Comparative Analysis of ECG and Holter Monitoring in the Assessment of Heart Rate in Heart Failure with Reduced
Fabio Eduardo Camazzola1,2, Pedro Vellosa Schwartzmann3, Marcelo Sabedotti1
1Universidade de Caxias do Sul (UCS) - Medicina, Caxias do Sul, RS - Brasil.
Insights
Resting electrocardiograms (ECG) accurately measure heart rate (HR) in heart failure with reduced ejection fraction (HFrEF) patients. However, Holter monitoring is recommended for those with HR below 70 bpm on ECG.
Area of Science:
- Cardiology
- Clinical Electrophysiology
- Heart Failure Management
Background:
- Heart rate (HR) is a significant prognostic indicator in patients diagnosed with heart failure with reduced ejection fraction (HFrEF) and who are in sinus rhythm.
- The optimal method for measuring HR in this patient population remains a subject of debate within the medical literature.
Purpose of the Study:
- To conduct a comparative analysis of heart rate (HR) measurements obtained via Holter monitoring versus three separate resting electrocardiogram (ECG) recordings.
- The study specifically focuses on patients with HFrEF and sinus rhythm.
Main Methods:
- A cross-sectional study design was employed, involving 135 patients with a confirmed diagnosis of heart failure with ejection fraction ≤ 40% and sinus rhythm.
- Heart rate (HR) was assessed using both standard electrocardiogram (ECG) and 24-hour Holter monitoring.
- Statistical analyses included intraclass correlation coefficient (ICC), robust regression, root mean squared error, Bland-Altman analysis, and area under the receiver operating characteristic (ROC) curve, with a significance level of 0.05 and Bonferroni-Holm adjustment.
Main Results:
- The intraclass correlation coefficient (ICC) for the three ECGs demonstrated high agreement (0.922).
- Robust regression analysis indicated significant correlation between ECG and Holter measurements (robust R² = 0.711).
- Bland-Altman analysis revealed wide limits of agreement (-17.0 to 32.0), and the area under the ROC curve was 0.896, suggesting good predictive value.
Conclusions:
- Electrocardiogram (ECG) measurements of heart rate (HR) show substantial agreement with Holter monitoring, supporting its clinical utility in HFrEF patients with sinus rhythm.
- However, agreement was found to be suboptimal in approximately one-third of patients with an ECG-measured HR below 70 bpm.
- For patients with lower heart rates on ECG, 24-hour Holter monitoring is recommended to ensure accurate assessment.
Background:
Heart rate (HR) has shown prognostic value in patients with heart failure with reduced ejection fraction (HFrEF) and sinus rhythm. However, the method of measurement is debated in the literature.
Objectives:
To compare HR on Holter with 3 resting electrocardiograms (ECG1, ECG2, and ECG3) in patients with HFrEF and sinus rhythm.
Methods:
This was a cross-sectional study with 135 patients with heart failure with ejection fraction ≤ 40% and sinus rhythm. HR was assessed by ECG and Holter. Analyses included intraclass correlation coefficient (ICC), robust regression, root mean squared error, Bland-Altman, and area under the receiver operating characteristic (ROC) curve. A significance level of 0.05 and Bonferroni-Holm adjustment were adopted to minimize type I errors.
Results:
The median [interquartile range] age and ejection fraction were 65 years [16] and 30% [11], respectively. The ICC of the 3 ECGs was 0.922 (95% confidence interval: 0.892; 0.942). The robust regression coefficients for ECG1 and ECG3 were 0.20 (95% confidence interval: 0.12; 0.29) and 0.21 (95% confidence interval: 0.06; 0.36). The robust R2 was 0.711 (95% confidence interval: 0.628; 0.76). In the Bland-Altman agreement analysis, the limits of agreement were -17.0 (95% confidence interval: -19.0; -15.0) and 32.0 (95% confidence interval: 30.0; 34.0). The area under the ROC curve was 0.896 (95% confidence interval: 0.865; 0.923).
Conclusion:
The HR on ECG showed high agreement with the HR on Holter, validating its clinical use in patients with HFrEF and sinus rhythm. However, agreement was suboptimal in one third of patients with HR below 70 bpm on ECG; thus, 24-hour Holter monitoring should be considered in this context.
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