Clinical Applications of Heart Rhythm Monitoring Tools in Symptomatic Patients and for Screening in High-risk Groups

Mafalda Carrington; Rui Providência; C. Anwar A. Chahal; Fabrizio Ricci; Andrew E. Epstein; Sabina Gallina; Artur Fedorowski; Richard Sutton; Mohammed Y. Khanji


Europace. 2022;24(11):1721-1729. 

In This Article

Abstract and Introduction


Recent technological advances have facilitated and diversified the options available for the diagnosis of cardiac arrhythmias. Ranging from simple resting or exercise electrocardiograms to more sophisticated and expensive smartphones and implantable cardiac monitors. These tests and devices may be used for varying periods of time depending on symptom frequency. The choice of the most appropriate heart rhythm test should be guided by clinical evaluation and optimized following accurate characterization of underlying symptoms, 'red flags', risk factors, and consideration of cost-effectiveness of the different tests. This review provides evidence-based guidance for assessing suspected arrhythmia in patients who present with symptoms or in the context of screening, such as atrial fibrillation or advanced conduction disturbances following transcatheter aortic valve implantation in high-risk groups. This is intended to help clinicians choose the most appropriate diagnostic tool to facilitate the management of patients with suspected arrhythmias.


Heart rhythm monitoring options have expanded beyond the classic 12-lead surface electrocardiogram (ECG), exercise ECGs and Holter monitors, now including smartphones, smartwatches and wristbands using electrodes or photoplethysmographic (PPG) sensors, extended rhythm recording using patches and wearables, external loop recorders (ELRs) and post-event recorders, handheld devices, ambulatory continuous cardiac telemetry monitoring, and implantable cardiac monitors (ICMs).[1] Prolonged out-of-hospital heart rhythm monitoring is a key component of atrial fibrillation (AF) diagnosis and assessment of its burden. They are also essential to evaluate patients who suffered events potentially related to arrhythmia, such as stroke, or who present with unexplained symptoms such as palpitations or syncope that may be caused by other suspected arrhythmias. In the latter group of patients, the assessment of both frequency and severity of symptoms is crucial for choosing the most adequate method and duration of rhythm monitoring.

In this report, we summarize the current and future clinical applications for heart rhythm testing in patients at increased arrhythmic risk or with symptoms suspected to be due to arrhythmia (Figure 1).

Figure 1.

Indications for monitoring intermittent arrhythmias with smart electronic devices. Guideline recommendations (arrow); evidence-based indications suggested by the authors (dashed arrow). AC, arrhythmogenic cardiomyopathy; BBB, bundle branch block; CAD, coronary artery disease; CIED, cardiac implantable electronic devices; CMP, cardiomyopathy; CPVT, catecholaminergic polymorphic ventricular tachycardia; ECG, electrocardiogram; EPS, electrophysiological study; HCM, hypertrophic cardiomyopathy; LQTS, long QT syndrome; LV, left ventricle; OSA, obstructive sleep apnoea; SCD, sudden cardiac death; VA, ventricular arrhythmia. **Particularly important in athletes.