It was with great interest that we read the recent report of the study in which Kinlay and colleagues prospectively compared Holter monitors with cardiac event recorders for assessment of intermittent palpitations [1]. The authors concluded that event recorders provide better data and are more cost-effective. We previously reviewed and presented data [2] on the utility of Holter monitoring at our institution.

We reviewed 278 consecutive Holter recordings for demographic data, reason for study, presence of significant dysrhythmias (atrial fibrillation, paroxysmal superventricular tachycardia, ventricular tachycardia, significant pauses, and atrioventricular block), symptom correlation, and source of referral. We then reviewed the outpatient medical record after the Holter report was available to see whether the results led the referring clinician to prescribe therapy. Although clinically significant dysrhythmias were noted in 23% of the referred patients (certainly a different sample than that studied by Kinlay and colleagues), only rarely did the study lead to a specific therapy. A symptom correlated with at least one dysrhythmic episode in only 12% of studies. We concluded that a more directed or simpler test would have been optimal in most cases in our institution. Two-minute rhythm strips in patients with frequent symptoms or ectopic beats noted on examination, exercise treadmill tests in patients suspected of having exercise-induced arrhythmias or silent ischemia, and electrophysiologic studies in patients with syncope and organic heart disease are examples of tests that can replace Holter monitoring in selected patients. Perhaps more important, one can question the usefulness of any sort of cardiac recording in patients in whom occasional, brief, or mild palpitations alone are present with no evidence of serious organic heart disease shown by history, physical examination, or 12-lead electrocardiography. If a specific diagnosis is sought by the patient or physician, we agree that the cardiac event recorder is the better test.