Comparative Analysis of ECG and Holter Monitoring in the Assessment of Heart Rate in Heart Failure with Reduced Ejection Fraction and Sinus Rhythm

Camazzola, Fabio Eduardo; Schwartzmann, Pedro Vellosa; Sabedotti, Marcelo; Massuti, Rafael; Zortea, Tulio; Chen, Vitoria; Maggi, Ana Carolina Guimarães; Souza, Francine Fonseca de; Cardoso, Andressa da Silva; Selistre, Luciano da Silva

doi:10.36660/abc.20230771i

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Original Article • Arq. Bras. Cardiol. 121 (8) • Aug 2024 • https://doi.org/10.36660/abc.20230771i copy

Comparative Analysis of ECG and Holter Monitoring in the Assessment of Heart Rate in Heart Failure with Reduced Ejection Fraction and Sinus Rhythm

Authorship SCIMAGO INSTITUTIONS RANKINGS

Central Illustration
: Comparative Analysis of ECG and Holter Monitoring in the Assessment of Heart Rate in Heart Failure with Reduced Ejection Fraction and Sinus Rhythm

Comparative analysis of heart rate on ECG versus Holter. CI: confidence interval; ECG: electrocardiogram; HFrEF: heart failure with reduced ejection fraction; LVEF: left ventricular ejection fraction.

Abstract

Background

Heart rate (HR) has shown prognostic value in patients with heart failure with reduced ejection fraction (HFrEF) and sinus rhythm. However, the method of measurement is debated in the literature.

Objectives

To compare HR on Holter with 3 resting electrocardiograms (ECG1, ECG2, and ECG3) in patients with HFrEF and sinus rhythm.

Methods

This was a cross-sectional study with 135 patients with heart failure with ejection fraction ≤ 40% and sinus rhythm. HR was assessed by ECG and Holter. Analyses included intraclass correlation coefficient (ICC), robust regression, root mean squared error, Bland-Altman, and area under the receiver operating characteristic (ROC) curve. A significance level of 0.05 and Bonferroni-Holm adjustment were adopted to minimize type I errors.

Results

The median [interquartile range] age and ejection fraction were 65 years [16] and 30% [11], respectively. The ICC of the 3 ECGs was 0.922 (95% confidence interval: 0.892; 0.942). The robust regression coefficients for ECG1 and ECG3 were 0.20 (95% confidence interval: 0.12; 0.29) and 0.21 (95% confidence interval: 0.06; 0.36). The robust R² was 0.711 (95% confidence interval: 0.628; 0.76). In the Bland-Altman agreement analysis, the limits of agreement were −17.0 (95% confidence interval: −19.0; −15.0) and 32.0 (95% confidence interval: 30.0; 34.0). The area under the ROC curve was 0.896 (95% confidence interval: 0.865; 0.923).

Conclusion

The HR on ECG showed high agreement with the HR on Holter, validating its clinical use in patients with HFrEF and sinus rhythm. However, agreement was suboptimal in one third of patients with HR below 70 bpm on ECG; thus, 24-hour Holter monitoring should be considered in this context.

Heart Rate; Heart Failure; Electrocardiography; Ambulatory Electrocardiography

Age, years	65 [IQR: 16]
Male sex, n (%)	85 (63%)
Race, n (%)	White – 112 (83%)
Race, n (%)	Black – 23 (17%)
NYHA functional class, n (%)	I – 20 (14.8%)
	II – 69 (51.1%)
	III – 40 (29.6%)
	IV – 6 (4.4%)
Ejection fraction, %	30% [IQR:11]
Ischemic etiology, n (%)	73 (54.1%)
LBBB, n (%)	31 (29.8%)
Hospitalization, 6 months, n (%)	66 (49.6%)
BMI, Kg/m²	27.04 [IQR: 6.2]
SAH, n (%)	88 (65.2%)
DM, n (%)	50 (37%)
Dyslipidemia, n (%)	67 (49.6%)
Tobacco use, n (%)	21 (26.1%)
NT-pro-BNP, pg/mL	1.345 [IQR: 2.348.2]
Creatinine, mg/dL	1.1 [IQR: 0.49]
GFR, mL/min/1,73 m²	66.2 [IQR: 33.2]
Potassium, mEq/L	4.5 [IQR: 0.8]
Sodium, mEq/L	139 [IQR: 3]
Hemoglobin, g/dL	13.8 [IQR: 2.6]
Hematocrit, %	40.9 [IQR: 7.6]
Holter, bpm	76 [IQR: 17]
ECG1, bpm	79 [IQR:28]
ECG2, bpm	80 [IQR: 28]
ECG3, bpm	81 [IQR: 30]
Medication use
Sacubitril/valsartan, n (%)	47 (34.8%)
ACEI, n (%)	57 (42.3%)
ARB, n (%)	17 (12.6%)
Beta-blocker, n (%)	127 (94%)
Spironolactone, n (%)	98 (72.6%)
SGLT2i, n (%)	88 (65.2%)
Ivabradine, n (%)	11 (8.1%)
Digoxin, n (%)	11 (8.1%)
Furosemide, n (%)	74 (54.8%)
Hydralazine, n (%)	7 (5.2%)
Nitrate, n (%)	10 (7.4%)

	Dependent variable
	Holter
ECG1	0.20 (95% CI: 0.12; 0.29) ^‡
ECG2	0.13 (95% CI: –0.03; 0.28)
ECG3	0.21 (95% CI: 0.06; 0.36) ^‡
Constant	30.7 (95% CI: 25.8; 34.5) ^‡
Robust R²	0.711 (95% CI: 0.628; 0.769)
RMSE	7.2 (95% CI: 6.8; 7.7)
Mean difference	7.4 (95% CI: 6.2; 8.7)
Lower limit of agreement, 2.5%	–15.0 (95% CI: –19.0; –17.0)
Upper limit of agreement, 97.5%	32.0 (95% CI: 30.0; 34.0)

Metric parameters	Values
Area under the curve	0.896 (95% CI: 0.865; 0.923)
Sensitivity	0.978 (95% CI: 0.953; 1.000)
Specificity	0.767 (95% CI: 0.716; 0.817)
Accuracy	0.837(95% CI: 0.836; 0.838)
Positive predictive value	0.677 (95% CI: 0.611; 0.743)
Negative predictive value	0.986 (95% CI: 0.970; 1.000)
Positive likelihood ratio	4.190 (95% CI: 3.371; 5.201)
Negative likelihood ratio	0.029 (95% CI: 0.009; 0.089)
Intraclass correlation coefficient	0.922 (95% CI: 0.892; 0.942)

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[1] Mailing Address: Fabio Eduardo Camazzola • Universidade de Caxias do Sul (UCS) – Medicina – Rua Francisco Getúlio Vargas, 1130. Postal Code 95070-560, Caxias do Sul, RS – Brazil. E-mail: fecamaz1@ucs.br