Key result
Abnormal baseline ECG drives Holter diagnostic yield in pediatric patients, yielding severe dysrhythmias in ~4%.
Why the study?
The diagnostic yield of 24-hour Holter monitoring in children presenting with chest pain, palpitations, or syncope and predictors of clinically significant dysrhythmia and intervention were unclear.
Does the presenting symptom independently predict clinically significant dysrhythmia on 24-hour Holter monitoring or the need for clinical intervention in children?
Cross-Sectional (n=584)
No
Does the presenting symptom independently predict clinically significant dysrhythmia on 24-hour Holter monitoring or the need for clinical intervention in children?
p-value: p=0.007
Variations in Holter monitoring yield across pediatric symptom presentations are driven by underlying ECG abnormalities rather than the symptoms themselves, highlighting the primary role of baseline ECG in risk stratification.
Abnormal baseline ECG may identify children warranting intervention after Holter; leaves open prospective validation of symptom-independent predictors.
Objective: The aims of this study were to evaluate the diagnostic yield of 24-hour Holter monitoring (HM) in children referred for chest pain, palpitations, and/or syncope, to identify independent predictors of clinically significant dysrhythmia and of the need for clinical intervention, and to assess the value of repeat HM. Materials and Methods: Single-center retrospective study of 584 patients aged 6–18 years who underwent 24-hour HM between February 2023 and February 2024, grouped by presenting symptom (isolated palpitations, isolated chest pain, isolated syncope, or combined [≥2 symptoms]). HM findings were classified as normal, clinically non-significant arrhythmia, or severe dysrhythmia. Independent predictors were assessed by multivariable Firth penalized-likelihood logistic regression. Results: Mean age was 13.4 years; 64.6% were female. HM was normal in 83.4%, non-significant in 12.7%, severe in 3.9%. Findings differed across groups (p=0.007; only chest pain vs syncope, p=0.002). No isolated syncope patient had a severe dysrhythmia or required intervention (0/108). Intervention was most frequent in isolated chest pain (13.2%), but 7 of 12 were empirical beta-blockers for benign ectopy or normal HM. An abnormal ECG was the only independent predictor of intervention (OR 6.78, 95% CI 3.15–14.29; p<0.001) and of severe dysrhythmia (OR 13.32, 95% CI 5.46–33.16; p<0.001); presenting symptom was not independently associated with either. Arrhythmia on the initial HM predicted later actionable arrhythmia (27.1% vs 2.3%). Of those with a normal initial HM, 10.2% underwent repeat HM and 12.0% showed a new finding. Family history of sudden death was not associated with severe dysrhythmia (p=0.406). Conclusion: The diagnostic yield of HM varies by presenting symptom, but this variation is explained by ECG findings rather than the symptom itself. Arrhythmia on the initial HM strongly predicts subsequent intervention. No patient with isolated syncope had a severe dysrhythmia, although the retrospective single-center design precludes a definitive exclusion of risk.
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Urunca et al. (2026) conducted a cross-sectional in Chest pain, palpitations, and/or syncope (n=584). 24-hour Holter monitoring vs. Other symptom groups was evaluated on Frequency and type of arrhythmias on 24-hour Holter monitoring by presenting-symptom group (p=0.007). The diagnostic yield of 24-hour Holter monitoring varied significantly across pediatric presenting symptoms (p=0.007) with severe dysrhythmias found in 3.9% overall, though this variation was independently driven by abnormal baseline ECGs rather than the symptoms themselves.
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