- Holter Monitoring
- OHC uses Holter Monitoring to record every heartbeat for a 24 hour
period. The patient has 5 leads attached to their chest and wear the
monitor for 24 hours. At the end of 24 hours the patient returns to
OHC to have the device remove. Our trained technicians downloads the
information into a computer and generates a printout of the 24 hour time
period. One of our cardiologists, then analyzes the data and reports
their findings to the ordering physician or the patient during their next
The Aria recorder is
state-of-the-art Holter monitoring made simple. No larger than a typical
pager, it uses four leads to record three channels of patient data. Worn
under the shirt in a chest pouch and can record up to 48 hours of
full-fidelity ECG data without data compression.
14 Sep 2004
History of Holter Monitoring
A Review of Literature - By: R. Hal Gant
The first ambulatory electrocardiograms (AECG) were conducted by Jefferis
(Jeff) Holter and Dr. W. R. Glasscock in 1961 using a heavy, complicated and
cumbersome assortment of radio telemetry and tape recording equipment that
allowed a limited range and time of measurement for human subjects.(1,2,3) Bruce
Del Mar teamed up with Holter to develop and produce a smaller, lighter "Electrocardiocorder®"
and high speed review technique that allowed a practical method to record and
interpret long term AECGs of 24 or more hours.(4) Through the Holter monitoring
technique, patients' ECGs are routinely recorded and analyzed during normal
daily activity, even during sleep. High speed playback and computer assisted
analysis provide the physician with valuable information regarding the
electrical activity of the patient's heart that are especially useful for the
determination of cardiac abnormalities, drug efficacy, pacemaker follow-up,
Sudden Infant Death Syndrome (SIDS), differential diagnosis of patient symptoms
and activity related cardiac changes.(5,6,7,8,9)
Although Holter's first efforts consisted of an 85 pound radio transmitter
and a receiving device that required the same amount of analysis time as the
time recorded, the first commercial AECG device manufactured in 1962 by Del Mar
Engineering Laboratories under the name Avionics Research Products Corporation
was much lighter and easier to use.(4) A large number of research and clinical
findings were published immediately after the introduction of this technology to
the medical community leading to wide spread acceptance of the technique by
1966. Del Mar Avionics continued to improve upon Holter's earlier concepts by
miniaturizing portable tape recorders, speeding up and simplifying analysis
techniques and increasing the number of channels that could be recorded and
analyzed. Concerns regarding the volume of data, accuracy of analysis, operator
dependency/fatigue and other technical considerations resulted in the
development of computerized models for analysis of the ECG and summary report
generation for physician interpretation.(4,11) Refinements to the recording
technique include; three channel recording, timing track speed correlation,
development of reusable cartridge tapes, utilization of standardized cassette
tape, use of micro cassette recorders and tape; simultaneous recording of
Electroencephalogram (EEG), Blood Pressure (BP) or gastric pH with ECG.(14)
Augmentation of the analysis technique has included refinements in arrhythmia,
ST, Pacemaker and heart rate variability analysis.(15,16,17,18) Signal Averaging
techniques and high resolution analysis of the ECG signal have also been added
to increase clinical utility of AECG.(12,13) Computerized analysis of the QT
intervals of each normal beat is the latest innovation in the ever expanding use
of Holter ECG data.(19,20)
Intended primarily for cardiac patients, the benefits of a portable recording
device that is non-invasive and poses no risk to the patient are apparent. An
LCD digital clock used in conjunction with a diary of the patient's activities
and symptoms allows the technician to correlate cardiac activity with diary
entries. A patient event button can also be utilized to mark the recording for
symptom correlation. Originally designed using magnetic tape, recording
limitations such as wow, flutter, tape head misalignment and mechanical
malfunctions are eliminated with the use of a PCMCIA type II digital recorder
which acquires 8-bit data on a Flash memory device. Digitized data is more
quickly and accurately transferred to the analysis station and time searching of
the data is more easily accomplished by the technician leading to an improved
reproducibility of results. The recorder, cable and electrodes are arranged
under the patient's clothing so that they are unobtrusive to the patient. The
recorder can be worn by shoulder strap or waist belt in such a way that it will
not interfere with normal motion and has been attached to athletes during
strenuous activity.(6,7,10) It is estimated that more than 100,000 Del Mar
Holter recorders have been, and still are, in service.
The recorded ECG is analyzed at a work station or, "scanner," that allows
technician overview and computer assisted analysis of both the wave shapes and
rate/rhythm of the signals.(8) The first commercially available systems could
only record 10 hours and playback speed was limited to 60 times faster than real
time. Today, 48 hour Holter recordings are common and playback speed is in
excess of 500 times real time. Detection and quantification of cardiac anomalies
is performed simultaneously with the documentation of the patient's ECG in the
process referred to as, "scanning." Documentation of cardiac abnormalities
allows the physician to interpret the Holter recording in an effort to further
understand the patient's increased risk for sudden death or response to
treatment. By providing a global assessment and examples of ECG from the
recording period, the physician has a better picture of the patient's
electrocardiographic activity during their normal daily routine.
1. Holter, N.J.: Historical Background and Development of Ambulatory Monitoring:
The Nature of Research, in Jacobsen, N.K., and Yarnall, S.R. (eds.): Ambulatory
ECG Monitoring, Seattle, Wash.: MCSA, 1976; pp. 1-9.
2. Holter, N.J.: New method for heart studies continuous electrocardiography of
active subjects, Science 1961; 134:1214-20.
3. Gilson, J.S., Holter, N.J., and Glasscock, W.R.: Continuous ambulant
electrocardiograms and their analysis: Clinical observations using the
electrocardiocorder and AVSEP analyzer, Am. J. Cardiol. 1964; 14:204-17.
4. Corday, E.: Historical Vignette Celebrating the 30th Anniversary of
Diagnostic Ambulatory Electrocardiographic Monitoring and Data Reduction
Systems, JACC 1991; 17:286-92.
5. Knoebel, S.B., Fisch, C., et.al.: ACC/AHA Task Force Report Guidelines for
ambulatory electrocardiography: J. Amb Mon. 1989; 2:4:313-328.
6. Canete, D.R., Sol, J., et.al.: The Honolulu Holter Marathon Study, John A.
Burns School of Medicine, Honolulu, Hawaii: 1975
7. Tzivoni, D., Benhorin, J.: Holter Recording During Treadmill Testing in
Assessing Myocardial Ischemic Changes: Am J. Card. 1985; 55:1200-1203.
8. Corday, E., Lang, T.: Accuracy of data reduction systems for diagnosis and
quantification of arrhythmias: Am. J. Card. 1975;35:927-28.
9. Kennedy, H.L.: Ambulatory Electrocardiography including Holter Recording
Technology: Philadelphia, Lea & Febiger, 1980.
10. Horner, S.L.: Ambulatory Electrocardiography Applications and Techniques:
J.B. Lippincot Company.
11. DiBianco, R., Katz, R.J. et. al.: Evaluation of Technician Audiovisual
Scanning of Ambulatory Electrocardiographic Recordings Utilizing the Rapid
Oscillographic Printout Technique of Validation: Clin. Card. 1982:5,39-45.
12. Henkin R., Caref E.B., Kelen G.J., El-Sherif N.: A Comparitive Analysis of
Commerical Signal-Averaged Electrocardiogram Devices. In: High Resolution
Electrocardiography. El-Sherif and Turitto (EDS.) Futura Publisher. 1991:pp.
13. Kelen, G, Henkin, R.: Correlation Between the Signal-Averaged
Electrocardiogram from Holter Tapes and from Real-Time Recordings. Amer Jour of
Card. 1989; pp. 1321-1325.
14. McCall, V.R.: fully Automated Indirect Blood Pressure Measurement Techniques
and Clinical Applications. 1987 © DMA.
15. Salerno, D.M., Granrud, G, et. al.: Accuracy of Commercial 24-Hour
Electrocardiogram Analyzers for Quantitation of Total and Repetitive Ventricular
Arrhythmias. Am J. Card. 1987; 60:1299-1305.
16. Hammill, S.C.: Evaluation of a Holter System to Record ST-Segment Changes.
J. Electrocard. 1987; Supplemental Issue-Oct.
17. Kennedy, H., Wiens, R.D.: Ambulatory (Holter) electrocardiography and
myocardial ischemia. St. Louis University School of Medicine; 1988.
18. Van Gelder, L.M., El Gamal, M.I.H.: Undersensing in VVI-Pacemakers Detected
by Holter Monitoring. PACE 1988;11:1507-1511.
19. Baranowski, R., Poawska, W., Rydlewska-Sadowska, W.: Day to day
reproducibility of beat by beat Holter QT analysis. Abstract for National
Institute of Cardiology, Warsaw, Poland.
20. Bent, T. J., et al: Reproducibility of QT Dynamics in Healthy Subjects.
Abstract for University of Copenhagen, Copenhagen, Denmark.