الفهرس 
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Abstract
Holter monitoring (HM) is widely used in arrhythmic disorders of adult patients; however, studies in the pediatric age group are limited. This study aims to determine the value of Holter Monitoring in diagnosis and treatment of disorders related to arrhythmias in pediatric patients. Continous ECG Recording show to be one of the most effective noninvasive clinical tools in the diagnosis of cardiac symptoms, prognostic assessment and in the evaluation of many cardiac therapeutic intervention. Holter Monitoring is a way to continuously check the electrical activity of the heart for at least 24 to 7days, This is different from electrocardiography (ECG), ECG checks the heart for only a few minutes.
The clinical utility of ambulatory ECG lies in its ability to examine continuously a patient over an extended period of time, permitting patient ambulatory activity and facilitating the diurnal electrocardiographic examination of a patient in a changing environmental conditions (both physical and psychological).
Children are referred for 24 hour ECG monitoring for many indications. Syncopal attack is a common cause of referral for Holter. In these patients, Holter was valuable in excluding arrhythmias as a cause for syncope. A careful history and ECG is essential prior to Holter monitoring to exclude arrhythmia. Also, in patients with DCM it may identify several independent predictors of mortality including non sustained VT and mean HR.
In patients referred for arrhythmias suspected on physical examination (rapid heart / slow heart/ irregular heart).Follow up of anti-arrhythmic drug efficacy during periods of somatic growth is an important indication for HM. HM has been found extremely valuable in determining predictive factors for Adams stokes attacks and heart failure in children and adolescents with complete heart block.
The present work aimed to study the various indications, values and missuses of Holter monitoring in the diagnosis and management of paediatric patients.
Eighty holter records were reviewd. Age of the studied patients ranged from 29 days to 15 years with mean age of 6.18 years. 46 (57.5%) males and 34 (42.5%) females were included.
Holter recording was done for 80 cases , 22 (27.50%) patients had palpitation, 22 (27.50%) patients with syncopy ,17 (21.25%) patients had abnormal examination, 13 (16.25%) patients had chest pain and 6 (7.50%) patients had cardiomyopathy (one patient with HCM and 5 patients with DCM).
There were 35 (43.75%)patients of the 80 studied patients their ECG were normal , 11 (13.75%) patients had heart block, 10 (12.50%)patients had sinus bradycardia, 9 (11.25%) patients had sinus tachycardia , 14 (17.50%) patients had ectopics, and 1 (1.25%) patients had WPWS pattern.
There were 22 patients complaining of palpitation, the ECG was normal in 11 patients, one patient had heart block, 6 patients had sinus tachycardia, 3 patients had ectopics and one patient had WPWS pattern.
There were 22 patients had Syncope, the ECG was normal in 13 patients, 4 patients had heart block, one patient had sinus bradycardia and 4 patients had ectopics.
17 Patients with abnormal examination, which include irregular HR (heart block & ectopics), tachycardia and bradycardia, the ECG was normal in one patient, 3 patients had heart block, 8 patients had sinus bradycardia, 3 patients had sinus tachycardia and 2 patients had ectopics.
There were 13 patients with chest pain, the ECG was normal in 8 patients, 3 patients had heart block and 2 patients had ectopics.
There were 6 patients with cardiomyopathy (5 DCM & 1 Hypertrophic cardiomyopathy), the ECG was normal in 2 patients, one patient had sinus bradycardia and 3 patients had ectopics.
Of the 22 patients with palpitation ECG was useful in diagnosis of 10 (45.45%) patients and was useful in management of 7 (31.82%) patients.
Of the 22 patients with syncopy ECG was useful in diagnosis of 10 (45.45%) patients and was useful in management of 10 (45.45%) patients.
Of the 17 patients with abnormal examination ECG was useful in diagnosis of 7 (41.18%) patients and was useful in management of 7 (41.18%) patients.
Of the 13 patients with chest pain ECG was useful in diagnosis of 6 (46.15%) patients and was useful in management of 6 (46.15%)patients.
Of the 6 patients with cardiompopathy ECG was useful in diagnosis of 4 (66.67%) patients and was useful in management of 3 (50.00%) patients.
There were 30 (37.50%) patients their holter recording was normal,8 (10.00%) patients had sinus bradycardia, 9 (11.25%) patients had sinus tachycardia , 2 (2.5%) patients had atrial ectopics, 3 (3.75%) patients had junctional ectopics , 13 (16.25%) patients had ventricular ectopics, 4 (5.00%) patients had 1st degree heart block, 1 (1.25%) patients had 2nd degree heart block, 2 (2.50%) patients had 3rd degree heart block, 3 (3.75%) patients had SVT , 1 (1.25%) patient had WPWS pattern and 4 (5.00%) patients had ventricular tachycardia.
There were 22 patients with palpitation, the holter recording was normal in 11 patients , 4 patients had sinus tachycardia, 3 patients had ventricular ectopics, one patient had 2nd degree heart block , 2 patients had SVT and one patient had WPWS pattern.
There were 22 patients with Syncope , the holter recording was normal in 8 patients, one patient had sinus bradycardia, another one patient had sinus tachycardia ,2 patients had atrial ectopics, one patient had junctional ectopics , 5 patients had ventricular ectopics,3 patients had 1st degree heart block and one patient had ventricular tachycardia(diagnosed by stress ECG as catecholaminergic ventricular tachycardia).
17 Patients with abnormal examination which include irregular HR (heart block & ectopics) ,tachycardia and bradycardia. The holter recording was normal in 2 patients, 6 patients had sinus bradycardia, 3 patients had sinus tachycardia, one patient had junctional ectopics, one patient had ventricular ectopics, one patient had 1st degree heart block , 2 patients had 3rd degree heart block and one patients had SVT.
There were 13 patients with chest pain , the holter recording was normal in 9 patients one patient had sinus tachycardia, one patient had junctional ectopics and 2 patients had ventricular ectopics.
There were 6 patients with cardiomyopathy (5 DCM & 1 Hypertrophic cardiomyopathy),their holter recording showed that one patient had sinus tachycardia, 2 patients had ventricular ectopics and 3 patients had ventricular tachycardia.
Of the 22 patients with palpitation holter recording was useful in diagnosis of 5 (22.73%) patients and was useful in management of 4 (18.18%) patients.
Of the 22 patients with syncopy holter recording was useful in diagnosis of 10 (45.45%) patients and was useful in management of 7 (31.82%) patients.
Of the 17 patients with abnormal examination holter recording was useful in diagnosis of 6 (35.29%) patients and was useful in management of 4 (23.53%) patients.
Of the 13 patients with chest pain holter recording was useful in diagnosis of 4 (30.77%) patients and was useful in management of 2 (15.38%) patients.
Of the 6 patients with cardiompopathy ECG was useful in diagnosis of 5 (83.33%) patients and was useful in management of 2 (33.33%) patients.
Of 22 patients with palpitation 11 (50.00%) patients showed abnormalities in both ECG & holter recording , of 22 patients with syncopy 9 (40.91%) patients showed abnormalities in ECG & 15 (68.18%) patients showed abnormalities in holter recording , of 17 patients with abnormal examination 16 (94.12%) patients showed abnormalities in ECG & 15 (88.24%) patients showed abnormalities in holter recording , of 22 patients with chest pain 5 (38.46%)patients showed abnormalities in both ECG & holter recording and of 6 patients with cardiomyopathy 4 (66.67%) patients showed abnormalities in ECG & 6 (100%) patients showed abnormalities in holter recording.
84% of patients who had abnormal ECG had abnormal holter recording, with astastically significant difference between patients who had normal ECG and abnormal ECG regarding positive abnormality in holter.
Holter recording was useful in diagnosis of 55% of patients with astastically significant difference between patients who had abnormal holter and those had normal holter recording.
In addition, Holter recording was useful in managment of 36% of patients with astastically significant difference between patients who had normal & abnormal holter recording.
There were a statistically significant difference between palpitations, syncope and chest pain with cardiomyopathy as regard PNN50.
There were a statistically significant difference between palpitation, syncope and chest pain with cardiomyopathy as regard rmsSD.
There were a statistically significant difference between palpitation, syncope and chest pain with cardiomyopathy as regard SDNN.
There were no statistically significant relation between different complaints and QTc interval.
As regard age, there was a moderate negative correlation between age & HR , positive weak correlation between age & PNN50 and positive weak correlation between age & QTc.
As regard HR, there was a strong negative correlation between HR & various HR variability parameters.
There was moderate positive correlation between QTc & various HR variability parameters.
Conclusion
1. The present work aimed to study the various indications, values and missuses of Holter monitoring in the diagnosis and management of pediatric patients.
2. Eighty holter records were reviewed.
3. One third of patients who did holter recording had palpitation, another one third of patients had syncopy ,one fifth of patients had abnormal examination, and small number of patients had chest pain and cardiomyopathy.
4. One third of patients had normal holter finding and two third of patients had abnormal holter finding as sinus bradycardia and sinus tachycardia in one fifth of patients, another one fifth of patients had ectopics , 9% of patients had heart block, 4%of patients had SVT and 1%of patients had WPWS pattern and 5% of patients had ventricular tachycardia .
5. Regarding patients with palpitation, the holter recording was normal in half of patients. Abnormalities in the other half of patients were in the form of sinus tachycardia, ventricular ectopics, heart block, SVT and one patient had WPWS pattern.
6. As regard patients with Syncope, the holter recording was normal in one third of patients. Abnormalities in the other two third of patients were in the form of sinus bradycardia, sinus tachycardia, ectopics, heart block and ventricular tachycardia.
7. As regard patients with chest pain, the holter recording was normal two third of patients. Abnormalities in the other third of patients were in the form of sinus tachycardia and ectopics.
8. As regard patients with cardiomyopathy, the holter recording was abnormal in all patients with cardiomyopathy in the form of sinus tachycardia, ventricular ectopics and ventricular tachycardia.
9. Holter recording was useful in diagnosis of half of patients.
10. Patients with cardiomyopathy had low HRV parameters compared to other different complaints.
11. As regard age, there was a moderate negative correlation between age & HR, positive weak correlation between age & PNN50 and positive weak correlation between age & QTc.
12. As regard HR, there was a strong negative correlation between HR & various HR variability parameters.
13. There was moderate positive correlation between QTc & various HR variability parameters.