Ambulatory ECG Holter Monitoring Research Articles

Adverse Myocardial and vascular side effects of Immune Checkpoint Inhibitors: a prospective multimodal cardiovascular assessment (AMICI study)

Abstract Background Immune checkpoint inhibitors (ICIs) are transformative treatments in oncology, yet they are also associated with a range of cardiovascular (CV) events. Purpose To identify the incidence of CV events (including subclinical) in patients receiving ICIs for solid cancer, either alone or in association with other cancer therapies (e.g., chemotherapies, target therapies). Objectives and methods The Adverse Myocardial and vascular side effects of Immune Checkpoint Inhibitors(AMICI) study prospectively assessed the incidence of CV changes by means of a thorough multimodal assessment. This included repeated CV imaging (transthoracic echocardiograms (TTE), cardiac magnetic resonance imaging (CMR)), serum biomarkers (troponin, brain natriuretic peptides in a single laboratory), and ambulatory ECG monitoring, before and during (at 6 weeks and at 6 months) ICI therapy (Figure). Cardiovascular events included myocarditis, pericarditis, acute coronary syndrome, heart failure (HF), high degree conduction abnormalities (defined as new grade 2 or 3 atrioventricular block) or sustained ventricular arrhythmias (defined as 3 or more ventricular beats at a rate ≥ 120/min), CV death as a composite endpoint, validated by an independent expert panel Results Out of 130 solid cancer patients considered for ICI therapy, 49 patients (38 (77.6%) male; mean age 64.3 (­SD 11.0) years old) were included (June 2020 -December 2021). 22 (55.1%) suffered from kidney or bladder cancer; 7 (14.3%) had CV disease prior to cancer diagnosis; 4 (8.2%) received PD1 and CTLA4 inhibitors. Early CV events were observed in 9 (18.4%) patients at mean 40.1 (SD 5.9) days, with heart failure (HF) in 5 (10.2%), ventricular arrhythmias or new conduction disorders in 4 (8.2%) patients. History of AF (HR 4.49 (CI 1.11-18.14), P=0.035) predicted early CV events at 6 weeks (Table). At 6 months follow-up, 18 CV events were observed in 15/49 (31%) patients, with 6 (12.2%) HF events, 5 (10.2%) significant ventricular arrhythmias or conduction disorders and 4 (8.2%) AF. There was a significant decline in LVEF (P<0.001) in patients even in the absence of CV event (P=0.003) or HF (P=0.003). Higher creatinine at inclusion (HR 0.99 [0.98-1.00], P=0.006) predicted HF. Conclusions Cardiovascular complications arising during cancer treatment with ICIs are primarily due to the exacerbation of pre-existing HF or the onset of non-inflammatory heart rhythm disorders. The majority of these CV changes manifest shortly after starting ICIs and do not need hospital admission. Our results suggest that more close follow-up may be needed in patients with underlying CV conditions when starting ICI therapy, by means of CMR and ambulatory ECG holter monitoring.

Clinical Characteristics of Cardiac Arrhythmias in Pediatric Age Group

Background: The Symptomatic manifestation of pediatric arrhythmias varies according to the age. Patients with disturbances in cardiac rhythm have several complaints, but also could be totally asymptomatic. This study aimed to assess clinical characteristics of Tachy and Brady arrhythmia in neonates, infant, children and adolescents of various age groups.
 Methods: This cross-sectional study included 253 patients of pediatric age below 18 years old presented with different types of tachyarrhythmia or bradyarrhythmia. All patients were subjected to clinical general examination of patient, vital data collection, local cardiac examination, 12 leads electrocardiography, ambulatory ECG Holter monitoring, exercise ECG stress testing if indicated and transthoracic echocardiography. 
 Results: There was a significant relation between age of presentation of the study patients and classification of arrhythmia (P < 0.001). Palpitations was the most common presentations of arrhythmia in our study patients (32%) followed by dyspnea in 17.8 % of the patients. 20.6 % of the study patients with arrhythmias were asymptomatic. Congenital heart anomalies were in 43 % of the patients.
 Conclusion: Pediatric arrhythmia can be totally asymptomatic and discovered accidentally. Congenital cardiac anomalies and cardiac arrhythmias are closely correlated. Holter monitoring and exercise ECG testing can help in diagnosing pediatric arrhythmia. Untreated or persistent arrhythmia causes LV myopathy and dilatation. Antiarrhythmic drugs can have their harmful effect on the growing child.

Holter ECG findings in diabetics with medial arterial calcification.

Medial arterial calcification (MAC) is a nonobstructive condition leading to reduced arterial compliance. The disease most commonly occurs in diabetes mellitus. Decreased ankle-brachial pressure index (ABI) is a well-known marker of increased cardiovascular mortality. However, also the values of ABI above 1.3, typical in MAC, are associated with increased mortality. By means of Holter ECG monitoring, we investigated 41 patients (25 men, 16 women) with mean age of 59±8 years, suffering of type 2 diabetes mellitus and identified as having MAC, and Holter ECG monitoring with an average duration of recording 22.36 hours, was carried out by GE-Marquette MARS ECG Holter system. We found frequent incidence of cardiac arrhythmias and myocardial ischemia in 22 patients (53.7 %). Only 19 patients (46.3 %) had normal Holter ECG recordings. ABI values were significantly higher in patients with abnormal ECG Holter recordings. Our results confirm the importance of ABI estimation in clinical practice. As the central goal of therapy for patients with myocardial ischemia and/or complex forms of cardiac arrhythmias is the reduction or elimination of these episodes. Ambulatory Holter ECG monitoring plays an important role in the management of these patients (Tab. 7, Ref. 16).

Validation of a novel single lead ambulatory ECG monitor – Cardiostat™ – Compared to a standard ECG Holter monitoring

BackgroundCardiostat™ is a single lead ambulatory ECG monitor. Recording is made through 2 electrodes positioned in a lead 1-like configuration. We first validated its accuracy for atrial fibrillation detection compared to a 12-lead ECG. In the second phase of the study, arrhythmia detection accuracy was compared between Cardiostat™ ambulatory ECG and a standard 24 h Holter ECG monitoring. Method/resultsPhase one of the study included patients undergoing cardioversion for atrial fibrillation (AF) or atrial flutter. Cardiostat™ tracings were compared with standard 12-lead ECG.In the second phase, patients undergoing 24 h ambulatory Holter ECG monitoring for control or suspicion of atrial fibrillation (AF) were included. Simultaneous Holter monitoring and Cardiostat™ ECG recordings were performed. Tracings were analysed and compared.Two hundred twelve monitoring were compared. AF was diagnosed in 73 patients. Agreement between Cardiostat™ ECG and standard Holter monitoring was 99% for AF detection with kappa = 0.99. Kappa correlation for atrial flutter detection was only moderate at 0.51. AF burden was similar in both recordings. Noise hindered analysis in a greater proportion with Cardiostat™ compared to Holter ambulatory ECG (8.5 vs 3.8%). ConclusionCardiostat™ ambulatory ECG device showed excellent correlation with the standard Holter ECG monitoring for AF detection. Holter monitoring was however superior to discriminate premature atrial and ventricular beats and to qualify the morphology of PVCs since it has more vectors for analysis. Added value of Cardiostat™ includes longer monitoring duration, less cumbersome installation and water resistance.

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Aim. To study the heart rate variability and autonomic regulation features in preterm infants with an analysis of adverse perinatal factors. Matherial and methods. Current study included preterm infants during infancy. We assessed thoroughly history, physical examination of patients, electrocardiography findings, ambulatory ECG Holter monitoring results. Results and discussion. We analyzed of the most significant perinatal risk factors for cardiovascular diseases such as burdened obstetric history, chronic fetoplacental insufficiency, preeclampsia, viral infections during the first trimester of pregnancy. There was a reduction of circadian index in the children with ELBW and VLBW, that is, the presence of the rigidity of the circadian profile of heart rate (HR). According to ECG Holter monitoring, preterm infants had such cardiac disorders as cardiac arrhythmia supraventricular and ventricular, conduction disturbances in the form of AV block, daily rhythm structure changes in the form of the rigidity of the circadian profile of HR. We found decreased temporal parameters of heart rate variability, which indicates a weakening of parasympathetic effects on the heart and relative sympathicotonia. Conclusion. The presence of autonomic imbalance with a predominance of sympathetic tone, reduced heart rate variability in conjunction with anatomical defects, overloading of the heart chambers volume or pressure and hypoxia may predispose the development of pathological myocardial remodeling in infants with extremely and very low birth weight.

The role of circulating autoantibodies in relation to proteins in structural cardiomyocytes and functional changes of the heart in patients with chronic myocarditis

Evidence that has been progressively gathered implicates an important role of the immune system in the course of heart failure. In the majority of heart disease patients, disturbances of humoral immunity with production of cardiodepressant antibodies may play a functional role in cardiac dysfunction. This study evaluates the role of autoantibodies to the cardiac myosin. We examined 52 patients (from 14 till 61 years) with chronic myocarditis. The main examination methods were clinical and biochemical blood tests, ECG, ambulatory Holter ECG monitoring, echocardiography. Autoantibodies to the cardiac myosin were determined by ELISA. These autoantibodies correlate with myocardial inflammation. Also they are associated with structural changes of the heart (hypertrophy, dilation) and cardiac dysfunction (contractility, rhythm and conduction). The degree of expression of these disorders is related to the severity of chronic heart failure.

Efficacy and safety of ivabradine in chronic heart failure across the age spectrum: insights from the SHIFT study

To test whether the efficacy and safety of the selective heart rate-reducing agent ivabradine changes according to age in chronic heart failure (HF) patients. The ivabradine and placebo arms of SHIFT, which enrolled 6505 chronic HF patients, were combined and age distribution was divided by quartiles to give four groups (<53 years, n = 1522; 53 to <60 years, n = 1521; 60 to <69 years, n = 1750; and ≥69 years, n = 1712). The effects of ivabradine on cardiovascular outcomes, changes in heart rate, and adverse events, particularly bradycardia, were evaluated according to age group. A subgroup (602 patients) underwent 24 h ambulatory ECG Holter monitoring. The relative risk of the primary endpoint (cardiovascular death or hospitalization for worsening HF) was reduced by ivabradine in all age groups, ranging from 38% [hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.50-0.78, P < 0.001] in the youngest patients <53 years to 16% (HR 0.84, 95% CI 0.71-0.99, P = 0.035) in the oldest patients ≥69 years. Ivabradine up-titration reduced heart rate similarly in all age groups, by 11 b.p.m. As anticipated, bradycardia and phosphenes occurred more frequently with ivabradine, at a similar rate whatever the age. In the Holter substudy, there were no episodes of severe bradycardia and no clinically relevant pauses with ivabradine in any age group. Age does not limit the appropriate use of ivabradine in patients with chronic HF and systolic dysfunction. The safety and efficacy of ivabradine are comparable across all age groups.

Real-time representation of multielectrode ablation catheters by integration of computed tomographic geometry with three-dimensional electroanatomic mapping of left atrium and pulmonary veins

t B f s t P l s a S t v A m c t f w t R l A 36-year-old man without apparent structural heart disase was referred for catheter ablation of atrial fibrillation. e had weekly episodes of palpitations that were resistant to iltiazem, propranolol, and flecainide. Short bursts of atrial achycardia and fibrillation were demonstrated on ECGs and 4-hour ambulatory ECG Holter monitoring recorded on ifferent days. The patient underwent 64-detector multislice omputed tomography (CT) of the left atrium and pulmoary veins before the ablation procedure. A 24-pole ring-shaped catheter (yellow in Figure 1) and custom octapolar ablation catheter (white in Figure 1) ere introduced into the left atrium for mapping and abla-

Self-limited bursts of atrial fibrillation following successful cardioversion

Background To evaluate if self-limited episodes of atrial fibrillation after DC cardioversion predict recurrence of persistent atrial fibrillation. To evaluate the incidence and duration of such episodes as well as their change over time. Methods Consecutive patients with persistent atrial fibrillation, scheduled for direct current cardioversion were prospectively included in the study. Ambulatory ECG Holter monitoring (24 h) was performed one, three and 6 weeks after successful cardioversion. Results A total of 84 patients were prospectively included in the study. Sinus rhythm was restored in 74 patients (88%). At 6 weeks of follow-up 40 patients out of 74 (54%) had sinus rhythm, and 34 patients (46%) had relapsed into persistent atrial fibrillation. Eight out of these 34 patients (24%) had bursts of atrial fibrillation at their first Holter recording, compared to 12 patients out of 40 (30%) in sinus rhythm at 6 weeks ( p > 0.05). On the first, second and third Holter recording 21 patients out of 51 (41%), 21 patients out of 43 (49%) and 15 out of 40 patients (38%) had self-limited bursts of atrial fibrillation, respectively. The incidence or duration of episodes did not vary over time during the 6 weeks of follow-up. Conclusion In patients successfully converted to sinus rhythm self-limited bursts of atrial fibrillation do not predict recurrence of persistent atrial fibrillation during 6 weeks of follow up. Brief self-limited episodes of atrial fibrillation are common, and the incidence and duration of such episodes are constant during a 6 weeks period after DC cardioversion.

The Heart of Trained Athletes

Young competitive athletes are widely regarded as a special subgroup of healthy individuals with a unique lifestyle who are seemingly invulnerable and often capable of extraordinary physical achievement.1–3 For more than 100 years, there has been considerable interest in the effects of intense athletic conditioning on the cardiovascular system.4–27 The advent of echocardiography more than 30 years ago provided a noninvasive quantitative assessment of cardiac remodeling associated with systematic training, and consequently, a vast body of literature has been assembled that is focused on the constellation of alterations known as “athlete’s heart.”4–27 Athlete’s heart is generally regarded as a benign increase in cardiac mass, with specific circulatory and cardiac morphological alterations, that represents a physiological adaptation to systematic training.1,6–27 However, the clinical profile of athlete’s heart has expanded considerably over the last several years as a result of greater accessibility to large populations of trained athletes studied systematically with echocardiography, ECG, cardiac magnetic resonance, and ambulatory Holter ECG monitoring. As a consequence, there is increasing recognition of the impact that prolonged conditioning has on cardiac remodeling, which may eventually mimic certain pathological conditions with the potential for sudden death or disease progression. Over the last several years, sudden deaths of trained athletes, usually associated with exercise, have become highly visible events fueled by news media reports and with substantial impact on both the physician and lay communities.1,28–36 Interest in these tragic events has accelerated owing to their increased recognition; awareness that underlying, clinically identifiable cardiovascular diseases are often responsible; and the availability of treatments to prevent sudden death for high-risk athlete-patients. In the present review, we offer a comprehensive assessment of many issues that target the interrelation of intense physical exertion with cardiac structure and function, as well as the rare, potentially adverse consequences of …

Evaluation of Patients with Palpitations: Cardiac Event Recorder Versus 48-hour Holter Monitoring

Objectives: (1) To compare a diagnostic yield of cardiac event recorders with that of 48-hour Holler monitoring, (2) to determine the etiologies of palpitations, and (3) to assess an optimal duration of using an event recorder by a patient. Background: Palpitation is a common symptom which accounts for 16% of total complaints reported by patients in general medical settings. An ambulatory Holter ECG monitoring or an event recorder can be used to establish the cause of palpitations. Methods: (1)The study group consisted of 33 consecutive patients (24 females, 9 males, mean age 50 ± 32 years) with undiagnosed attacks of palpitations, occurring at least once per month. Each patient was randomly allocated to use either an event monitor or 48-hour Holler monitoring. The patient kept the event monitor for 4 weeks. After the first monitor was returned, the patient was given the other device. Results: Holter monitoring determined the etiology of palpitations in 11 (33%) patients, and the event recorder in 21 (64%) patients (P = 0.0138). In the whole study group, the etiology of palpitations was disclosed in 23 (70%) patients. The diagnosis was possible using Holler ECG monitoring in only 2 (9%) patients, whereas the event recorder revealed the underlying mechanism of palpitations in 12 (52%) patients (P = 0.0007). In nine (39%) patients both methods were able to disclose the eliology of palpitations. The findings of 117 recordings obtained using an event recorder during palpitations were atrial fibrillation in 10 (9%), narrow QRS tachycardia in 4 (3%), frequent supraventricular eclopy in 17 (15%), frequent ventricular eclopy in 6 (5%), and episodes of palpitations sinus rhythm were recorded in the remaining 80 (68%). Of patients who experienced episodes of palpitations while using an event recorder, the earliest recording was obtained on the first day of the study, and the latest on the 18 day of using the event recorder. Conclusions: (1) The cardiac event recorders yield more diagnoses than 48-hour Holter monitoring in patients with palpitations occurring at least once per month, (2) in this group of patients the event recorder provided a diagnostic ECG recording during the first 18 days of using the device, and (3) in the majority (57%) of patients a normal sinus rhythm was recorded during episodes of palpitations. A.N.E. 2000;5(4):315–321

Spontaneous and inducible ventricular arrhythmias in a canine model of chronic heart failure: relation to haemodynamics and sympathoadrenergic activation.

The relationship between the incidence, frequency and complexity of spontaneous ventricular arrhythmias and the extent of haemodynamic compromise and sympathoadrenergic hyperactivity was evaluated in a canine model of chronic heart failure produced by multiple sequential intracoronary microembolizations. Ambulatory ECG Holter monitoring recorded during chronic heart failure in 18 dogs revealed spontaneous ventricular arrhythmias ranging from single ventricular premature beats (VPBs) to non-sustained episodes of ventricular tachycardia (VT). Single VPBs were present in 94% of dogs, couplets in 67%, triplets in 28% and spontaneous episodes of non-sustained VT in 33%. Dogs with > 28 VPBs.h-1 (n = 9) had a markedly higher plasma norepinephrine (PNE) concentration (1001 +/- 185 vs 561 +/- 31 pg.ml-1) (P < 0.03), and a higher pulmonary artery wedge pressure (PAWP) (18 +/- 2 vs 12 +/- 1 mmHg) (P < 0.03) than dogs with < or = 28 VPBs.h-1 (n = 9). Dogs that developed spontaneous episodes of VT also had significantly higher PNE levels (1119 +/- 247 pg.ml-1) compared to dogs that did not develop VT (612 +/- 64 pg.ml-1) (P < 0.02). Programmed ventricular stimulation performed in seven of 18 dogs resulted in the development of sustained monomorphic VT in three and ventricular fibrillation in three dogs each (43%, 43%). Dogs with inducible sustained monomorphic VT had a significantly higher number of ambient arrhythmias and higher PAWP compared to dogs that did not develop sustained VT. The observed complexity, frequency and incidence of spontaneous and inducible ventricular arrhythmias in this canine model are similar to those described in patients with chronic heart failure.