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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 61-65

Clinical indications and arrhythmic patterns of 24-h holter electrocardiography among cardiovascular disease patients

1 Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
2 Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya; Department of Cardiology, Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia

Date of Submission20-Feb-2021
Date of Acceptance18-May-2021
Date of Web Publication23-Jul-2021

Correspondence Address:
Dr. Rerdin Julario
Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Jalan Mayjen Prof. Dr. Moestopo No. 6-8, Surabaya 60286
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ljms.ljms_11_21

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Background: This study aimed to evaluate the clinical indications and arrhythmic patterns in cardiovascular disease patients who were referred for Holter electrocardiography (ECG) in Dr. Soetomo General Hospital, Surabaya, Indonesia. Methods: A retrospective cross-sectional study was held at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. Patient's data, including Holter ECG, was obtained from the local Holter Registry between July 2019 and December 2019. Results: A total of 89 patients were included in this study. The mean age was 50.1 ± 16.0 years old, and 48 patients (53.9%) were females. The most common indication was palpitation (39.3%) followed by the history of arrhythmia (14.6%), shortness of breath (13.5%), and chest pain (12.4%). Ventricular ectopic (VE) and supraventricular ectopic (SVE) were the most common arrhythmia in 70.8% and 12.4% of subjects, respectively. About 20.2% of patients had frequent VE, and Lown's Grade 4 was the most prevalent VE accounting for 45.9% of patients among all VE events. A total of 5.6% of patients had episodes of atrial fibrillation. Frequent SVE was found in 4.5% of patients, whereas 5.6% had supraventricular tachycardia. About 3.4% of patients had abnormal atrioventricular conduction, and 4.5% had chronotropic incompetence. Conclusions: Palpitation of unknown etiology was the most common clinical indication for Holter ECG among our patients. The most prevalent arrhythmias were VEs and SVEs, with Lown's Grade 4 being the most prevalent VEs. Holter ECG in patients with that indication was reasonably high diagnostic yield in detecting arrhythmia.

Keywords: Arrhythmia, cardiovascular diseases, heart rate, Holter electrocardiography, ventricular ectopic

How to cite this article:
Julario R, Budi Mulia EP, Dewi IP, Gunadi RI, Dharmadjati BB. Clinical indications and arrhythmic patterns of 24-h holter electrocardiography among cardiovascular disease patients. Libyan J Med Sci 2021;5:61-5

How to cite this URL:
Julario R, Budi Mulia EP, Dewi IP, Gunadi RI, Dharmadjati BB. Clinical indications and arrhythmic patterns of 24-h holter electrocardiography among cardiovascular disease patients. Libyan J Med Sci [serial online] 2021 [cited 2023 Mar 27];5:61-5. Available from: https://www.ljmsonline.com/text.asp?2021/5/2/61/322199

  Introduction Top

Cardiac arrhythmias are defined as impaired rate, rhythm, and conduction of heart impulses. Some arrhythmias last briefly, so they do not cause overall clinical symptoms. Undetectable arrhythmias can be dangerous such as the appearance of syncope, nocturnal agonal respiration, ventricular fibrillation (VF), and cardiac arrest.[1]

Holter Monitor or Ambulatory Holter Electrocardiography (ECG) (24-h ECG Holter) was first developed by Norman J Holter, an American biophysicist in 1949. Holter is a portable device used to monitor various electrical activities of the cardiovascular system continuously for at least 24 h, thus allowing outpatients to monitor ECG at home. The working principle of this tool is by attaching electrode cables to the patient's chest.[2] This tool works with battery power as a recording device that can be bagged or carried everywhere with a belt or shoulder strap. Electrocardiograms work by tapping electrical signals in the heart and reinforced so that the results can be read and diagnosed by the medical team. Holter can be used in assessing heart rate variability patterns and ST-segment analysis in ischemic heart.[3] In addition, Holter is also used to evaluate patient response to initiation, revision, or discontinuation of arrhythmic drug therapy and to assess prognosis in specific clinical contexts.[4]

Facilities for 24-h Holter ECG monitoring are currently limited in Indonesia, and there are still limited published data on the use of 24-h Holter ECG in the cardiac arrhythmia evaluation of cardiovascular disease (CVD) patients. Dr. Soetomo General Academic Hospital currently, as one of the tertiary referral hospitals in Indonesia, has conducted several 24-h ECG Holter examinations to evaluate cardiac arrhythmias in patients with CVD. This study aimed to evaluate clinical indications and arrhythmia patterns in CVD patients referred for 24-h Holter ECG.

  Methods Top

Study design and study setting

This was a descriptive observational study using a retrospective cross-sectional design. This study was held at Cardiac Center-Dr. Soetomo General Academic Hospital, Surabaya. This hospital is one of the biggest hospitals in Indonesia and being functioned as tertiary referral hospitals for the East Indonesia region.

Population and sample

All patients with any CVD diagnosis treated in the outpatient clinic, Cardiac Center-Dr. Soetomo General Academic Hospital, Surabaya which referred for 24-h Holter ECG (using SEER Light Digital Holter Recorder; GE, Milwaukee, WI, USA) over 6 months (between July and December 2019) were included in this study. Patients with a lack of complete medical record data were excluded. Informed consent was procured from all participants. This study used a total sampling of the eligible population.

Data collection

Each patient was given a detailed explanation of how the test was done and how to handle the recorder. Holter ECG was placed in the patient's waist, and the electrode leads were placed appropriately on the chest. The patients were instructed to go home, recommence normal daily activities, and return to the hospital after 24 h. Clinical indications for Holter ECG were established based on the American College of Cardiology (ACC)/American Heart Association (AHA) recommendations guidelines for ambulatory ECG.[5] The recordings were subsequently analyzed using MARS PC Holter Monitoring and Review System software. Each Holter ECG event recording was also analyzed according to guidelines manually by an experienced cardiologist and two senior residents.

Statistical analysis

Statistical analysis was conducted using SPSS version 25 software (Armonk, NY, USA: IBM Corp). Data were presented using descriptive statistics. Continuous data were given as mean (standard deviations [SD]) or median (interquartile range) depend on data distribution, while categorical data were given as N (%). Data distribution was tested using the One-Sample Kolmogorov-Smirnov test.

Ethical clearance

The institutional committee of research and ethics of Dr. Soetomo General Academic Hospital gave ethical clearance and approved the study (Ref: 1822/KEPK/II/2020).

  Results Top

Clinical characteristic of the studied patients

Characteristics of the study population are summarized in [Table 1]. The study sample involved 89 patients. The mean age was 50.1 ± 16.0 years old. Total 48 patients (53.9%) were females. History of arrhythmia become the most common comorbidity (62,9%) followed by HHD (20.2%) and hypertension (HTN) (12.4%). Each studied patient may have multiple comorbidities.
Table 1: Clinical characteristics of studied patients

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[Table 2] shows 9 clinical indications for performing a Holter ECG. The most frequent indication was found in the group complaining of palpitation, which comprise 35 patients (39.3%), followed by the history of arrhythmia found in 13 (14.6%) of the patients. The most uncommon indication was stroke, which was occurred only on one patient (1.1%). As stated by the ACC/AHA recommendations guideline for ambulatory ECG, 48 patients (53.9%) had Class I indication and 41 patients (46.1%) had Class IIb indications for Holter ECG.
Table 2: Clinical indications of holter electrocardiography

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Holter electrocardiography findings

Of the 89 patients, 86 patients (96.6%) had baseline rhythm of sinus, two patients (3.4%) with pacemaker rhythm, and one patient (1.1%) with junctional rhythm. The mean (SD) minimum heart rate (HR) was 50.02 ± 11.18 and the maximum HR was 125.07 ± 21.79. For the female group, the mean (SD) minimum HR was 49.17 ± 11.71 and the maximum was 123.74 ± 19.8. For the male group, minimum HR was 50.51 ± 10.31 and maximum HR was 126.59 ± 23.99.

Arrhythmia was documented in 84 patients (94.4%). Ventricular ectopics (VE) usually are described in terms of the Lown's grading system for ventricular premature beats, all patients were graded, and results showed that Lown's Grade 4 was the most prevalent VE accounting for 40 patients (45.9%) among all VE events, with Grade 4a being more common (32 patients) compared to Grade 4b (eight patients). Lown's Grade 1 had the second-highest prevalence consisting of 21 patients (29.2%), while the rest (two patients) were Grade 2. From 63 patients with VE, 18 patients (20.2%) had frequent VE, and the highest grade of VE was found in four patients (4.5%): sustained ventricular tachycardia (VT) (one of which was sustained polymorphic VT). Five patients (5.6%) experienced nonsustained VT (one of them was nonsustained polymorphic VT), and 3 others (3.4%) had the highest grade of premature ventricular contraction (PVC) amount of 3 (salvos). Nine patients (10.1%) had the highest grade of bigeminy VE.

A total of five patients (5.6%) had an episode of Atrial fibrillation (Afib). Frequent supraventricular ectopic (SVE) was found in four patients (4.5%), while five patients (5.6%) had supraventricular tachycardia (SVT), and two patients (2.2%) experienced non sustained SVT. Of 89 patients, three patients (3.4%) had abnormal AV conduction, and all 3 of them were patients with 2° atrioventricular block (AVB), with 1 having an episode of Total AVB. An amount of four patients (4.5%) had abnormal (incompetence) chronotropic competence, with all four patients suffering from bradyarrhythmia.

Based on Holter's clinical indications, only one type of arrhythmia finding was reported from each patient, which was the most significant form and/or which corresponds to the patient's symptoms/events during Holter recording, as shown in [Table 3]. Arrhythmias were documented in several clinical indications such as 94.3% in patients presenting with palpitations, 71.4% in syncope, and 100% in each: previously known arrhythmia, shortness of breath, chest pain, fatigue, dizziness, and pacemaker. VEs were also become the most common arrhythmia, with a total of 63 (70.8%) among all subjects, followed by SVE with a number of 11 patients (12.4%). PVC was found more prevalent in patients presenting with palpitations (60%), patients with previously known arrhythmia (46.2%), patients with a permanent pacemaker (100%), shortness of breath (83.3%), chest pain (81.8%), and patients with fatigue (80%). Sustained and nonsustained VT were found in 4 (4.5%) and five patients (5.6%), respectively. Sinus arrest/pause and Afib were found in three patients (3.4%) each. Severe bradycardia, Mobitz I AVB, Mobitz II AVB, and Total AVB each had an amount of one patient (1.1%) among all studied patients.
Table 3: Holter electrocardiography arrhythmic findings based on clinical indications

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  Discussion Top

Astonishingly, from a total of 89 patients, 29.2% (26 patients) were young population with age group 40 years and below [Table 1]. In addition, 14 patients were in the age group of 30 years and below. Harinder R. Singh wrote a chapter on Arrhythmia in Children and Young Adults and described that in healthy 10–13-year-old boys, 13% of them were reported to experience PACs (singlet PACs). Common causes of PACs in the young include high consumption of alcohol, caffeinated drinks, and various other stimulants, including nicotine. Atrial enlargement, electrolyte imbalances, parenchymal pulmonary disease, and the development of heart failure may also cause PACs. Whereas, PVCs in the young population are seen in neonates (18%), toddlers (20%), school-aged children (16%), adolescents (20%–30%), and the number increases subsequently with age. Holter monitoring of healthy subjects (with no found cardiac disease), 54% of young women, and 50% of young men experienced PVCs. Tetralogy of Fallot patients who have undergone surgical correction have an incidence of PVCS as high as 6%–48%.[6] Data from epidemiological studies reveal increasing numbers of incidence and prevalence of Afib, a number of <0.1%/year in patients below 40 years, and in patients older than 80 years may reach up to >20% in. Increasing Incidence of Afib in the younger population may be due to sedentary lifestyle/habits, obesity, heart disease, and premature HTN.[7] Omotoso et al. reported that after the fourth decade of life, arrhythmia is a common finding, and they conclude that the increasing prevalence of arrhythmia is age-related, and our study concurs with their findings.[8] From a total of 89 patients, 63 of our patients were patients aged above 40-year-old.

Among 9 clinical indications studied in our study, palpitation was the most prevalent (39.3%), with previously known arrhythmia (14.6%) and shortness of breath (13.5%) to be next in line [Table 2]. In their study, Adebayo et al. described palpitation and syncope as the most frequent indication.[1] This study showed that a history of arrhythmia was the most common comorbidity among the study subjects (62.9%), with hypertensive heart disease associated Left ventricular hypertrophy (LVH) (20.2%), coronary artery disease (14.6%), and HTN following the next (12.4%) [Table 3]. More than 15,000 White and African-American populations were studied in the atherosclerotic risk in communities and reported that multiple and malignant PVCs are linked to HTN, and an increased estimation of left ventricular mass through ECG findings increases PVC frequency. LVH associated with multiple and malignant PVCs are important risk factors of sudden cardiac death.[9] Another study that also concluded LVH increases arrhythmias was done by Ajayi, who studied 37 Hypertensive Heart Failure (HHF) CVD with or without valvular heart disease using 24-h Holter to analyze arrhythmic patterns. Their study stated that multi-valvular regurgitation leads to increased SVT and malignant PVCs incidence.[10] Cardiac arrhythmias are also common in cases of HHF with congestive symptoms or dilated cardiomyopathy (DCM). Among the occurring cardiac arrhythmias, some may include nonsustained VT episodes, which can develop into malignant sustained VT and VF, and may decondition into sudden cardiac death.[11] European heart rhythm association stated that atrial and ventricular remodeling (i.e., myocardial fibrosis), neuroendocrine influence, hemodynamic alterations, and a phenotype of proarrhythmogenic electrophysiologic in a hypertrophied left ventricle all contribute to the sophisticated mechanism of arrhythmogenesis in HTN.[12]

According to ACC/AHA recommendations guideline for ambulatory ECG, 48 patients (53.9%) had Class I indication and 41 patients (46.1%) had Class IIb indications for Holter ECG.[5] Clinical indications of 2,489 Holter ECG recordings were evaluated by Piccirilli et al. and concluded that 1,298 patients (52%) were distinctly pertinent (Class I), 311 patients (13%) were possibly pertinent, and 880 patients (35%) as impertinent (Class III).[13] Whereas in the study of clinical indication conducted by Adebayo et al., in 89 subjects (28.7%) was a Class III. Thirty-one of their patients (34.8%) had HTN.[1]

VEs were the most common arrhythmia, accounting for 63 patients (70.8%), followed by SVEs as much as 11 patients (12.4%). Similar results are shown by Katibi et al., which also stated PVCs (47.6%) as the most frequent arrhythmia.[14] Sultana et al. also concluded PVCs to be the most common arrhythmia in patients with LVH and HTN.[15] Adebayo et al. reported that patients with DCM (85.7%), HHF (40.1%), stroke (36.2%), and palpitation (32.8%) experienced ventricular arrhythmia more frequently. Using Lown's Grading, their study concluded that Lown's Grade 4 was frequent in patients with DCM (66.7%), palpitation (61%), and HHF (55.2%), with similar results from our study, showed that Lown's Grade 4 was the most prevalent PVC accounting for 45.9% (40 patients) among all PVC events, with Grade 4a being more common (32 patients) compared to Grade 4b (eight patients). It is important to state that four PVC patients in our study experienced an episode of sustained VT, whereas five patients with VE had periods of nonsustained VT. A study conducted by Adebayo et al. had six PVC patients (1.9%) went through sustained VT.[1] A few studies also stated that VT might decondition to malignant arrhythmia such as VF and thus increase the risk for sudden death.[11],[16]

Abnormal AV conduction is described when atrial electrical conduction is delayed or not at all conducted to the subsequent ventricles, while the AV conduction pathway is not physiologically refractory. Atrioventricular conduction abnormality was the first and remains the leading indication (approximately 50%) for cardiac pacing and pacemaker implantation. Incidence is age-related, with increasing numbers associated with increasing age, and may sum up to be near 30% in selected age faction. Congenital AV block is considered uncommon and takes place in 1 in 15, 000–1 in 22,000 live births.[17] From 89 patients, our study had three patients with abnormal AV conduction, and all three of them were patients with a 2° AV Block Type II, with one having an episode of TAVB. In the cohort study done by Barriales-Villa et al. describing the prevalence of complex cardiac conduction abnormalities in 451 subjects with hypertrophic cardiomyopathy, stated that pacemaker was implanted in 48 patients (11%) where 20 (4.4%) had sinus node dysfunction, and 28 (6%) had abnormal atrioventricular conduction.[18]

An amount of four patients had abnormal (incompetence) chronotropic competence, with all four patients suffering from bradyarrhythmia. A study done by Lukl et al. using 211 patients concluded that chronotropic incompetence is a usual finding in patients with a pacemaker; however, the highest frequency and implications were found in permanent atrial fibrillation patients. His study found the highest incidence in patients with atrial fibrillation was the highest (67%, P < 0.0005), compared to sick sinus syndrome (49%, P < 0.012) and AV block (30%).[19] On the contrary, our study did not find any chronotropic incompetence in our patients with Afib, but under the circumstances that our study lacks a sufficient amount of patients with Afib (only two patients), we cannot deduce any further conclusions.

Several limitations were found in our study. First, this was a single-center study with small sample sizes. Risk factors for the development of cardiac arrhythmia, which greatly vary according to the cardiac function and underlying diseases, including drugs consumed by patients, were not taken into account for the analysis.

  Conclusions Top

Palpitation was the most common Holter ECG clinical indication among our patients. The most prevalent arrhythmias were VEs and SVEs, where Lown's Grade 4 being the most prevalent VEs. Holter ECG in patients with that indication was reasonably high diagnostic yield in detecting arrhythmia.


The authors would also like to offer special thanks to all staffs, fellows, residents, and nurses from the Arrhythmia and Electrophysiology Division, Department of Cardiology and Vascular Medicine, Dr. Soetomo General Academic Hospital, Surabaya for their technical contribution.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Adebayo RA, Ikwu AN, Balogun MO, Akintomide AO, Ajayi OE, Adeyeye VO, et al. Heart rate variability and arrhythmic patterns of 24-hour Holter electrocardiography among Nigerians with cardiovascular diseases. Vasc Health Risk Manag 2015;11:353-9.  Back to cited text no. 1
Adebola A, Daniel F, Lasisi G, Ogunleye O. 24-Hour holter monitoring at the Lagos State University Teaching Hospital – A report of 85 cases. Niger J Clin Med 2010;2:11245. doi:10.4314/njcm.v2i2.49272.  Back to cited text no. 2
Zimetbaum P, Goldman A. Ambulatory arrhythmia monitoring: Choosing the right device. Circulation 2010;122:1629-36.  Back to cited text no. 3
Steinberg JS, Varma N, Cygankiewicz I, Aziz P, Balsam P, Baranchuk A, et al. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. Heart Rhythm 2017;14:e55-96.  Back to cited text no. 4
Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A Jr., et al. ACC/AHA Guidelines for Ambulatory Electrocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography). Developed in collaboration with the North American Society for Pacing and Electrophysiology. J Am Coll Cardiol 1999;34:912-48.  Back to cited text no. 5
Singh HR. Arrhythmias in children and young adults. In: Advances in Electrocardiograms-Clinical Applications. InTechOpen; London, UK, 2012. [doi: 10.5772/21661].  Back to cited text no. 6
Wasmer K, Breithardt G, Eckardt L. The young patient with asymptomatic atrial fibrillation: What is the evidence to leave the arrhythmia untreated? Eur Heart J 2014;35:1439-47.  Back to cited text no. 7
Omotoso A, Opadijo O, Araoye M. Pattern of arrhythmias among Nigerians with congestive heart failure. Nig Q J Hosp Med 1997;7:310-13.  Back to cited text no. 8
Adebayo RA, Ikwu AN, Balogun MO, Akintomide AO, Mene-Afejuku TO, Adeyeye VO, et al. Evaluation of the indications and arrhythmic patterns of 24 hour Holter electrocardiography among hypertensive and diabetic patients seen at OAUTHC, lle-lfe Nigeria. Diabetes Metab Syndr Obes Targets Ther 2014;7:565-70.  Back to cited text no. 9
Ajayi OE, Ajayi AA. Valvular regurgitations may increase risk of arrhythmias in Nigerians with hypertensive heart failure. J Cardiovasc Med 2013;14:453-60.  Back to cited text no. 10
Ajayi OE, Abiodun OO, Akintomide AO, Adebayo RA, Ogunyemi SA, Balogun MO, et al. Pattern of arrhythmias among Nigerians with congestive heart failure. Int J Gen Med 2015;8:125-30.  Back to cited text no. 11
Lip GY, Coca A, Kahan T, Boriani G, Manolis AS, Olsen MH, et al. Hypertension and cardiac arrhythmias: A consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamerican. Europace 2017;19:891-911.  Back to cited text no. 12
Piccirilli S, Gallagher MM, Vellini M, Padula M, Voumvourakis A, Santini L, et al. Appropriateness of ECG Holter requests in an outpatient service: A prospective study. J Cardiovasc Med (Hagerstown) 2007;8:517-20.  Back to cited text no. 13
Katibi I, Beshir S, Mudashiru Z. Ambulatory 24-hour holter electrocardiography among Nigerians: Our Experience at a Referral Cardiac Centre in Lagos, Nigeria. Niger Med J 2006;47:25-7.  Back to cited text no. 14
Sultana R, Sultana N, Rashid A, Rasheed SZ, Ahmed M, Ishaq M, et al. Cardiac arrhythmias and left ventricular hypertrophy in systemic hypertension. J Ayub Med Coll Abbottabad 2010;22:155-8.  Back to cited text no. 15
Ebrahimzadeh E, Pooyan M, Bijar A. A novel approach to predict sudden cardiac death (SCD) using nonlinear and time-frequency analyses from HRV signals. PLoS One 2014;9:e81896.  Back to cited text no. 16
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Barriales-Villa R, Centurión-Inda R, Fernández-Fernández X, Ortiz MF, Pérez-Alvarez L, Rodríguez García I, et al. Severe cardiac conduction disturbances and pacemaker implantation in patients with hypertrophic cardiomyopathy. Rev Esp Cardiol 2010;63:985-8.  Back to cited text no. 18
Lukl J, Doupal V, Sovová E, Lubena L. Incidence and significance of chronotropic incompetence in patients with indications for primary pacemaker implantation or pacemaker replacement. Pacing Clin Electrophysiol 1999;22:1284-91.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3]


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