous recording of cardiac electrical activity for an extended period, typically 24 to 72 hours. These monitors are indispensable when evaluating patients with intermittent symptoms, effectively capturing episodes of arrhythmias that might otherwise remain undetected. [8]

Holter monitors are lightweight devices comprising electrodes attached to the patient's chest and connected to a compact recording device approximately the size of a deck of cards that may be worn on the waist or carried in a convenient pouch. (See Image. Holter Monitor) Holter monitor recordings can be acquired in 2-, 3-, or 12-channel formats. The primary advantage of the Holter monitor is the capture of an extended duration of ECG data, enabling the detection and analysis of transient and infrequent arrhythmias easily missed during a snapshot ECG.

Conventional Holter monitors require active patient participation; patients must manually record their symptoms in a journal or mark their occurrence by pressing a button on the recording device. The data obtained from a Holter monitor is downloaded, and a comprehensive report is generated. Reports include various parameters, including total heartbeats, average heart rate, maximum and minimum heart rates, number and type of premature beats, the duration and type of various tachyarrhythmias, and ST segment changes. (See Image. Holter Monitor Data Output.) A Holter monitor may be the preferred modality of ambulatory ECG monitoring when evaluating patients with frequent daily symptoms.[9]

The utility of Holter monitors is limited by patient compliance and the brevity of the monitoring period. Patients must be willing to wear the monitor throughout the entire monitoring period; discomfort or skin irritation are common barriers to compliance. Due to the relatively brief duration of monitoring, a negative result does not exclude the existence of significant disease with infrequent events. Interpreting and analyzing such extensive ECG data requires expertise and is time-consuming. Holter monitors also do not provide real-time information and delay identifying essential events.[10]

Event Recorders: Loop Recorders and Post-Event Monitors

Event monitors are a suitable option for patients experiencing syncope, near syncope, or infrequent episodes of dizziness occurring weekly to monthly.[11] Traditional post-event recorders are small devices capable of recording a single ECG lead for several minutes. The patient presses a button on the device while holding it to their chest to activate the recording capability. The recorded data can be quickly downloaded, permitting real-time monitoring if the patient promptly performs the download.[12][13] Unlike a Holter monitor, a post-event recorder is unobtrusive and can be comfortably carried in a pocket when not in use; the need for chest wires is eliminated, and everyday activities are easily accomplished.

The most significant drawback of post-event recorders is the lack of continuous ECG monitoring; placing the device against the chest makes it challenging to capture brief symptomatic episodes, and asymptomatic events go unrecorded. Additionally, the onset of the episode is not recorded; this impairs accurate diagnosis.

External loop recorders address some of these limitations by continuously monitoring the cardiac conduction system, storing the data in a loop memory for 30 days, and actively recording event data when activated by the patient. External loop recorders are indicated monitoring modalities for patients with infrequent nonsyncopal symptoms; syncopal patients cannot activate the monitor when unconscious.[12] When activated, these recorders store data for a fixed period before and after the activation. 

While external loop recorders and event monitors are effective for frequent symptoms, the correlation between symptoms and ECG abnormalities is low for events that occur less than once monthly. In cases where extended monitoring is necessary, implantable loop recorders may be utilized. These devices are designed to be implanted subcutaneously in the chest wall via a minimally invasive procedure performed without general anesthesia. Implantable loop recorders can record data for up to 3 years, are MRI-compatible, and have low infection and complication rates.[14][15]

Patch Monitor

Patch monitors combine user-friendly features with patient comfort. Patch monitors have an adhesive backing, adhere securely to the skin, and eliminate the need for irritating wires and electrodes. The lightweight and unobtrusive design of most patch monitors permits unrestricted daily activities. Patients can conveniently annotate symptoms using a button on the device, facilitating better correlation between symptoms and conduction events. Patch monitors are typically worn for 14 days, significantly extending the monitoring duration compared to the conventional 48-hour monitors. Prolonged monitoring increases the likelihood of identifying arrhythmias that might go unnoticed in shorter monitoring periods. A study conducted by Barret et al demonstrated that the adhesive patch monitor outperformed the Holter monitor in detecting cardiac events in patients with suspected arrhythmia.[16][17]

Mobile Cardiac Outpatient Telemetry™

In contrast to the offline analysis permitted by typical patch monitors, Mobile Cardiac Outpatient Telemetry (MOCT) devices provide real-time, wireless arrhythmia monitoring, transmission, and analysis. Patients can trigger the machine to collect and automatically transmit data during symptomatic episodes.[18]

MOCT has demonstrated superior diagnosis of clinically significant arrhythmias compared to standard patient-triggered loop monitors.[19][20] Medic et al studied a cohort of 1000 patients with cryptogenic stroke and no history of atrial fibrillation to compare the expense and diagnostic accuracy of 30 days of MCOT followed by an implantable loop recorder (ILR) versus an ILR alone. The results demonstrated that an initial 30-day monitoring period with MCOT increased detection rates of atrial fibrillation at a cost 8 times lower than an ILR alone.[21] 

Implantable Cardioverter-Defibrillators and Permanent Pacemakers

Implantable cardioverter-defibrillators (ICDs) and permanent pacemakers (PPMs) can be continuous monitoring devices with detection algorithms for arrhythmias, including supraventricular and ventricular tachycardia. (See Image. Implantable Cardioverter-Defibrillator Recording) When appropriately programmed, these devices exhibit sensitivity and specificity of greater than 95% in detecting atrial fibrillation.[22] In specific scenarios, patients with ICDs or PPMs may undergo external ECG monitoring to assess the functionality of implanted devices and identify potential malfunctions. Device interrogation allows data retrieval regarding the frequency and duration of arrhythmias, ventricular rates, and the necessity for shock termination episodes. Additionally, remote monitoring of these devices is available to evaluate arrhythmias and the efficacy of delivered therapies.[23]

Consumer Devices

Rapidly advancing technology has led to the widespread availability of heart rate and rhythm monitors, employing smartphones as convenient storage devices for the captured data. Some of these monitors feature algorithms that can detect irregularities, particularly atrial fibrillation, offering the potential for early detection, treatment, and reduction of stroke risk. Some rhythm monitors in smartphones and handheld devices record single-lead ECG data, including rhythm strips, during symptomatic episodes; this data can be shared with physicians for review to streamline the process of atrial fibrillation detection.

The iTransmit study introduced a compact handheld monitoring device that attaches to smartphone cases. This device exhibited 100% sensitivity and 97% specificity in detecting atrial flutter and atrial fibrillation compared to traditional trans-telephonic monitors.[24] Lubitz et al conducted a study involving 455,699 participants who wore smartwatches with photoplethysmography sensors. The identification of irregular heart rhythms prompted the use of a 1-week ECG patch monitor for arrhythmia confirmation. The smartwatches achieved a 97% positive predictive value in detecting irregular heart rhythms compared to the patch monitor.[25]

Integrating heart rate and rhythm monitors with smartphones and handheld devices reshapes ambulatory cardiac monitoring. These technological innovations, along with improved algorithms and seamless data sharing, hold significant promise for the early detection and management of atrial fibrillation and other dysrhythmias, advancing personalized cardiovascular care.



Syncope is the loss of consciousness and postural control followed by spontaneous recovery without residual neurological effects. Syncope has many etiologies, including primary cardiac causes such as bradyarrhythmias, tachyarrhythmias, or inherited disorders such as Brugada or long-QT syndromes. Correlating symptoms with rhythm is the key to confirming cardiac electrical system involvement in syncope.[26] A 12-lead ECG may establish this link; ECG monitoring over an extended period is an essential evaluation component in cases of intermittent syncope. The 2017 American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) Guidelines for the Evaluation and Management of Patients With Syncope suggest ambulatory ECG monitoring in symptomatic patients with near syncope, unexplained syncope, or episodic dizziness with an unknown cause.[27]

In a study of 85 patients with recurrent, undiagnosed syncope who underwent ILR placement to facilitate diagnosis, 42% of patients who recorded a rhythm during symptomatic syncopal episodes demonstrated an arrhythmia, usually some form of bradycardia.[28] Data indicates that external loop recorders (ELRs) may be comparably effective to ILRs. Locati et al demonstrated that ELRs offered a diagnostic yield similar to ILRs within the same timeframe in patients with syncope and presyncope.[29] Consideration of an ELR is a viable initial step for patients requiring extended ECG monitoring before resorting to implantable options.


The 2017 ACC/AHA/HRS Guidelines for the Evaluation and Management of Patients With Syncope also suggest ambulatory ECG monitoring in symptomatic patients with recurrent palpitations of an unknown cause. [27] Palpitations are one of the most prevalent reasons for ambulatory ECG monitoring. The underlying cause of palpitations can often be identified through an initial assessment and a 12-lead ECG; one-third of cases will have a psychiatric origin.[30] Ambulatory ECG monitoring is recommended when the cause of the palpitations remains unknown, even after obtaining a comprehensive medical history, performing a physical examination, and evaluating a resting 12-lead ECG.[31][32] Choosing an appropriate ECG monitoring device is predicated upon consideration of the clinical presentation and frequency of the palpitations. A traditional Holter monitor is indicated for patients experiencing daily symptoms. Loop recorders and patch monitors offer more diagnostic potential for those with infrequent palpitations, and opting for a 2-week monitoring period strikes a reasonable balance between diagnostic effectiveness and overall cost for most patients.[33][34]

Chest Pain and Ischemic Episodes

Ambulatory ECG monitoring is valuable for patients with atypical chest pain associated with stresses other than exercise by enabling the assessment of myocardial ischemia during routine activities. Ambulatory ECG monitoring sometimes unveils an underlying arrhythmia as the initiator of chest pain. In a study by Stern et al of 50 patients with precordial pain, where positive results in ambulatory ECG monitoring were characterized by ST-segment deviations of ≥1 mm from the baseline pattern or significant T wave inversions demonstrated that of the 32 patients with positive abnormalities, 28 had severe coronary disease during coronary angiography. Conversely, among the 18 patients without positive monitoring results, only 3 met the angiographic criteria for severe coronary disease.[35]

Standard 24-hour ambulatory ECG monitoring helps recognize and evaluate early ischemic heart disease by recording dynamic changes, even when the resting 12-lead ECG appears normal. However, dynamic ST-segment changes may be confounded by body position or cardiac medications; cautious interpretation is warranted.[36] Crawford et al. In a study of 70 patients with chest pain, normal resting ECGs, and known significant coronary artery disease, Crawford et al determined a 62% sensitivity and 61% specificity rate for ST depression during ambulatory monitoring, concluding that continuous ambulatory ECG monitoring is limited in detecting or ruling out coronary artery disease in symptomatic patients with normal resting ECGs. [37]

Ambulatory ECG monitoring likely benefits patients with chest pain suggestive of variant angina secondary to transient coronary artery spasms. The baseline 12-lead ECG is typically expected in patients with variant angina, as transient coronary vasospasm usually occurs during periods of rest and without conventional triggers such as stress or exercise; capturing ECG changes during routine activities becomes imperative to the diagnosis.[38] Clinicians can correlate patient symptoms with recorded ECG patterns, allowing for precise diagnosis, disease progression assessment, and therapeutic strategies. Significant ventricular tachyarrythmias can develop in about 50% of patients during vasospasm-induced ischemic attacks. [39] Other ECG changes commonly seen during coronary vasospasm include ST-segment elevation, premature atrial and ventricular contractions, ventricular tachycardia, and complete atrioventricular block.[40] 

Normal and Critical Findings

Dilated Cardiomyopathy

Nonischemic dilated cardiomyopathy (NIDCM) is characterized by dilated left or bilateral ventricles and impaired systolic contractile function. NIDCM may result in life-threatening arrhythmias and sudden cardiac death (SCD). [41] The clinical utility of ambulatory ECG monitoring in NIDCM is debatable and may be of limited prognostic value. Some studies demonstrate that ambulatory ECG monitoring is a risk-stratification tool for SCD by detecting nonsustained ventricular tachycardia (NSVT) episodes.[41][42] Other studies suggest that ambulatory ventricular arrhythmias alone may not reliably predict SCD.[43] Notably, 24-hour Holter monitoring has revealed NSVT in 40% to 60% of cases of SCD occurring during ambulatory monitoring.[44]

However, the role of ambulatory ECG monitoring extends beyond prognostication by identifying atrial fibrillation, thereby influencing therapeutic decisions, including initiating anticoagulation therapy to prevent strokes in patients with NIDCM.[45] Moreover, recognizing paroxysmal supraventricular arrhythmias in young patients with NIDCM should warrant consideration of the possibility of underlying familial Lamin-A/C (LMNA) cardiomyopathy. [46]

Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is linked to an elevated risk of sudden cardiac death (SCD), particularly among young individuals, including athletes.[47] Patients with HCM frequently report syncopal episodes and palpitations.[48] Asymptomatic NSVT with a ventricular rate exceeding ≥120 beats per minute is observed in approximately 25% of adults with HCM cases and correlates with a notable escalation in SCD risk.[49] Additionally, paroxysmal supraventricular arrhythmias manifest during ambulatory ECG monitoring in up to 38% of patients with HCM.[50]

Given the pronounced vulnerability to SCD and arrhythmias, the 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients with HCM recommends 24- to 48-hour ambulatory ECG monitoring during the initial assessment and every 1 to 2 years after that for patients with HCM.[51] This proactive approach promotes early detection and risk stratification for patients with this genetic condition, enabling clinicians to devise targeted management strategies and improve the overall prognosis and quality of life.

Chronic Obstructive Pulmonary Disease

Ventricular and supraventricular arrhythmias are common among individuals with chronic obstructive pulmonary disease (COPD). A study by Rusinowicz et al of 152 patients experiencing a COPD exacerbation revealed that 97% exhibited arrhythmias during 24-hour Holter monitoring. The most prevalent arrhythmia in the study was premature ventricular contractions (PVCs), occurring at an average of 1870 PVCs in 24 hours; supraventricular premature beats (SPBs) occurred at an average of 699 SPBs within the same timeframe. Additionally, supraventricular tachycardia was reported in 34% of the subjects.[52]

A retrospective investigation by Konecny et al of 6351 patients analyzed the incidence of ventricular tachycardia within a population of patients with COPD using Holter monitoring. Patients with COPD exhibited a higher prevalence of VT compared to their healthy counterparts; the occurrence of VT increased with the severity of COPD.[53] Another study demonstrated arrhythmias in 72% of patients with COPD during ambulatory Holter monitoring.[54]

Dialysis and End-Stage Renal Disease

Patients with end-stage renal disease (ESRD) have an increased risk of cardiovascular events, including arrhythmia.[55] Hemodialysis results in substantial hemodynamic and perfusion shifts; the dialysis procedure itself has been established as a contributor to the onset of atrial fibrillation.[56][57]

A cross-sectional study by Rantanen et al utilized 48-hour Holter monitors initiated just before each dialysis session in 152 patients and revealed PACs and PVCs in most patients; paroxysmal supraventricular tachycardia affected 41% of studied patients. Another 8.6% of patients exhibited persistent atrial fibrillation, 3.9% experienced paroxysmal atrial fibrillation, 19.7% had NSVT, 4.6% had bradycardia, 1.3% had second-degree atrioventricular block, and 2.6% experienced third-degree atrioventricular block. PVCs were more prevalent on dialysis days, and tachyarrhythmias were more pronounced during dialysis and the immediate post-dialytic phase.[58] This data suggest that ambulatory ECG monitoring during dialysis could promote the early detection of arrhythmias in asymptomatic patients, which may prompt timely strategies for effective management.

Mitral Valve Prolapse

Arrhythmias are a frequent manifestation in patients with mitral valve prolapse. In patients with prominent symptoms or detectable auscultatory findings, ambulatory ECG monitoring demonstrates a substantial prevalence of atrial and ventricular arrhythmias. Symptoms commonly experienced by those with mitral valve prolapse include dyspnea, palpitations, syncope, and chest pain. Ambulatory ECG monitoring assesses these symptoms and establishes if arrhythmias contribute to their occurrence [59]. One study revealed that only 27% of symptomatic patients with mitral valve prolapse exhibited arrhythmias linked to their symptoms.[60]

Pre-Excitation Syndrome

Wolff-Parkinson-White (WPW) syndrome is characterized by an anomalous accessory electrical pathway within the heart and intermittent symptoms. Traditional resting 12-lead ECGs occasionally fail to detect WPW syndrome, prompting the consideration of ambulatory ECG monitoring. Among confirmed patients with WPW syndrome, ambulatory ECG monitoring has demonstrated that pre-excitation is intermittent in up to 67% of patients.[61][62]

Sinus Node Dysfunction

Historically known as "sick sinus syndrome," sinus node dysfunction is frequently associated with age-related degenerative fibrosis affecting the sinus nodal tissue and surrounding atrial myocardium. During symptomatic episodes, sinus node dysfunction commonly manifests as prolonged sinus pauses lacking an accompanying escape rhythm. Ambulatory 24-hour ECG monitoring is often required to correlate symptoms with electrocardiographic evidence. Some patients with sinus node dysfunction remain asymptomatic during sinus pauses.[63]

Sinus node dysfunction may manifest with other ECG abnormalities, including periods of severe bradycardia, atrial fibrillation, and alternating patterns of bradycardia and atrial tachyarrhythmias.[64][65] When a comprehensive history, physical examination, and initial 12-lead ECG fail to yield a diagnosis, ambulatory monitoring is a valuable tool for confirming the presence of sinus node dysfunction. A Holter monitor is recommended for individuals encountering daily symptoms, while those with less frequent symptoms are better evaluated with more prolonged monitoring.[63]

Sleep Apnea

Cardiac arrhythmias and conduction disorders are frequently encountered in patients with sleep apnea.[66] A comprehensive investigation comprising 400 patients diagnosed with sleep apnea and monitored with a 24-hour Holter device found that 48% exhibited cardiac arrhythmias during sleep.[67] Javaheri et al conducted a prospective study on 81 men with stable heart failure, 41 of whom had sleep apnea, and demonstrated that patients with sleep apnea have a high incidence of ventricular arrhythmias and atrial fibrillation.[68]

Holter monitoring may be a valuable tool for predicting the risk of obstructive sleep apnea. In a comparative analysis of 63 patients, Holter monitoring captured apnea events with 90% sensitivity and 82.6% specificity, compared to polysomnography, suggesting that Holter monitoring may enhance diagnostic and therapeutic strategies in patients with certain sleep disorders.[69]

Transcatheter Aortic Valve Replacement 

Ambulatory ECG monitoring has become essential for understanding arrhythmias before and after transcatheter aortic valve replacement (TAVR). Studies using ambulatory ECG monitoring found bradyarrhythmias or tachyarrhythmias in approximately 15% of patients before TAVR, which led to treatment changes in approximately half of these cases. Identifying severe bradyarrhythmias before TAVR permits planned pacemaker implantation and decreases procedural complications. Detecting atrial fibrillation before TAVR can prompt early anticoagulation therapy and potentially reduce post-TAVR cerebrovascular events.[70]

Patient Safety and Education

To uphold patient safety during this process, healthcare providers must adhere to strict quality control measures and ensure the accurate placement and functioning of the monitoring device. Additionally, comprehensive patient education is vital to optimizing the use and management of the monitoring device. Educating patients about potential discomforts, troubleshooting procedures, and the importance of maintaining baseline activities and routines can enhance their adherence to the monitoring process and increase the overall quality of the collected data. Healthcare professionals can maximize the diagnostic yield, facilitate timely interventions, and improve patient outcomes by fostering patient safety and education in ambulatory ECG monitoring.

Clinical Significance

Ambulatory ECG monitoring plays a pivotal role in cardiology by providing continuous, prolonged ECG recording outside the clinical setting. Ambulatory ECG monitoring promotes the capture of elusive arrhythmias, gauges treatment efficacy, aids in risk stratification, and enhances syncope evaluation. As technology evolves, the potential for more advanced ambulatory monitoring devices promises further refinement of patient care strategies in cardiology.

Diagnosing Arrhythmias and Cardiac Abnormalities

Ambulatory ECG monitoring offers a dynamic insight into the heart's electrical activity throughout an extended period, enabling the detection of arrhythmias and cardiac abnormalities that might be missed during conventional ECGs. This technique captures intermittent or transient arrhythmic events, such as atrial fibrillation, bradyarrhythmias, and premature ventricular contractions. By providing a comprehensive overview of a patient's heart rhythm, ambulatory monitoring aids in accurate diagnosis and informs appropriate treatment strategies.[71]

Risk Stratification and Prognosis

Risk stratification is critical to managing cardiac patients, and ambulatory ECG monitoring contributes significantly to this process. Through continuous monitoring, clinicians can quantify the burden of arrhythmias, aiding in identifying high-risk patients who may benefit from interventions such as anticoagulation therapy or ICDs.[41]

Syncope Evaluation

Syncopal episodes often pose diagnostic challenges due to their transient nature. Ambulatory ECG monitoring offers a valuable solution by recording cardiac activity during these episodes, potentially capturing arrhythmias or cardiac anomalies that could underlie the syncopal events. This data-driven approach enhances the accuracy of diagnosis and facilitates appropriate management strategies for patients experiencing unexplained syncope.[72]

Long-Term Monitoring

Certain cardiac conditions necessitate extended monitoring to assess their impact on patient health. Ambulatory ECG monitoring conducted over an extended duration of days to months provides insight into the chronicity and variability of arrhythmic events. Conditions such as atrial fibrillation benefit from such monitoring, enabling the fine-tuning of treatment plans based on long-term trends. 


(Click Image to Enlarge)
<p>Holter Monitor</p>

Holter Monitor

Contributed by I Ahmed, MBBS, FCPS

(Click Image to Enlarge)
<p>Holter Monitor Data Output. A Holter monitor recording reveals the start of supraventricular tachycardia.</p>

Holter Monitor Data Output. A Holter monitor recording reveals the start of supraventricular tachycardia.

Contributed by I Ahmed, MBBS, FCPS

(Click Image to Enlarge)
<p>Implantable Cardioverter-Defibrillator Recording

Implantable Cardioverter-Defibrillator Recording. An implantable cardioverter-defibrillator (ICD) recording reveals the initiation of tachycardia.

Contributed by I Ahmed, MBBS, FCPS



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