Vol. 21, No.
11 November 1999 V 20TH ANNIVERSARY
CE Refereed Peer Review
FOCAL POINT
★Event-based recorders (EBRs)
can confirm or eliminate cardiac
arrhythmia as the cause of
episodic clinical signs by
recording an electrocardiogram
while an episode is occurring.
KEY FACTS
■ EBRs have several distinct
advantages over continuous
(Holter) monitors, including
their light weight, prolonged
duration of monitoring, and
transtelephonic transmission
capability.
■ Two potential drawbacks of EBRs
compared with Holter monitors
are periodic rather than
continuous monitoring and
the need for increased owner
participation.
■ Certain artifacts can alter the
appearance of event-based
recordings.
■ A wireless EBR exists, but its
usefulness in clinical veterinary
medicine is questionable.
Event-Based Cardiac
Monitoring in Small
Animal Practice
California Animal Hospital Beverly Glen Medical Systems
Los Angeles, California Los Angeles, California
Etienne Côté, DVM Elizabeth Charuvastra, RN
Veterinary Specialty Hospital of San Diego
San Diego, California
Keith Richter, DVM
ABSTRACT: Available ambulatory electrocardiographic devices include 24-hour (Holter) monitors
and event-based recorders (EBRs; event-based monitors). EBRs are smaller and less expensive,
can be worn for longer periods, and are more versatile regarding transmission of the acquired
electrocardiographic information than are Holter monitors. These characteristics have made EBRs
useful in small animal practice. However, EBRs may miss asymptomatic arrhythmias and are not
useful for monitoring antiarrhythmic drug therapy. Attachment and use of EBRs are technically
simple, but owner participation is required to activate the recorder when the patient exhibits clini-
cal signs. EBRs help to identify whether intermittent clinical signs are due to a cardiac arrhythmia;
if they are, the monitor reveals the type of arrhythmia. This important information can then be of
therapeutic value, as demonstrated in the clinical cases discussed in this article.
E
lectrocardiography is the test of choice for the clinical diagnosis of cardiac
arrhythmias in dogs and cats.1–3 However, routine electrocardiograms
(ECGs) have obvious shortcomings. Although they provide useful infor-
mation regarding cardiac rhythm at the time of recording, they may be of little
to no use in diagnosing arrhythmias that occur sporadically. This deficiency is
particularly problematic when an animal is presented for evaluation of severe
clinical signs (e.g., recurrent syncope) but the physical examination and in-hos-
pital ECG are normal. In addition, the stress of being handled in the hospital
environment has significant effects on an animal’s cardiovascular system and can
alter heart rate and other variables.4–7 Portable ECG recorders offer an excellent
solution to these problems.
PORTABLE RECORDERS
Holter Monitors
Conceived by Dr. Norman Holter in 1957,8 Holter monitors are portable
ECG units (Figure 1). They consist of a recording unit and several wires that are
attached to a patient using adhesive electrode patches. The unit continuously
records ECGs on a cassette tape for a specified period, usually 24 hours. The re-
Small Animal/Exotics 20TH ANNIVERSARY Compendium November 1999

corded signal is read using a choice for evaluating many

computer designed to de- types of arrhythmias as well as
code the signal on the tape; response to antiarrhythmic
a full record of the cardiac treatment.16,31,35
rhythm during the record- Holter monitoring is not
ing period is produced. perfect. First, although the
Such ambulatory ECG recording unit is compact, it
monitoring is an integral part may be too bulky for very
of diagnostic cardiology.8–33 small veterinary patients. A
The brevity of routine, in- typical Holter monitor weighs
hospital ECGs9,15,34 and the 400 g (14 oz), which (in our
white-coat effect (i.e., physio- experience but not that of
logic changes associated with Figure 1—Types of portable electrocardiographic monitors others32) may be cumbersome
include (from left to right) the Holter monitor, the event-
hospital-induced anxiety)4,5,5a,7,15 based recorder, and the wireless event-based recorder. The for a cat or small dog. Some
are two reasons portable ECG ruler is in centimeters. clinicians have circumvented
monitors may provide a more this problem by keeping small
accurate indication of the di- animals caged during the
urnal heart rate and rhythm compared with routine elec- recording period and leaving the Holter unit on the
trocardiography; the ability of patients to perform the cage floor,a,11,13 but then the benefit of having the animal
physical and mental activities that induce cardiac arrhyth- a
Personal communication: Goodwin JK, DVM, Diplomate
mias may be a third.18 In human medicine, Holter moni- ACVIM (Cardiology), Veterinary Heart Institute, Gainesville,
toring has replaced in-hospital ECGs as the method of FL, 1998.

TABLE I
Technical and Clinical Differences between Holter and Event-Based Recordersa
Parameter Holter Monitor Event-Based Recorder

ECG data 24- or 48-hr continuous two- or 5 min of one-channel ECG; intermittent,
three-channel ECG owner-activated data acquisition
Duration of evaluation 24–48 hr Up to 1 wk or more
Cost Recorder ($1000–$3000) and playback Recorder ($750–$1500) and in-hospital
analysis system ($80,000–$250,000) receiving station ($12,000) or telephone
contact with receiving station
Cost if done through a 24-hr study: $150 (DVM costb); 1 wk: $95 (DVM costb); $165 (client cost);
commercial service $200–275 (typical client cost) 30 days: $280 (DVM costb); $375 (client
cost)
Information transmission Must return Holter tape to the veterinary Can send recording transtelephonically
hospital or recording center to be interpreted
Weight of unit 400 g (14 oz) 100 g (3.5 oz)
Owner participation Keeps diary of patient’s activity Monitors and keeps diary of patient’s activity;
must trigger the recorder when an episode
occurs
Clinical indications Frequent symptomatic arrhythmias; Infrequent episodes (<1 every 24 hr) of
asymptomatic arrhythmia monitoring; suspected arrhythmia; small or weak patients
antiarrhythmic drug monitoring (some)
a
Adapted from Kennedy HL: Role of Holter monitoring for arrhythmia (bradyarrhythmia and tachyarrhythmia) assessment and man-
agement, in Podrid PJ, Kowey PR (eds): Cardiac Arrhythmia: Mechanisms, Diagnosis, and Management. Baltimore, Williams &
Wilkins, 1995, p 226. Used with permission.
b
DVM cost represents the amount veterinarians must pay the commercial service for use of the device.
ECG = electrocardiogram.

WHITE-COAT EFFECT ■ HOLTER MONITORS VERSUS EBRs

Compendium November 1999 20TH ANNIVERSARY Small Animal/Exotics

in its normal environment is lost. ans to assess fewer but longer pe-
Second, the duration of record- riods if necessary (e.g., to record
ing is limited to the capacity of two 2.5-minute episodes).
the tape (i.e., 24 hours). Clinical Event-based recorders are
signs that occur infrequently small and lightweight. A typical
(e.g., once weekly) simply may model is roughly the size of a
not occur during the period cho- beeper and weighs 100 g (3.5
sen for Holter monitoring. oz). It is connected by wires to
Third, the amount of informa- two electrode patches adhered
tion acquired in a full-disclosure to the skin, one on each side of
Holter report is voluminous, and the thorax around the fifth in-
much of it may be nondiagnos- tercostal space at the level of the
tic. At worst, the marked heart Figure 2A costochondral junction (modi-
rate variations in normal dogs fied single precordial lead). In
may be misinterpreted as patho- very active or strong animals, a
logic (e.g., bradycardia), resulting small amount of coupling gel is
in an erroneous diagnosis.9 Final- added to the gel center of the
ly, the Holter tape must be de- electrode patch before adhesion
coded by its parent computer and a tiny drop of tissue glue
system; therefore it must be re- may be placed on two or four
turned to the veterinary hospital corners of the patch to improve
or recording center to provide adhesion to the skin (but not in
any useful information. fragile-skinned animals).
Figure 2B
The unit is usually secured
Event-Based Recorders to the patient by using a special-
Most if not all of the limita- Figure 2—Dogs typically wear an event-based re- ly made harness or is wrapped
corder in a specially made harness (A). In smaller pa-
tions of Holter monitoring can tients, a customized “vest” to hold the event-based re- against the torso using roll
be avoided with event-based corder can be made from bandage material (B). gauze (to prevent excess adhe-
recording (Table I). Event-based sion to hair) under copious elas-
recording has received little at- tic bandage (Figure 2). Excess
tention in veterinary medicine.19,24,25,27,33 Like Holter wire is tucked into the harness to prevent damage. In
monitors, event-based recorders (EBRs) are portable our opinion, small animal patients tolerate EBRs as
ECG units with wires that are attached to a patient using well as or better than they tolerate Holter monitors. No
adhesive ECG patches. However, EBRs record different- damage to EBR equipment has been reported, and even
ly than do Holter monitors. They receive the electric sig- anecdotal evidence of patient-inflicted damage to these
nal from the heart continuously but transiently—they do units is scant.
not retain it. Instead, EBRs have a large button that
must be pressed when an episode (e.g., syncope or weak- ACCESSING THE INFORMATION
ness) occurs (Figure 1); pressing the button triggers the Event-based recordings provide single-lead ECG trac-
EBR to store a segment of ECG in its memory. This ings, which are printed by a receiving unit printer in
ECG segment covers the period just before, during, and the veterinary hospital or receiving center. Each event
after the button was pressed and is saved in the unit’s in the recorder’s memory is printed when the “send”
memory until retrieved. button on the recorder is pressed. The recorder is held
The exact duration of the recorded ECG can be pre- either directly to the receiver–printer unit or to the
programmed by the veterinarian; typically, a “recall” peri- mouthpiece of a telephone that is in direct communica-
od of 45 seconds and an “ongoing” (post–button-press- tion with the hospital or receiving center. Thus it is
ing) period of 15 seconds are programmed. The result is a possible for a patient’s owner to transmit the ECG in-
1-minute segment of recorded ECG that spans the occur- formation transtelephonically, have it evaluated by a
rence of the clinical episode. A total memory of 5 min- veterinarian, and resume monitoring if necessary with-
utes is available; thus up to five episodes can be triggered out having to return to the veterinary hospital.
and recorded before being retrieved by the clinician. Al-
though 1 minute is usually enough time to record most ARTIFACTS
events, the programmability of the EBR allows veterinari- Certain artifacts can alter the appearance of an EBR

HOLTER MONITOR LIMITATIONS ■ RECALL PERIOD ■ ATTACHING EBRs TO PATIENTS

Small Animal/Exotics 20TH ANNIVERSARY Compendium November 1999

tracing. A grossly crenellated episodes triggered for dem-

tracing without evidence of onstration purposes can be
cardiac activity (Figure 3) oc- cleared from the recorder’s
curs if the recorder is trig- memory by pressing the
gered when the recall period Figure 3—A grossly crenellated artifact (first three quarters of “send” button before dis-
is longer than the time the the tracing) occurs when an event-based recorder is triggered charging the animal, and a
monitor has actually been on prematurely after patient hookup.b practice “send” to the receiv-
the patient. This artifact is ing center helps confirm
prevented simply by waiting that the recorder and trans-
to trigger the first recording mission system are working
until enough time has passed properly.
after connecting the recorder At the time of discharge, an
to the patient (45 seconds with appointment should be made
usual programming). for a return visit so that the
Another type of artifact Figure 4A monitor can be rechecked or
that can mimic cardiac activ- removed (if its memory con-
ity is caused by a sharp exter- tains triggered events). The
nal noise during transmis- duration of home monitoring
sion of the recording (Figure varies according to clinician
4A), such as the sound of the preference; we typically have
recorder striking the tele- patients return in a week or
phone mouthpiece. Retrans- Figure 4B less. The monitor’s 9-volt bat-
mission after abolishing ex- Figure 4—Extraneous noise during transmission can produce tery should be changed once
ternal noise eliminates this artifacts that, although narrow and without T-wave changes, weekly.
artifact (Figure 4B). may be misinterpreted as ectopic ventricular activity (A). Re-
A patient’s physical activi- transmission without external noise eliminates the artifact (B). WIRELESS EVENT-
ty during the recording pe- BASED RECORDERS
riod may create a motion A recent development in
artifact (Figure 5), which com- portable ECG monitoring is
plicates interpretation of the the wireless EBR (Figure 1).
tracing. This type of artifact This unit is 5 × 8 cm (ap-
may be impossible to elimi- proximately the size of a cred-
nate if muscular activity (e.g., Figure 5—A motion artifact disrupts this tracing of normal si- it card), is 4 mm thick, and
tremors) is a feature of every nus arrhythmia. has four metal studs on its
clinical episode. back. A square “record” but-
ton is on the front of the unit. The back of the unit is ap-
OWNER INVOLVEMENT plied directly to the chest surface when an arrhythmia is
When discharging a patient wearing an EBR, the clini- suspected (e.g., when syncope occurs). The metal studs are
cian should review important points with the pet owner. electrodes that transmit the electric activity of the heart
The recorder unit must not be chewed, scratched, or into the unit; as many as three 30-second events can be
otherwise harmed and especially must be kept dry. Own- recorded. The signal can then be transmitted transtele-
ers should be instructed to keep a written record of the phonically to the receiving station as previously described.
date and time the monitor is triggered, the animal’s ac- The major advantage of this monitor compared with
tivity, and the outcome. other portable ECG monitors—its lack of wires and
It is helpful to demonstrate how to trigger a recording patches—may be its major drawback in small animal
while the animal is in the examination room (even if the cardiology. Good tracings can be acquired under “hos-
pet is asymptomatic at that time) and then to have own- pital” conditions (hair clipped, skin cleaned with alco-
ers trigger a recording themselves under the veterinari- hol, contact gel applied, and no patient motion; Figure
an’s supervision. The goal is to make owners familiar 6). However, under “field” conditions (hair clipped but
and more comfortable with the procedure when a true no specific preparation of the skin), such as might be
episode occurs. Proper triggering of the “record” button expected in an animal’s usual environment, the quality
is confirmed when a high-pitched, wavering, whistling b
For all ECG tracings, paper speed = 25 mm/sec and ampli-
sound emanates from the recorder. The “practice” tude is 1 cm = 1 mV.

DIARY ENTRIES ■ TRIGGERING THE EBR ■ HOSPITAL VERSUS FIELD CONDITIONS

Small Animal/Exotics 20TH ANNIVERSARY Compendium November 1999

of the tracing is unacceptably poor

(Figure 6). The lack of a “recall” com-
ponent to the recording is another sub-
stantial limitation.

DISCUSSION
Good EBR tracings answer two
very important questions in episodi-
cally symptomatic animals: (1) Are
the clinical signs associated with a car-
diac arrhythmia, and (2) if so, what
kind of arrhythmia is it? In our expe-
rience, the first question applies to an-
imals in which the cardiac examina- Figure 6—Wireless event-based recorder (EBR; upper two strips) and simultaneously
tion (physical examination; routine recorded real-time in-hospital electrocardiograms (lower two strips) from a 5-year-old
hematologic, serum chemistry, and spayed female boxer with cardiomyopathy. The first wireless EBR strip (upper left)
urine profiles; standard nine-lead, in- was made after careful skin preparation; correlation with the real-time electrocardio-
hospital ECG; thoracic radiographs; gram (lower left) is good. The second wireless EBR strip (upper right) was made un-
and echocardiogram) is normal and der “field conditions” (i.e., without skin preparation). It is uninterpretable (com-
pared with simultaneously recorded real-time tracing on the lower right).
with episodes that are neither clearly
neurogenic nor clearly cardiogenic
based on owners’ descriptions. Obtaining a tracing dur- rhythmia as the cause of clinical signs.
ing such an episode either diagnoses the arrhythmia The second question, in our experience, applies to
outright or makes the diagnosis of “nonarrhythmic dis- animals with a known medical problem (e.g., valvular
ease” (e.g., neurologic, respiratory, or other cause) by heart disease) that could trigger either pathologically
exclusion. Thus the EBR helps confirm or eliminate ar- high or pathologically low heart rates. The owners of
these patients describe episodes that are unmistakably
syncopal, but it is not clear whether bradyarrhythmia
Your comprehensive guide to or tachyarrhythmia is to blame. Because excessively
high or low heart rates can cause syncope,2 this situa-
diagnostic ultrasonography tion presents a diagnostic dilemma. As long as the pa-
Nautrup and Tobias tient’s owner is able to trigger the recorder when an
episode occurs and the system is working properly, the
■ Sonographic diagnosis
in dogs and cats, dilemma can be resolved.
including ultrasound, Ideally, EBRs are used in the patient’s normal envi-
M-mode, pulsed and ronment. For a 5-year period (1994–1999), the Cali-
color Doppler fornia Animal Hospital in Los Angeles used an in-hos-
echography pital EBR on 53 consecutive patients with a chief
■ Echocardiography,
abdominal and pelvic complaint of syncope, collapse, or episodic weakness
sonography, and fetal (this number excludes patients in which the arrhyth-
New ultrasonography mia was detected on routine, nine-lead ECG). In
■ Case illustrations these dogs and cats, diagnostic evaluations up to the
using conventional time they were fitted with an EBR had been highly
radiography,
suggestive of but not diagnostic for symptomatic car-
149
computed microfocal
$ diac arrhythmia.
tomography, specimen
photography, and line For each of the 53 patients, the unit was connected
drawings to the animal, and the animal was then hospitalized
Robert E. Cartee, Editor ■ Recognition of the
400 pages, hard cover and monitored for 24 hours. The EBR was to be trig-
disease process and
1597 illustrations courses of treatment gered by the nursing staff when an episode occurred,
but no episode was ever detected in any of the pa-
tients during hospitalization. The EBR was also de-
CALL OR FAX TODAY TO ORDER liberately triggered during asymptomatic periods of
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Compendium November 1999 20TH ANNIVERSARY Small Animal/Exotics

and stair climbing), and ex- of syncopal episodes. Initia-

citement in each patient dur- tion of hydralazine treat-
ing the hospital stay. The ment was associated with
goal of monitoring patients vomiting, and the drug was
under these conditions was Figure 7—Tracing from the dog in case 1 during syncope. discontinued.
to acquire information about Bradycardia is seen, with marked ST segment depression. This The dog was fitted with
the cardiac rhythm that finding was contrary to expectations; medications were adjusted an EBR, which captured the
accordingly, with good results.
would not have been found tracing shown in Figure 7 at
on a routine ECG. Despite the time of an episode of syn-
these conditions, in-hospital cope at home. Based on the
use of the EBR did not reveal bradycardia that was detect-
any information that had not ed by the EBR and the in-
been present on routine hospital resting heart rate of
ECGs in any patient. EBRs 170 beats/min, the β-block-
therefore subjectively appear er was tapered and discon-
to provide little meaningful, tinued and the digoxin dose
episode-related information was increased. This change
when they are used solely in was well tolerated by the pa-
the hospital. Figure 8—Tracings from the dog in case 2 during two epi- tient. Subsequent episodes
sodes of collapse. First tracing (top): heart rate = 33 beats/min of syncope recurred every 2
CASE EXAMPLES (wavy baseline due to motion artifact); second tracing (bot- weeks rather than every 2 to
tom): heart rate = 140 beats/min. The first tracing suggests
Case 1 that the collapse may have been induced by bradycardia; the
3 days, and the dog lived
A 14-year-old intact male second tracing shows that it is not. Antiarrhythmic treatment comfortably for several
Chihuahua was referred for was not prescribed, and the frequency of episodes decreased months with this treatment
evaluation of recurrent con- spontaneously. regimen.
gestive heart failure and syn-
cope. On physical examina- Case 2
tion, the dog was bright, A 14-year-old spayed fe-
alert, responsive, and thin. male Chihuahua was evaluat-
A grade IV/VI systolic mur- ed for episodes of collapse. A
mur in the mitral region Figure 9—Tracing from the cat in case 3. The electrocardio- grade III/VI systolic murmur
and a grade V/VI systolic gram reveals advanced second-degree atrioventricular block (loudest over the mitral valve
murmur in the tricuspid re- with 8 seconds of ventricular asystole. area) was auscultated, and the
gion were detected. Tho- dog had a regular heart rate
racic radiographs and an of 150 beats/min. Thoracic
echocardiogram showed marked enlargement of both radiography and echocardiography were consistent with
atria and severe mitral and tricuspid valvular endocar- chronic mitral valvular insufficiency without evidence of
diosis, prolapse, and regurgitation. Interstitial infiltrates congestive heart failure. A resting ECG showed a sinus
consistent with pulmonary edema were also present. tachycardia (180 beats/min), with one ventricular prema-
The ECG showed sinus tachycardia (heart rate, 170 ture complex. Benazepril treatment was instituted, and
beats/min) and occasional (three to five per minute) no further workup was pursued.
atrial premature complexes. One month later, an increased frequency and severity
Treatment was instituted using furosemide, digoxin, of collapse led to application of an EBR to record the
and enalapril. Over the following weeks, there was patient’s cardiac rhythm during the episodes. The EBR
some improvement in ease of respiration, alertness, tracings showed a sinus bradycardia (Figure 8) at the
and exercise capacity, but syncope continued to occur time of one episode at home and a normal sinus
every 2 to 3 days. Resting, in-hospital ECGs showed rhythm during another, more severe episode. Based on
frequent atrial premature complexes (3 to 10 per these findings, cardiac arrhythmia was excluded as a
minute); although paroxysmal atrial tachycardia was cause of collapse and no further treatment was pre-
suspected as the cause of the syncope,1–3,35 it could not scribed. The episodes spontaneously decreased in fre-
be demonstrated despite multiple in-hospital ECGs. A quency, and the dog did well for 2 months. At that
β-blocker was added to the treatment regimen, but no time, it developed immune-mediated hemolytic anemia
change was noted by the owner in terms of frequency and was euthanized. Whether the hematologic problem

SYSTOLIC MURMUR ■ BRADYCARDIA ■ TACHYCARDIA

Small Animal/Exotics 20TH ANNIVERSARY Compendium November 1999

The tracings (Figure 9) revealed advanced second-de-

Figure 10—Tracing from the dog in case 4. The episodes of
tachypnea and “bounding cardiac apical beat,” which oc-
curred during tracings such as this one, were not caused by a
cardiac arrhythmia.
gree atrioventricular block involving prolonged ven-
tricular asystole. The response to parasympatholytic
drugs was poor; the owner declined pacemaker im-
plantation and elected euthanasia. Postmortem evalu-
ation of the heart revealed normal cardiac dimensions
with numerous left ventricular moderator bands
grossly and myocardial and conductive tissue fibrosis
histologically.

was related to the episodes of collapse is unknown;
necropsy was not performed.
Case 3
An 11-year-old spayed female domestic shorthaired cat
was evaluated for periods of disorientation and loss of
balance. The owner reported a 2-week history of increas-
ingly frequent episodes of a sudden, “glassy-eyed look” in
the cat, followed by stumbling and collapse. The
episodes lasted less than 10 seconds, and the cat was fully
normal within 1 minute of onset. Physical examination,
neurologic examination, routine clinicopathologic tests,
and blood pressure measurement were unremarkable.
Multiple in-hospital ECGs repeatedly demonstrated a si-
nus tachycardia in this fractious cat. Thoracic radio-
graphs and an echocardiogram were normal. The cat was
kept under hospital obser-
PENDIU vation for 36 hours, but no
M
M’
Case 4
A 5-year-old spayed female Labrador retriever was eval-
uated for periods of lateral recumbency, tachypnea, and
apparent discomfort. The owner described a 1-week his-
tory of sudden prostration, a markedly bounding apical
heartbeat seen on the thoracic wall, and rapid breathing,
all occurring once or twice daily. Physical examination re-
vealed marked obesity but no other abnormal findings.
Resting ECG, complete blood count, serum chemistry
panel, thoracic radiographs, and an echocardiogram were
unremarkable. The possibility of the signs simply being
manifestations of the dog’s obesity compounded by hot
weather was discussed but discounted by the owner. An
EBR was applied. The owner noted several episodes at
home over the following 3 days, and the recorded tracings
revealed normal sinus arrhythmia during all of them (Fig-
ure 10). No cardiac medications were prescribed, and a
weight loss program was instituted.

SUMMARY
20th

CO

episodes occurred.
S

1 9 7
9 - 1
9 9 9
ANNIVERSARY
A LookBack
In veterinary medicine during
the past two decades,
ambulatory cardiac monitoring
has evolved in two important
ways: miniaturization and
availability. When designed by
Dr. Holter, the original
monitor alone weighed more
than most of our patients. With
time, the units have become
truly portable and more refined
(e.g., the event-based recorder
introduced in 1987) and,
thanks to overnight mail, are
now widely available to
veterinarians.
Shortly after discharge,
the episodes recurred with
increasing frequency, usu-
ally five to eight times dai-
ly. A home videotape clear-
ly showed a sudden onset
of disorientation and ataxia
while the cat was resting,
followed by falling to one
side and difficulty rising,
over a period of 15 sec-
onds. The cat was readmit-
ted, and again no episodes
were seen during 48 hours
of observation. An EBR
was applied, and the cat
was discharged.
The owner was able to re-
cord several episodes with-
in the first 2 days; these
were associated with quiet,
resting behavior immedi-
ately before the episode.
These cases demonstrate the usefulness of an EBR
when in-hospital evaluations fail to pinpoint the cause
of episodic clinical signs. Like any diagnostic test, EBRs
have their limitations (Table I). However, their ability
to associate an ECG tracing with the occurrence of an
episode, send a recording transtelephonically, and mon-
itor a pet for several days or more without returning to
the veterinary hospital set them apart from continuous,
Holter-type ECG recorders. Furthermore, their reason-
able cost and light weight make them well-suited to
small animal applications in our experience.
ACKNOWLEDGMENTS
All photography by Cottonwood Images, Cotton-
wood, CA. The authors thank Dr. S.-K. Liu, Animal
Medical Center, New York, for pathologic evaluation of
the specimen in case 3. The authors also thank Drs.
David Feldman, Lisa Kurosky, Samantha Ahrens, and
Wendy Fife for editorial comments and Denise Asaro,
RVT, for technical and clerical assistance.
REFERENCES
1. Ettinger SJ, Suter P: Canine Cardiology. Philadelphia, WB
Saunders Co, 1970.

ATAXIA ■ SECOND-DEGREE ATRIOVENTRICULAR BLOCK ■ OBESITY

Compendium November 1999 20TH ANNIVERSARY
2. Ettinger SJ, Lunney J: Cardiac arrhythmias, in Ettinger SJ,
Feldman EC (eds): Textbook of Veterinary Internal Medicine,
ed 4. Philadelphia, WB Saunders Co, 1995, pp 959–995.
3. Tilley LP: Essentials of Canine and Feline Electrocardiography,
ed 3. Philadelphia, Lea & Febiger, 1992.
4. Hamlin RL: Heart rate of the cat. JAAHA 25:284–286,
1989.
5. Bovee KC: A comparison of indirect blood pressure mea-
surements to direct continuous telemetry in normal dogs
(Abstr). Proc 14th ACVIM Forum:743 1996.
5a. Kallet AJ, Cowgill LD, Kass PH: Comparison of blood pres-
sure measurements obtained in dogs by use of indirect oscil-
lometry in a veterinary clinic versus at home. JAVMA
210(5):651–654, 1997.
6. Hamlin RL, Olsen I, Smith CR, Boggs S: Clinical relevancy
of heart rate in the dog. JAVMA 151(1):60–63, 1967.
7. Belew AM, Berlett T, Brown SA: Evaluation of the white-
coat effect in cats. J Vet Intern Med 13:134–142, 1999.
8. Mandel WJ, Peter CT, Bleifer SB: Holter-monitor record-
ing, in Mandel WJ (ed): Cardiac Arrhythmias: Their Mecha-
nisms, Diagnosis, and Management, ed 3. Philadelphia, Lip-
pincott, 1995, pp 811–861.
9. Moïse NS: Diagnosis and management of canine arrhyth-
mias, in Fox PR, Sisson DD, Moïse NS (eds): Canine and
Feline Cardiology, ed 2. Philadelphia, WB Saunders Co,
1999, pp 331–385.
10. Moïse NS, De Francesco T: Twenty-four–hour ambulatory
electrocardiography (Holter monitoring), in Bonagura JD
(ed): Kirk’s Current Veterinary Therapy XII. Philadelphia,
WB Saunders Co, 1995, pp 792–799.
11. Goodwin JK, Lombard CW, Ginex DD: Results of continu-
ous ambulatory electrocardiography in a cat with hyper-
trophic cardiomyopathy. JAVMA 200(9):1352–1354, 1992.
12. Ware WA: Twenty-four hour ambulatory electrocardiogra-
phy in normal cats. J Vet Intern Med 13:175–180, 1999.
13. Fox PR, Moïse NS, Price RA, et al: Analysis of continuous
ECG (Holter) monitoring in normal cats and cardiomy-
opathic cats in congestive heart failure (Abstr). Proc 16th
ACVIM Forum:689, 1998.
14. Meurs KM, Brown WA: Update on boxer cardiomyopathy.
Proc 16th ACVIM Forum:119–120, 1998.
15. Miller RH, Lehmkuhl LB, Bonagura JD, Beall MJ: Retro-
spective analysis of the clinical utility of ambulatory electro-
cardiographic (Holter) recordings in syncopal dogs: 44 cases
(1991–1995). J Vet Intern Med 13:111–122, 1999.
16. Mason JW, for the ESVEM Investigators: A comparison of
electrophysiologic testing with Holter monitoring to predict
antiarrhythmic drug efficacy for ventricular tachyarrhyth-
mias. N Engl J Med 329(7):445–451, 1993.
17. Kennedy HL: Role of Holter monitoring for arrhythmia
(bradyarrhythmia and tachyarrhythmia) assessment and
management, in Podrid PJ, Kowey PR (eds): Cardiac Ar-
rhythmia: Mechanisms, Diagnosis, and Management. Balti-
more, Williams & Wilkins, 1995, pp 219–232.
18. Zipes DP: Genesis of cardiac arrhythmias: Electrophysiologi-
cal considerations, in Braunwald E (ed): Heart Disease: A
Textbook of Cardiovascular Medicine, ed 5. Philadelphia, WB
Saunders Co, 1997, pp 548–592.
19. Goodwin JK: Holter monitoring and cardiac event record-
ing. Vet Clin North Am Small Anim Pract 28(6):1391–1407,
1998.
20. Ulloa HM, Houston BJ, Altrogge DM: Arrhythmia preva-
Small Animal/Exotics
lence during ambulatory electrocardiographic monitoring of
beagles. Am J Vet Res 56(3):275–281, 1995.
21. Calvert CA: Diagnosis and management of ventricular ar-
rhythmias in Doberman pinschers with cardiomyopathy, in
Bonagura JD (ed): Kirk’s Current Veterinary Therapy XII.
Philadelphia, WB Saunders Co, 1995, pp 799–806.
22. Calvert CA, Pickus CW, Jacobs GJ: Efficacy and toxicity of
tocainide for the treatment of ventricular tachyarrhythmias
in Doberman pinschers with occult cardiomyopathy. J Vet
Intern Med 10(4):235–240, 1996.
23. Kennedy HL: Ambulatory (Holter) electrocardiography re-
cordings, in Zipes DP, Jalife J (eds): Cardiac Electrophysiolo-
gy: From Cell to Bedside, ed 2. Philadelphia, WB Saunders
Co, 1995, pp 1024–1038.
24. Abbott JA: The diagnostic evaluation of patients with syn-
cope. Proc 14th ACVIM Forum:182–184, 1996.
25. De Francesco TC: Why is this dog fainting? Proc 15th
ACVIM Forum:140–142, 1997.
26. Hall LW, Dunn JK, Delaney M, et al: Ambulatory electro-
cardiography in dogs. Vet Rec 129:213–216, 1991.
27. Beardow A: Ambulatory ECG recording. Proc 16th ACVIM
Forum:102, 1998.
28. Jacobs GJ: Comprehensive update on Doberman cardiomy-
opathy. Proc 16th ACVIM Forum:107–109, 1998.
29. Sheffield LT, Berson A, Bragg-Remschel D, et al: Recom-
mendations for standards of instrumentation and practice in
the use of ambulatory electrocardiography. Circulation 71(3):
626A–636A, 1985.
30. Knoebel SB, for the AHA/ACC/ACP Task Force on Clinical
Privileges in Cardiology: Clinical competence in ambulatory
electrocardiography. Circulation 88(1):337–341, 1993.
31. Morganroth J: Evaluation of antiarrhythmic therapy using
Holter monitoring. Am J Cardiol 62:18H–23H, 1988.
32. Ware WA: Practical use of Holter monitoring. Compend
Contin Educ Pract Vet 20(2):167–177, 1998.
33. Brownlie SE: Evaluation for veterinary use of the Chiltern
box: A device for home electrocardiographic monitoring. Vet
Rec 120:85–87, 1987.
34. Raeder EA, Hohnloser SH, Graboys TB, et al: Spontaneous
variability and circadian distribution of ectopic activity in
patients with malignant ventricular arrhythmias. J Am Coll
Cardiol 12(3):656–661, 1988.
35. Podrid PJ, Kowey PR: Handbook of Cardiac Arrhythmia.
Baltimore, Williams & Wilkins, 1996.
About the Authors
When this article was submitted for publication, Dr. Côté
was affiliated with the California Animal Hospital, Los An-
geles, California. He is now with Angell Memorial Animal
Hospital, Boston, Massachusetts and is a Diplomate of
the American College of Veterinary Internal Medicine. Ms.
Charuvastra is affiliated with Beverly Glen Medical Sys-
tems, Los Angeles, California. Dr. Richter, a Diplomate of
the American College of Veterinary Internal Medicine, is
affiliated with the Veterinary Specialty Hospital of San
Diego, San Diego, California.