Ambulatory electrocardiographic monitoring clinical scenarios

Ambulatory ECG monitor type	Indications/patient selection
Continuous ECG monitor (ie, Holter monitor)	Daily or near daily symptoms (palpitations) Assessment for adequate rate control in AF Assessment of VPB or APB burden, NSVT in hypertrophic cardiomyopathy Heart rate assessment for inappropriate sinus tachycardia, postural orthostatic tachycardia syndrome, suspected chronotropic incompetence
Event (loop) monitor	Less frequent symptoms (weekly or biweekly) Assessment for arrhythmic source of palpitations Assessment for arrhythmic source of dizziness or presyncope/syncope Assessment for AF (though asymptomatic episodes could be missed unless an auto-triggered event monitor is used)
Patch monitor	Daily, near daily, or weekly frequency of symptoms Assess arrhythmia burden (eg, AF, VPBs) Assess for NSVT in hypertrophic cardiomyopathy Assessment for AF as a source of cryptogenic stroke (diagnosis limited by length of time the monitor is worn)
MCOT	Assess arrhythmia burden (eg, AF, VPBs) Assessment for arrhythmic source of palpitations Assessment for arrhythmic source of dizziness or presyncope/syncope Assessment for AF as a source of cryptogenic stroke (diagnosis limited by length of time the monitor is worn)
Implantable loop recorder	Infrequent (less than monthly) symptoms associated with syncope or other high-risk features Assessment for AF as a source of cryptogenic stroke Assessment for recurrence of AF (eg, postablation)
Commercially available heart rate monitor (eg, wristbands, smartwatches)	No approved indications
Commercially available heart rhythm monitors (eg, smartwatches, hand held devices, smartphone based electrode cards, etc)	No approved indications Can be considered for monitoring for arrhythmic source or palpitations Can be considered for monitoring for symptomatic AF recurrence
Clinical monitoring scenarios	Available monitoring options
Symptoms (palpitations) daily or near daily	Continuous ECG monitor (Holter) Patch monitor
Symptoms (palpitations) weekly or biweekly	Event (loop) monitor Patch monitor MCOT
Symptoms infrequently (monthly or less) associated with syncope or high-risk features	Implantable loop recorder
Assessment for occult AF^*	Event (loop) monitor, ideally an auto-triggered event monitor Patch monitor MCOT Implantable loop recorder
Assessment for arrhythmia burden (eg, VPB burden) or average heart rate (eg, AF, inappropriate sinus tachycardia, etc)	Continuous ECG monitor (Holter) Patch monitor MCOT

AF: atrial fibrillation; APB: atrial premature beats; ECG: electrocardiogram; MCOT: mobile cardiac outpatient telemetry; NSVT: nonsustained ventricular tachycardia; VPB: ventricular premature beats.

* Notably, the longer the monitoring duration, the higher the diagnostic yield.

Adapted from:

Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2017; 70:e39.
Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2018.

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Ambulatory electrocardiographic monitoring clinical scenarios