24hr ECG Interpretation

17th September 2015

Trinity Park, Ipswich

Andrew Chalk, Chief Cardiac Physiologist

Jamie Williams, Senior Cardiac Physiologist
 Learning objectives
• Ambulatory monitoring: a brief introduction
• The “standard” 24hr ECG report
• ECG rhythm interpretation
• Cardiologist support
• Summary
• Questions
 Indications for ambulatory monitoring

• Syncope

“People with a suspected cardiac arrhythmic cause of

syncope are offered an ambulatory electrocardiogram
(ECG) as a first‑line specialist cardiovascular investigation”
(NICE Quality Statement, 2014).

• Palpitations
• Presyncope
• Rate control in AF patients
 Ambulatory Monitors
Holter monitors (spacelabs)
• 3 electrodes, usually 24hrs (48-72hr)

External event recorders (R test, Novacor)

• 2 electrodes, loop recorder, patient activated and
also device will record “important” events, 1-4
weeks

Implantable loop recorder (Reveal, Medtronic)

• Surgical implant, regular follow ups in CRM clinic,
patient activated and also device will record
“important” events, 2-3 yrs
So what happens when the patient returns
the monitor…?
• Analysed by the Physiologist Team
• Report generated
• D/w Cardiologist if
any concerns
 The standard report
• Predominant rhythm (?normal intervals and
rates)
• Important observations (e.g. pauses, sustained
tachycardias)
• Ventricular ectopics
• Supraventricular ectopics
• Bradycardias
• Any other arrhythmias
• Patient diary events
 Predominant rhythm
• Are there P waves present? Are they normal?
• Is the PR interval prolonged? (120-200ms)
• Is the QRS complex normal duration?
(<120ms)
• Is there a sufficient HR variability?
- HR range
- Mean HR
• Are they any paroxysmal rhythms (?PAF)
Normal sinus rhythm
1st degree AV block (prolonged PR interval >200ms)

Junctional rhythm (inverted P wave)

Atrial fibrillation

Atrial flutter

Paroxysmal atrial fibrillation

 Important observations
• Pauses – type, duration, diurnal/nocturnal
- Sinus pauses/arrest
- 2nd degree AV block (Mobitz type 1 & II)
- 3rd degree AV block

Sinus Arrest
 Advanced AV block

2nd degree AV block (Mobitz type I, Wenckebach)

2nd degree AV block (Mobitz type II)

 Advanced AV block
3rd degree AV block

Ventricular standstill
• Sustained arrhythmias
- Broad complex tachycardias (Sustained/Non-
sustained ventricular tachycardia)
- Supraventricular tachycardias (SVT)
 Ventricular ectopics
• How many? Alternative focus? Runs of VE’s?
Salvos, bigeminy, trigeminy?
Ventricular bigeminy

Ventricular trigeminy
 Supraventricular rhythms
Supraventricular/atrial ectopics (SVE’s)
Supraventricular tachycardia (SVT)
 Quantifying arrhythmias
• Very occasional: ≤10
• Occasional: 11 – 1499
• Moderate: 1500 – 2499
• Frequent: >2500
• Very frequent: > 25% of total beats

• 60bpm x 60 minutes x 24hrs = 86400 beats per

day
Sinus bradycardia

Chronotropic incompetence
• Inability for heart to > rate in relation to >
physical demand
• Fatigue/SOB
• SSS
 Patient diary
• Very important each patient has one
• We check 5 minutes pre and post documented
time
• Confirm/rule out cardiac cause of symptoms
• Noctural/diurnal bradycardia
• Patient exercising or cardiac arrhythmia??
 Cardiologist Support for Physiologists
Urgent discussion if…
• 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
 Summary
• Examples of available ambulatory monitors
• Explanation of physiologist reports
• ECG interpretation
• Cardiologist support
 References
• Houghton, A and Gray, D. (2015). Making Sense of the ECG:
A hands on guide, 4th Edition. Taylor & Francis Group, UK
• Thaler, M. (2015). The Only EKG Book You’ll Ever Need, 8th
Edition. Wolters Kluwer, USA
• Hampton, J. (2013). The ECG in Practice, 6th Edition.
Churchill Livingstone Elsevier, UK
• Nice (2015). Quality statement 6: Specialist cardiovascular
investigation – ambulatory electrocardiogram (ECG).
www.nice.org.uk/guidance/qs71
• American Heart Association Journal – Circulation
• BMJ Journal – Heart
Any questions?

andrew.chalk@ipswichhospital.nhs.uk
andrew.chalk@nhs.net