Diagnostic and prognostic value of ambulatory ECG (Holter) monitoring in patients with coronary heart disease: a review

Abstract

Silent ischemia, the most common expression of atherosclerotic heart disease, affects approximately 30-50% of patients during their activities of daily living. The present review provides a comprehensive and practical summary of current knowledge on perioperative myocardial ischemia through MEDLINE searches up to June 2005, using keywords including "silent ischemia," "transient ischemia," and "Holter monitoring." Holter monitoring (i.e., continuous ambulatory ST-segment monitoring) is an effective tool for assessing the frequency and duration of silent transient myocardial ischemia, particularly in patients who are post-acute myocardial infarction (MI), those with acute coronary syndromes (ACS), and in patients in the acute post-operative period. Holter monitoring allows for further risk stratification of patients who have a positive exercise ECG by collecting long-term ECG data on ischemic and arrhythmic events while patients perform routine activities. Both the presence and increased duration of transient ischemia as detected by continuous ST-segment Holter monitoring are associated with increased rates of coronary events and mortality. Holter monitoring may aid in the identification of patients and subgroups of patients with ACS who may derive the greatest benefit from antiplatelet and antithrombotic therapy. Indeed, many ongoing and upcoming trials of pharmacotherapy include ischemia on Holter monitoring as an endpoint.

Perioperative use of statins in noncardiac surgery

“…In this cohort of patients, the great majority of myocardial infarctions occurred within the fi rst 3 days postoperatively (Badner et al 1998). It may be diffi cult to assess the true incidence of postoperative myocardial infarction, as it is dependent on the specifi city and sensitivity of the method of diagnosis (Gibson et al 2007), and the fact that some are silent clinically (Pasternack et al 1989). In a prospective study involving 444 patients with or at high risk for coronary artery disease who underwent elective noncardiac surgery, Mangano and colleagues (1992) found that postoperative myocardial ischemia increased the odds for long-term (30 days to 2 years after surgery) cardiac events (unstable angina, nonfatal myocardial infarction, cardiac death, surgical coronary revascularization) by 2.2-fold.…”

Perioperative use of statins in noncardiac surgery

“…In this cohort of patients, the great majority of myocardial infarctions occurred within the first 3 days postoperatively (Badner et al 1998). It may be difficult to assess the true incidence of postoperative myocardial infarction, as it is dependent on the specificity and sensitivity of the method of diagnosis (Gibson et al 2007), and the fact that some are silent clinically (Pasternack et al 1989). In a prospective study involving 444 patients with or at high risk for coronary artery disease who underwent elective noncardiac surgery, Mangano and colleagues (1992) found that postoperative myocardial ischemia increased the odds for long-term (30 days to 2 years after surgery) cardiac events (unstable angina, nonfatal myocardial infarction, cardiac death, surgical coronary revascularization) by 2.2-fold.…”

Predicting the outcome in patients with unexplained syncope and suspected cardiac cause: Role of electrophysiologic studies

“…Whereas in 40% of patients, the cause of syncope remains unknown after extensive clinical workup (5, 6). The disappointing results of ambulatory ECG monitoring are well known, since the heart rhythm of the patient is seldom monitored during an event (7, 8). The major difficulties to diagnosis are the unpredictable and uncommon nature of events and the high spontaneous recovery.…”