Electrophysiology

Club

Basic
Holter
Monitoring
PRIMASITHA MAHARANY H. - FEB 6TH 2023
Electrophysiology
Club

Guidelines

02
 Electrophysiology
Club

Introduction
Ambulatory ECG monitoring provides a view of ECG
data over an extended period of time.

Since 1960 Evaluation Longer Periods

Introduced by Norman of dynamic and transient cardiac More sensitive than standard ECG for
Holter. electrical phenomena during detecting spontaneous, often highly
periods of physical and variable cardiac arrhythmias or 03
psychological stress. conduction abnormalities
Electrophysiology
Club

AECG Modalities
2 categories of modalities: continuous and intermittent.

04
Electrophysiology
Club

Characteristics
Electrophysiology
Club

Our Approaches
in choosing an ambulatory ECG monitoring strategy
Electrophysiology
Club
 Electrophysiology
Club

Indications
To assess symptoms possibly related to
rhythm disturbances

Class I To assess risk for future cardiac events

• Patients with unexplained in patients without symptoms from
syncope, near syncope, or arrhythmia
Class IIB
episodic dizziness in whom the
• Post-MI patients with LV
cause is not obvious
• Patients with unexplained dysfunction (ejection fraction

recurrent palpitation ≤40%)

Class IIB
• Patients with CHF
• Patients with episodic shortness
• Patients with idiopathic
of breath, chest pain, or fatigue
hypertrophic cardiomyopathy
that is not otherwise explained
(HCM)
• Patients with neurological events
when transient atrial fibrillation
or flutter is suspected
Electrophysiology
Club
To assess antiarrhythmic therapy
Class I
To assess antiarrhythmic drug
response in individuals in whom
baseline frequency of arrhythmia has
been characterized as reproducible
and of sufficient frequency to permit
analysis
Class IIA
To detect proarrhythmic responses to
antiarrhythmic therapy in patients at
high risk
Class IIB
To assess rate control during atrial
fibrillation
Indications
To Assess Pacemaker and ICD Function
• Evaluation of frequent symptoms of
Class I palpitation, syncope, or near syncope For Ischemia Monitoring
to assess device function to exclude
• Patients with suspected variant
myopotential inhibition and
angina [IIa]
pacemaker-mediated tachycardia and
• Evaluation of patients with chest
to assist in the programming of
pain who cannot exercise [IIB]
enhanced features such as rate
• Preoperative evaluation for
responsivity and automatic mode
vascular surgery of patients who
switching
cannot exercise [IIB]
• Evaluation of suspected component
• Patients with known CAD and
failure or malfunction when device
atypical chest pain syndrome
interrogation is not definitive in
[IIB ]
establishing a diagnosis
• To assess the response to adjunctive
pharmacological therapy in patients
receiving frequent ICD therapy
Electrophysiology
Club
 Electrophysiology
Club

As Diagnostic Tool
 Electrophysiology
Club

Placing a Holter
 Electrophysiology
Club
• Very important; each
patient has one
• We check 5 minutes pre
and post documented time
• Confirm/rule out cardiac
cause of symptoms
• Nocturnal/diurnal
bradycardia
• Patient exercising or
Patient Diary

cardiac arrhythmia??
Electrophysiology
Club

Follow up
AFTER AMBULATORY ECG MONITORING
• The patient had symptoms with corresponding ECG abnormalities (ie, arrhythmia
or conduction abnormality) >> treat appropriately
• The patient had symptoms with no ECG abnormalities (assuming that the
monitor was functioning properly and the available ECG data are interpretable) >>
non-cardiac, no need for additional ambulatory ECG monitoring.
• No symptoms and no ECG abnormalities during the monitoring period >> The
decision to pursue additional testing following a period of ambulatory ECG
monitoring depends on the potential severity of the clinical conditions.

Years Experience Happy Customer Service Complete Satisfactions

04
 Electrophysiology
Club

• A PVC-induced cardiomyopathy occur Quantifying arrhythmias

at PVC burdens of 16% to 24%
• Most cases of PVC-induced 60bpm x 60 minutes x 24hrs = 86.400 beats per day
cardiomyopathy occur at burdens
>10%-24%
• However, consistent with evidence that
• Very occasional: ≤10
those with 6% PVCs can experience
• Occasional: 11 – 1.499
benefit in reducing their systolic
• Moderate: 1.500 – 2.499
dysfunction with catheter ablation.
• Frequent: >2.500
AHA 2020
• Very frequent: > 25% of total beats

06
 Electrophysiology
Club

Urgent discussions
These conditions prompt urgent discussions and more
rapid treatments.

• Sinus pauses >3 seconds

• Ventricular pauses >3 seconds
• Mobitz type II, 3rd degree AV block
• Diurnal heart rates <40bpm
• Sustained (>30secs) atrial fibrillation/flutter/ SVT >120bpm
• Recurrent (>1 episode) ventricular tachycardia
• Prolonged (≥5 beats) ventricular tachycardia
10
Electrophysiology
Club

Reporting Holter:
Step-by-step
Electrophysiology
Club

Langkah Awal
• Diari pasien : esensial
• Idealnya: melihat langsung komputer
• Layak baca atau tidak >> Noise?
• Lamanya perekaman
• Kalau dianggap perlu, Holter dapat diulang
Electrophysiology
Club

Interpretasi
Irama Dasar
• Irama dominan: SR, AF, Atrial FLutter, irama
junctional, irama ektopik, AV total
• Dapat ditambahkan laju jantung rata-rata,
minimal dan maksimal.
Electrophysiology
Club

Interpretasi
Kompetensi kronotropik
• Laju jantung rata-rata per jam yang disesuaikan dengan
siklus sirkadian
• Dikorelasikan dengan catatan aktivitas pasien yang
terperinci sehingga dapatdikorelasikan dengan laju
jantung saat aktivitas
• Kompeten atau inkompeten
Electrophysiology
Club

Interpretasi
Konduksi atrioventrikular
• Interval PR dan hubungan gelombang P dengan
QRS
• Konduksi baik, blok AV derajat 1 sampai blok AV
total baik permanen maupun intermiten
Electrophysiology
Club

Interpretasi
Takiaritmia
• Sinus takikardia yang tidak lazim (inappropiate)
• Takikardia supraventrikular dan ventrikular
• Dianjurkan deskripsi yang terperinci berupa
jumlah, durasi dan morfologi
Electrophysiology
Club

Interpretasi
Bradiaritmia
• Bradiaritmia pada Irama sinus perlu diperhatikan
siklus sirkadiannya
• Irama dibawah 40 bpm perlu perhatian khusus
• Adanya pause baik jumlah maupun durasi (>3
detik) dikorelasikan dengan keluhan dan aktifitas
pasien
Electrophysiology
Club

Interpretasi
Segmen ST
• EKGA multikanal memiliki kemampuan analisa
segmen ST yang sebandingdengan EKG 12
sadapan
• Dapat dilaporkan perubahan segmen ST yang
dikaitkan dengan aktivitas danperubahan laju
jantung selama perekaman.
Electrophysiology
Club

Interpretasi
Korelasi dengan keluhan
• Perlu diperhatikan keluhan pasien yang tercatat
pada data event pasien denganadanya kelainan
aritmia
• Bisa menyingkirkan adanya aritmia bila keluhan
pasien tersebut tidak berkorelasi dengan irama
jantungnya
Electrophysiology
Club

Fitur Khusus
Special Features

Variabilitas laju jantung (VLJ) (domain time & domain frekuensi)

• Analisis VLJ dapat digunakan untuk menilai keseimbangan saraf otonom yang berperan mengatur aktivitas
jantung. Dapat melihat risiko aritmogenik dan SCD.

Turbulensi laju jantung (TLJ)

• Merupakan fluktuasi laju jantung berupa kenaikan singkat yang diikuti denganpenurunan laju jantung
segera setelah terjadinya ekstrasistol ventrikel (ESV). TLJ merupakan manifestasi dari respons baroreseptor
terhadap perubahan tekanan arteri

Gelombang T-alternans (GTA)

• Suatu variasi morfologi dan amplitudo antar gelombang T ataupun segmen ST . GTA telah diketahui
Electrophysiology
Club
Electrophysiology
Club

Example
Electrophysiology
Club

Terima
Kasih

10