Abstract
Background: To date, Holter monitoring has been predominantly utilized in the investigation and monitoring of ventricular arrhythmias and myocardial ischemia. Whether currently employed lead configurations are optimal for recording atrial electrocardiograms (ECGs) is unknown.
Hypothesis: This study was undertaken to determine which conventional and novel lead configurations are optimal for recording atrial electrical activity during sinus rhythm and atrial fibrillation.
Methods: Recordings were performed on eight healthy volunteers in sinus rhythm and four patients in atrial fibrillation. Each subject had 10 ECGs of three bipolar and three augmented unipolar leads recorded during supine rest, while rising to upright, and during standing rest, yielding a total of 60 leads (30 bipolar leads). Each tracing was inspected by two observers, and parameters such as P‐wave amplitude and duration, whether the P‐wave onset was clearly seen, atrial fibrillatory‐wave amplitude, and amplitude of noise during standing were scored.
Results: Leads recording interiorly and leftward orientated bipoles provided the best registration of sinus P waves. The Pwave amplitude in the standard bipolar C5 lead (0.12 d̊ 0.02 mV) was, however, inferior to others such as recordings between Cl and C6 positions (P‐wave amplitude 0.16 d̊ 0.02 mV) or from below the right clavicle to the left upper quadrant of the abdomen (0.16 d̊ 0.01 mV). Optimal recording of fibrillatory waves was from different leads, such as a bipole from below the left clavicle to a low C1 position (fibrillatory wave amplitude 0.27 d̊ 0.03 mV).
Conclusion: When Holter recordings are performed for the investigation of atrial arrhythmias, nonstandard lead configurations provide superior recording of atrial electrical activity. We advocate the use of electrodes positioned from C1 to C6, from below the left clavicle to a low C1 position, and a vertically orientated lead from the manubium to the twelfth vertebra or the xiphisternum.
Keywords: ambulatory electrocardiography, atrial arrhythmias, atrial fibrillation
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References
- 1. Bleifer SB, Bleifer DJ, Hansmann DR, Sheppard JJ, Harold HL: Diagnosis of occult arrhythmias by Holter electrocardiography. Prog Cardiovasc Dis 1974; 16: 569–599 [DOI] [PubMed] [Google Scholar]
- 2. Harrison DC, Fitzgerald JW, Winkle RA: Ambulatory electrocardiography for diagnosis and treatment of cardiac arrhythmias. N Engl J Med 1976; 294: 373–380 [DOI] [PubMed] [Google Scholar]
- 3. Morganroth J: Ambulatory Holter electrocardiography: Choice of technologies and clinical uses. Ann Intern Med 1985; 102: 73–81 [DOI] [PubMed] [Google Scholar]
- 4. Stern S, Tzivoni D: Dynamic changes in the ST‐T segment during sleep in ischemic heart disease. Am J Cardiol 1973; 32: 17–20 [DOI] [PubMed] [Google Scholar]
- 5. Deanfield JE, Shea M, Ribiero P, de Landsheere CM, Wilson RA, Horlock P, Selwyn AP: Transient ST‐segment depression as a marker of myocardial ischemia during daily life. Am J Cardiol 1984; 54: 1195–1200 [DOI] [PubMed] [Google Scholar]
- 6. Jespersen CM, Rasmussen V: Detection of myocardial ischaemia by transthoracic leads in ambulatory electrocardiographic monitoring. Br Heart J 1992; 68: 286–290 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Racine N, Ripley R, Ramsay J, Silberberg J, Sami MH: Holter monitor recording for the detection of myocardial ischemia: Validation of a new recorder and chest lead positions. Can J Cardiol 1992; 8: 465–468 [PubMed] [Google Scholar]
- 8. Shandling AH, Bernstein SB, Kennedy HL, Ellestad MH: Efficacy of three‐channel ambulatory electrocardiographic monitoring for the detection of myocardial ischemia. Am Heart J 1992; 123: 310–316 [DOI] [PubMed] [Google Scholar]
- 9. Frank E: An accurate, clinically practical system for spacial vectorcardiography. Circulation 1956; 13: 737–749 [DOI] [PubMed] [Google Scholar]
- 10. Holm M, Pehrson S, Ingemansson M, Smideberg B, Sormo L, Olsson SB: Non‐invasive assessment of the atrial cycle length during atrial fibrillation in man. Introducing, validating and illustrating a new ECG method. Cardiovasc Res 1998; 38: 69–81 [DOI] [PubMed] [Google Scholar]
- 11. Kennedy HL: Importance of the standard electrocardiogram in ambulatory (Holter) electrocardiography. Am Heart J 1992; 123: 1660–1677 [DOI] [PubMed] [Google Scholar]
- 12. Quyyumi AA, Crake T, Mockus LJ, Quyyumi AA, Crake T, Mockus LJ, Wright CA, Rickards AF, Fox KM: Value of the bipolar lead CM5 in electrocardiography. Br Heart J 1986; 56: 372–376 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Brembilla‐Perrot B: Study of P wave morphology in lead V1 during supraventricular tachycardia for localizing the reentrant circuit. Am Heart J 1991; 121: 1714–1720 [DOI] [PubMed] [Google Scholar]
- 14. Herzog LR, Marcus FI, Scott WA, Faitelson LH, Ott P, Hahn E: Evaluation of electrocardiographic leads for detection of atrial activity (P wave) in ambulatory ECG monitoring: A pilot study. Pacing Clin Electrophysiol 1992; 15: 131–134 [DOI] [PubMed] [Google Scholar]