Week 3: The Learning Curve of Holter Analysis

It’s my third week of my penultimate year’s clinical placement, and I‘ve analysed nine tapes, unassisted. This whole piece of reflection took a great deal less time for me to write, than completing an analysis of a Holter recording does, but it’s only week three, so I didn’t expect much more. In fairness, I didn’t expect to have become this comfortable with the analysis software quite so quickly, but this placement has already been filled with pleasant surprises, so I’m just going with it at the moment.

I will add that the feedback gained from these completed reports has been extremely positive, which is a bonus. The returned work has been annotated, informing that my rhythm recognition and ability to use my knowledge to correct the computer software is excellent, as is my report structure and clarity of information. Given areas for improvement highlight my initial propensity for forgetting to include basic rhythm strips (saying it’s sinus is fine, but it has to be proved), and learning the nuances in the software itself.

This, I have found to be the most difficult thing in the entire analysis process; Pathfinder is an incredibly user-friendly piece of kit, for the most part, but there are certain aspects of its functionality that don’t make a jot of sense to the beginner; certain screens don’t allow for 3 lead strip printing (even if you select it), selecting a beat to reclassify doesn’t always give you all of the different classification options, rather, it presents a select few, and (in my case, at least) 90% of the time they aren’t what you want to reclassify as, and perhaps most bafflingly, it reclassifies each event category as you analyse; on a few occasions now, I’ve reached the end of a tape, only to find another 30 un-viewed events have appeared in previously completed categories. Being aware of these things is vital, but don’t take too long to get to grips with, however.

Receiving feedback on completed reports is nerve-wracking, especially when they’re being marked right next to you. I have noticed, however, that everyone (literally EVERYONE) has a preferred way of writing a report, and classifying certain beats. Below, I have provided an illustration of an event I encountered in a 48hr recording:temporary_1464866820783 Pathfinder had classified this as a ventricular triplet, but I noticed there was a pause between the second and third beats indicating a couplet with a compensatory pause, followed by a further single ventricular ectopic. I had never encountered this before, so erring on the side of caution I asked a colleague for advice. I was informed to go with the software in this instance, as it most likely was a triplet. In essence, I was told that as long as I highlighted it in my report, then it would be visible.

After taking this advice, I submitted my complete report, only to be informed that my initial assessment was correct; it was indeed a couplet followed by a pause and another PVC, but that people would have different opinions on such a subjective event, so it wasn’t a big deal.

Whilst writing this same report, I used the cardiac event frequency guidelines suggested by my trust;

  • Rare = <15 per hour
  • Occasional = 15 – 30 per hour
  • Frequent =   >30 per hour

For analysis of a 24hr recording, for example, 263 single ventricular ectopic events across the whole tape would give just under 11 events per hour, so these would be reported thusly;

Rare PVCs seen singly

If, however, the majority of these beats were recorded between 5 and 7 pm (i.e. more than 30 per hour for this given period), the above report would need to be altered.

I have employed this structure:

Rare PVCs seen singly (frequent between 17:00hrs – 19:00hrs)

This style documentation has been approved by some, but not by all. The marking that has been returned to me thus far has been as subjective as the reading of a difficult 12-lead ECG, so I’m not entirely sure what to go with as yet. Some have instructed me to use full sentences in this instance, others say that I’ve included the perfect amount, and ALL have said that the subjective nature of this marking is inescapable, so I’ll have to get used to it, as if I change my report style now, I’ll get the same divided comments, only in reverse.

Wording aside, I’m both pleased and excited with my progress already, so hopefully I can overcome these few hiccups in the weeks to come.

Screenshot (6)





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I'm a qualified clinical physiologist with a keen interest in free open access meducation (FOAMed), pacing and electrophysiology.

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