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Cardiac Event Recorders Yield More Diagnoses and Are More Cost-effective than 48-Hour Holter Monitoring in Patients with Palpitations: A Controlled Clinical Trial

Scott Kinlay, MBBS, PhD, FRACP; James W. Leitch, MBBS, FRACP; Amanda Neil, BSc; Barry L. Chapman, MBBS, FRACP; David B. Hardy, DMU, RDCS; and Peter J. Fletcher, MBBS, PhD, BMed(Sci), FRACP
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From John Hunter Hospital and and Centre for Clinical Epidemiology and Biostatistics, New South Wales, Australia. Acknowledgments: The authors thank Helen Bednar, Fiona Broderick, Jenny Key, Jodie Pettit, Tammie Powell, and Mia Tolfree for technical assistance and Tammie Hodges for secretarial assistance. Requests for Reprints: Scott Kinlay, MBBS, PhD, FRACP, Cardiovascular Unit, John Hunter Hospital, Locked Bag 1, Hunter Mail Centre, New South Wales 2310, Australia. Current Author Addresses: Drs. Kinlay, Leitch, Chapman, Hardy, and Fletcher: Cardiovascular Unit, John Hunter Hospital, Locked Bag 1, Hunter Mail Centre, New South Wales 2310, Australia.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;124(1_Part_1):16-20. doi:10.7326/0003-4819-124-1_Part_1-199601010-00003
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Objective: To compare the diagnostic yield and cost-effectiveness of transtelephonic event monitors with those of Holter monitoring in patients with intermittent palpitations.

Design: Randomized crossover trial.

Setting: Diagnostic service of a teaching hospital and surrounding primary care practices.

Patients: 43 patients with previously uninvestigated palpitations who were referred for Holter monitoring.

Measurements: Patients were randomly allocated to receive an event monitor or 48-hour Holter monitor and then to receive the other device. Event monitors were used for 3 months or until two recordings were obtained while symptoms occurred. The main end point was an electrogram recorded during symptoms. The incremental cost-effectiveness of obtaining a diagnostic rhythm strip from event monitors was compared with that of Holter monitoring.

Results: The mean (±SD) patient age was 45 ± 19 years; 37 patients (88%) were women. Event monitors were twice as likely to provide a diagnostic rhythm strip electrocardiogram during symptoms as 48-hour Holter monitoring (29 patients [67%] and 15 patients [35%], respectively; P < 0.001). Event monitors detected 8 patients (19%) with clinically important arrhythmias (6 patients with supraventricular tachycardia and 2 with atrial fibrillation or flutter), whereas the Holter monitors detected no significant arrhythmia (P < 0.005). With the event monitors, most patients transmitted an electrocardiogram recording by 6 weeks. Event monitors were dominant and therefore more cost-effective than 48-hour Holter monitoring, resulting in a cost savings of $213 for each additional diagnostic rhythm strip obtained during symptoms.

Conclusions: Holter monitoring is a poor diagnostic test for intermittent palpitations. Event recorders provide better data and are more cost-effective.


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Figure 1.
Electrocardiogram recording from an event recorder showing atrial fibrillation during palpitations.
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Figure 2.
Cumulative number of patients who sent an electrocardiogram from an event recorder by the number of days needed to record an electrocardiogram while symptoms were occurring.
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