Long-term electrocardiogram

Authors: M. Malík
Authors‘ workplace: Kardiovaskulární divize Lékařské školy Sv. Jiří, Londýn ;  Kardioelektrofyziologie Sv. Pavla, Londýn
Published in: Čas. Lék. čes. 2009; 148: 353-357
Category: Review Article


The review deals with the technical and clinical advances achieved in the field of long-term electrocardiography over the past decades, and outlines possible future developments. The technological background is reviewed from the initial conception by Dr Norman J Holter up to the modern loop and implantable recorders. The contemporary clinical applicability is considered including arrhythmia monitoring, tracking the morphological electrocardiographic changes with particular attention to ischaemia monitoring, and high-precision electrocardiographic measurements related to the assessment of drug-induced myocardial repolarisation changes. The section on future outlook discusses the possibility of using long-term electrocardiograms for identification of patients at increased risk of sudden arrhythmic death that might be preventable by prophylactic use of implantable defibrillators.

Key words:
electrocardiogram, heart rhythm disorders, ischaemic changes, proarrhythmia, risk of sudden arrhythmic death.


1. Hinkle LE Jr, Meyer J, Stevens M, Carver ST. Tape recordings of the ECG of active men. Limitations and advantages of the Holter-Avionics instruments. Circulation 1967; 36: 752–765.

2. Tzivoni D, Stern S. Improved method of operating the Holter--Avionics ECG recording system. Am Heart J 1972; 83: 846–847.

3. Gula LJ, Klein GJ, Zurawska U, Massel D, Yee R, Skanes AC, Krahn AD. Does familiarity with technology predict successful use of an external loop recorder? The loop recorder technology cognition study (LOCO). Pacing Clin Electrophysiol 2009; 32: 466–472.

4. Entem FR, Enriquez SG, Cobo M, Expósito V, Llano M, Ruiz M, Jose Olalla J, Otero-Fernandez M. Utility of implantable loop recorders for diagnosing unexplained syncope in clinical practice. Clin Cardiol 2009; 32: 28–31.

5. Cain ME, Arthur RM, Trobaugh JW. Detection of the fingerprint of the electrophysiological abnormalities that increase vulnerability to life-threatening ventricular arrhythmias. J Interv Card Electrophysiol 2003; 9: 103–118.

6. Pratt CM, Yepsen SC, Bloom MG, Taylor AA, Young JB, Quinones MA. Evaluation of metoprolol in suppressing complex ventricular arrhythmias. Am J Cardiol 1983; 52: 73–78.

7. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med 1989; 321: 406–412.

8. Kamath GS, Cotiga D, Koneru JN, Arshad A, Pierce W, Aziz EF, Mandava A, Mittal S, Steinberg JS. The utility of 12-lead Holter monitoring in patients with permanent atrial fibrillation for the identification of nonresponders after cardiac resynchronization therapy. J Am Coll Cardiol 2009; 53: 1050–1055.

9. Van Den Berg MP, Van Noord T, Brouwer J, Haaksma J, Van Veldhuisen DJ, Crijns HJ, Van Gelder IC. Clustering of RR intervals predicts effective electrical cardioversion for atrial fibrillation. J Cardiovasc Electrophysiol 2004; 15: 1027–1033.

10. Materazzo C, Piotti P, Mantovani C, Miceli R, Villani F. Atrial fibrillation after non-cardiac surgery: P-wave characteristics and Holter monitoring in risk assessment. Eur J Cardiothorac Surg 2007; 31: 812–816.

11. Stern S, Tzivoni D. Silent myocardial ischemia: diagnosis, clinical significance and management. Herz 1987; 12: 318–327.

12. Kennon S, Price CP, Mills PG, MacCallum PK, Cooper J, Hooper J, Clarke H, Timmis AD. Cumulative risk assessment in unstable angina: clinical, electrocardiographic, autonomic, and biochemical markers. Heart 2003; 89: 36–41.

13. Shusterman V, Goldberg A, Schindler DM, Fleischmann KE, Lux RL, Drew BJ. Dynamic tracking of ischemia in the surface electrocardiogram. J Electrocardiol 2007; 40: S179–S186.

14. Malik M, Hnatkova H, Schmidt A, Smetana P. Electrocardiographic QTc changes due to moxifloxacin infusion. J Clinical Pharmacol 2009; 49: 674–683.

15. Fenichel RR, Malik M, Antzelevitch C, Sanguinetti M, Roden DM, Priori SG, Ruskin JN, Lipicky RJ, Cantilena LR. Drug-induced torsades de pointes and implications for drug development. J Cardiovasc Electrophysiol 2004; 15: 475–495.

16. Malik M. Errors and misconceptions in ECG measurement used for the detection of drug induced QT interval prolongation. J Electrocardiol 2004; 37: S25–S33.

17. Batchvarov VN, Ghuran A, Smetana P, Hnatkova K, Harries M, Dilaveris P, Camm AJ, Malik M. QT-RR relationship in healthy subjects exhibits substantial intersubject variability and high intrasubject stability. Am J Physiol Heart Circ Physiol 2002; 282: H2356–H2363.

18. Malik M, Hnatkova K, Novotny T, Schmidt G. Subject-specific profiles of QT/RR hysteresis. Am J Physiol Heart Circ Physiol 2008; 295: H2356–H2363.

19. Berntson GG, Bigger JT Jr, Eckberg DL, Grossman P, Kaufmann PG, Malik M, Nagaraja HN, Porges SW, Saul JP, Stone PH, van der Molen MW. Heart rate variability: origins, methods, and interpretative caveats. Psychophysiol 1997; 34: 623–648.

20. Meijer JW, Bosma E, Lefrandt JD, Links TP, Smit AJ, Stewart RE, Van Der Hoeven JH, Hoogenberg K. Clinical diagnosis of diabetic polyneuropathy with the diabetic neuropathy symptom and diabetic neuropathy examination scores. Diabetes Care 2003; 26: 697–701.

21. Odemuyiwa O, Malik M, Farrell T, Bashir Y, Poloniecki J, Camm AJ. A comparison of the predictive characteristics of heart rate variability index and left ventricular ejection fraction for all-cause mortality, arrhythmic events and sudden death after acute myocardial infarction. Am J Cardiol 1991; 68: 434–439.

22. Wichterle D, Simek J, La Rovere MT, Schwartz PJ, Camm AJ, Malik M. Prevalent low-frequency oscillation of heart rate: novel predictor of mortality after myocardial infarction. Circulation 2004; 110: 1183–1190.

23. Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G. A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med 1999; 341: 1882–1890.

24. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL, Brown MW, Andrews ML. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002; 346: 877–883.

25. Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R, Domanski M, Troutman C, Anderson J, Johnson G, McNulty SE, Clapp-Channing N, Davidson-Ray LD, Fraulo ES, Fishbein DP, Luceri RM, Ip JH. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352: 225–237.

26. Bauer A, Kantelhardt JW, Barthel P, Schneider R, Makikallio T, Ulm K, Hnatkova K, Schomig A, Huikuri H, Bunde A, Malik M, Schmidt G. Deceleration capacity of heart rate as a predictor of mortality after myocardial infarction: cohort study. Lancet 2006; 367: 1674–1681.

27. Schmidt G, Malik M, Barthel P, Schneider R, Ulm K, Rolnitzky L, Camm AJ, Bigger JT Jr, Schomig A. Heart-rate turbulence after ventricular premature beats as a predictor of mortality after acute myocardial infarction. Lancet 1999; 353: 1390–1396.

28. Bauer A, Barthel P, Schneider R, Ulm K, Müller A, Joeinig A, Stich R, Kiviniemi A, Hnatkova K, Huikuri H, Schömig A, Malik M, Schmidt G. Improved Stratification of Autonomic Regulation for risk prediction in post-infarction patients with preserved left ventricular function (ISAR-Risk). Eur Heart J 2009; 30: 576–583.

29. Bauer A, Malik M, Schmidt G, Barthel P, Bonnemeier H, Cygankiewicz I, Guzik P, Lombardi F, Müller A, Oto A, Schneider R, Watanabe M, Wichterle D, Zareba W. Heart rate turbulence: standards of measurement, physiological interpretation, and clinical use: International Society for Holter and Noninvasive Electrophysiology Consensus. J Am Coll Cardiol 2008; 52: 1353–1365.

30. Rosenbaum DS, Jackson LE, Smith JM, Garan H, Ruskin JN, Cohen RJ. Electrical alternans and vulnerability to ventricular arrhythmias. N Engl J Med 1994; 330: 235–241.

31. Verrier RL, Kumar K, Nearing BD. Basis for sudden cardiac death prediction by T-wave alternans from an integrative physiology perspective. Heart Rhythm 2009; 6: 416–422.

32. Zabel M, Acar B, Klingenheben T, Franz MR, Hohnloser SH, Malik M. Analysis of 12-lead T-wave morphology for risk stratification after myocardial infarction. Circulation 2000; 102: 1252–1257.

33. Zabel M, Malik M, Hnatkova K, Papademetriou V, Pittaras A, Fletcher RD, Franz MR. Analysis of T-wave morphology from the 12-lead electrocardiogram for prediction of long-term prognosis in male US veterans. Circulation 2002; 105: 1066–1070.

34. Giannpoulos G, Dilaveris P, Batchvarov V, Synetos A, Hnatkova K, Gatzoulis K, Malik M, Stefanadis C. Prognostic significance of inverse spatial QRS-T angle circadian pattern in myocardial infarction survivors. J Electrocardiol 2009; 42: 79–84.

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