The Value of Holter Monitoring for Detection of Ischemic Heart Disease

M.L. Simoons, T. Boeluner, J. Roelandt, and J. Pool*

Introduction

The diagnosis of stable coronary artery disease can be established by making a careful
history of the patient, documentation of ECG changes during episodes of coronary
insufficiency, visualization of regions with temporarily impaired uptake of thallium-201
or other isotopes, measurement of impaired left ventricular function during ischemic
episodes and, fmally, coronary arteriography. Optimal results will be obtained when
the proper methods are selected for each individual patient.
Characteristic ECG changes can be elicited through an exercise test. Furthermore,
ECG changes during spontaneous ischemic episodes can be recorded by Holter electro-
cardiography. In this paper the relative values of these two methods will be discussed.

Holter Electrocardiography

With a small, portable tape recorder the ECG can be recorded during various activities
of a patient at home, in his work or elsewhere. The ECG can be analyzed at high speed
(30,60, or 120 x normal speed) by a trained technician. With this method arrhytlunias
can be detected, as well as transient QRS or ST changes. For the latter purpose it is
mandatory that both the recording system and the analyzer have a proper frequency
response, especially in the low frequency range of the ECG. A calibration system is
necessary. The patient is requested to keep a diary of his activities and complaints,
if any.
A trend plot of heart rate and ST amplitude can be generated by most systems.
Episodes with possible ST changes can then be marked and the ECG at those instances
is recorded on paper for visual inspection.

Advantages of Holter Electrocardiography

1. ECG is recorded during normal activities. The method is particularly suited to detect-
ing abnormalities related to specific activities, e.g., during work, and abnormalities
which occur predominantly at rest.
2. No personnel is required during the recording period.
3. Holter ECG is the most sensitive method for detection of arrythmias.

* With technical assistance by Angela Peterse, Flora ten Cate, and Hanneke van Meurs

F. Loogen et al. (eds.), Detection of Ischemic Myocardium with Exercise

© Springer-Verlag Berlin Heidelberg 1982
44 M.L. Simoons et al.

Limitations of Holter Electrocardiography

1. BeG recording is limited to one or two leads.

2. The occurrence of abnormalities may depend on the activities of a patient. It is not
safe to instruct the patient to stress himself without supervision.
3. The sensitivity of Holter electrocardiography for detection of coronary artery
disease is lower than exercise testing (see below).

Exercise Testing

Patients can be exercised on either a treadmill or a bicycle ergometer. The workload is

increased gradually, e.g., 10 W/min, until the patient develops complaints or until
severe abnormalities occur. The BeG is continuously displayed and recorded at regular
intervals.

Advantages of Exercise Testing

1. In addition to the BeG, other information can e'asily be obtained during an exer-
cise test: the physical work capacity, the patterns of the heart rate and blood
pressure response, and the development of complaints or symptoms.
2. It is reasonably safe to exercise a patient under medical supervision until symptoms
appear.
3. Multiple BeG leads can be obtained simultaneously, including the standard 12 leads
and orthogona1leads (vectorcardiogram).

Limitations of Exercise Testing

1. The test should be attended by personel trained in interpretation of the complaints

and of the electrocardiogram as well as in cardiopUlmonary resuscitation. In most
instances this should be a physician.
2. It is not easy to relate the workload during the exercise test to the level of other
activities of a patient.

Detection of Arrhythmias

In Table 1, ventricular arrhythmias are presented in 141 patients with coronary artery
disease who underwent Holter BeG and an exercise test at the Thoraxcenter. In 57 of
141 patients the same arrhythmias were observed in both tests. Bight patients had more
severe arrhythmias during exercise and 76 had the highest degree of arrhythmias in the
Holter BeG. These data are consistent with earlier publications as illustrated in Table
2 [4]. The greater yield of arrhythmias with Holter monitoring is probably due to the
duration of the recording: 24 h in comparison with 30 min duration of an exercise test.
The Value of Holter Monitoring for Detection of Ischemic Heart Disease 45

Table 1. Distribution of the highest grade of ventricular arrhythmias in

141 patients during Holter monitoring and during symptom-limited exer-
cise test. (Grade 0-4 modified after Ryan et a1.)

Exercise
0 1 2 3 4

H 22 2 0: No PVC
0 26 12 3 2 1: PVC < 5/min
L 3 3 2: PVC ~ 5/min
T 9 10 3 3 3: Multiform
E 11 5 5 3 17 4: Repetitive
R

N = 141

Detection of Repoiarization Changes

The relative sensitivities of Holter ECG and exercise electrocardiography for detection
of ST-T segment changes were compared in 45 patients with a history of angina pec-
toris. The Holter system (Oxford Instruments, Medilog II) was attached before the
exercise test. Recording continued until 24 h later. Lead MC5 was used for analysis of
the ST changes.
Trend plots were generated of heart rate and the ST amplitude, approximately
60 ms after the end of QRS; ECG strips were made in all instances where ST changes
were suspected in the trend recording, at points when the patient reported chest pain
or other complaints, and once every hour.
Of 45 patients, 20 had no ST changes either during exercise or during 24-h monitor-
ing. Seventeen patients had ST changes exceeding 0.1 mY in both tests, and the re-
maining eight patients had ST depression during exercise only (Table 3). In 13 of 17
patients with ST changes in both tests, those during exercise were of greater magnitude
(Table 4), while one patient had the greatest ST changes the evening after the exercise
test. This particular patient developed a myocardial infarction after an automobile
accident at that time. He recovered afterward.
The greater yield of ST segment depression during exercise compared with Holter
monitoring may be due to differences in the level of physical stress. The peak heart
rate during exercise exceeded the highest heart rate during other activities in 41 of
45 patients (Fig. 1).
In our study we did not observe patients with ST changes during Holter monitoring
and a normal exercise BCG. This is at variance with results from other centers (Table 3).
This difference may be due to patient selection or to insufficient workload during the
exercise tests.
46 M.L. Simoons et a1.

Table 2. Comparison of the occurrence of the highest grade of ventricular

arrhythmias in 100 patients reported by Ryan et a1. [2] and in the 141 pa-
tients from the Thoraxcenter

Most complex PVC

No PVC Same Holter Exercise

Ryan et a1. [4] 10 20 60 10

Thorax 22 35 76 8

n = 241 32 55 136 18
13% 23% 56% 7%

Table 3. Occurrence of ST segment depression or ST elevation (0.1 mV or

greater) in four studies

NoST Both Holter Exercise

Wolf [7] 23 13 5 6
Stern [6] 20 23 2 3
O'Rourke [3] 18 21 7 10
Thorax 20 17 8

n= 206 81 84 14 27
39% 41% 7% 13%

Table 4. ST segment changes during exercise, in comparison

with Holter ECG (in millimetres = 0.1 mY)

Exercise 0 2 3 4

H 4
0 3 1a
L 2 1 5
T
2 3 5
E
0 20 3 4
R

a Patient with myocardial infarction during Holter recording

Conclusions

Holter monitoring is the most sensitive method for detection of arrhythmias; exercise
testing may give additional information, in particular when the history of the patient
suggests exercise-related arrhythmias.
The Value of Holter Monitoring for Detection of Ischemic Heart Disease 47

200 PEAK HEARTRATE

EXERCISE TEST

• •
• •• •
• • •
•
150
•
••
• • • •
•• • • •
• •
••
100

100 150 200

PEAK HEARTRATE 24 HOUR HOLTER

Fig. 1. Peak heart rate during 24-h Holter monitoring and during a symptom-limited
exercise test in 45 patients. The line of identity is shown. Note higher heart rate during
the stress test in 41 of 45 patients

On the other hand, exercise testing is the method of choice for detection of ECG
changes related to myocardial ischemia. Holter electrocardiography may be used for
the analysis of symptoms which are unrelated to exercise or which occur during specific
activities, e.g., at work. It is mandatory that both the recording system and the play-
back unit have an adequate frequency response for proper representation of the
QRS complex, and the ST segment [1,2].
The method for analysis of arrhythmias differ from those for ST segment analysis.
Furthermore, false negative fmdings obtained with Holter ST analysis may be due to
the selection of ECG leads which have been recorded [5].
48 M.L. Simoons et al.

References

American Heart Association Committee on Electrocardiography (1975) Recom-

mendations for standardization of leads and of specifications for instruments in
electrocardiography and vectorcardiography. Circulation.52:11
2 Balasubramanian V, Lahiri A, Green HL, Stott FD, Raferty EB (1980) Ambulatory
ST segment monitoring. Problems, pitfalls, solutions and clinical application. Br
Heart J 44:419
3 O'Rourke R, Crawford MH (1978) The value of ambulatory electrocardiographic
monitoring for detection ischemic heart disease. In: Mason DT (ed) Advances in
heart disease. Green and Shaffon, New York
4 Ryan M, Lown B. Horn H (1975) Comparison of ventricular ectopic activity during
24-hour monitoring and exercise testing in patients with coronary heart disease.
New Engl J Med 292:224-29
5 Selwyn AP, Fox K, Eves M, Oakley D, Dargie H, Shillingford J (1978) Myocardial
ischemia in patients with frequent angina pectoris. Br Med J 1191-96
6 Stern S (1978) Ambulatory ECG monitoring. Year Book Medical Publishers,
Chicago
7 Wolf E, Tzivoni D, Stern S (1974) Comparison of exercise tests and 24-hour ambu-
latory electrocardiographic monitoring in detection of ST-T changes. Br Heart J
36:93-95