Utility of Holter monitoring in pediatric patients with arrhythmia symptoms in the ED: A retrospective cohort study

Abstract

Background

Pediatric patients presenting to an Emergency Department (ED) with symptoms that may represent cardiac arrhythmia can be challenging due to low prevalence of dysrhythmias and variable ability to detect and report symptoms. We aimed to determine the overall diagnostic yield of Holter monitoring (HM) in this population.

Methods

We performed a retrospective cohort study of patients ≤21 years of age presenting to an academic urban tertiary care center with embedded pediatric ED between January 2015–June 2023 with symptoms suggestive of cardiac arrhythmia who were discharged with a HM after ED evaluation. Patients with a known cardiac history or an abnormal electrocardiogram (ECG) at presentation were excluded. Positive diagnostic yield for HM was defined as capturing the patient's reported symptoms, regardless of arrhythmia presence, or detecting a silent arrhythmia.

Results

There were 159 patients included in the study. Thirty-two patients with a known cardiac history and one patient with an abnormal ECG were excluded. The most common chief complaints were palpitations (n = 51, 32 %), followed by syncope/pre-syncope (n = 47, 30 %), and chest pain (n = 33, 21 %). Out of the 91 patients (57 %) reporting symptoms while wearing the HM, only one patient experienced symptomatic arrhythmia. None of the symptomatic patients with a negative HM result had recorded arrhythmia in their medical charts within one year following the initial ED visit. Holter monitoring recorded “silent” arrhythmias in nine (6 %) patients. These included three cases of supraventricular tachycardia, three cases of non-sustained ventricular tachycardia, and three patients with second-degree (Mobitz 1) atrioventricular block. The overall diagnostic yield for HM in our study cohort was 63 %.

Conclusion

Ambulatory HM in low-risk pediatric patients presenting to the ED with symptoms suggestive of cardiac arrhythmia is a useful diagnostic tool in excluding arrhythmias. In addition, a subset of patients will have potentially relevant silent arrhythmia detected.