Continuous Ambulatory Electrocardiographic Monitoring· Use in Cardiac Exercise Programs Gerald F. Fletcher, M.D.;·· and]ohn D. CantweU, M.D.t

In order to evaluate cardiac rate and rhythm in 20 patieDts with coroaary atherosclerotic disease who were eagaged in a medically supervised exercise program, continuous ambulatory electrocardiograp moDitoring was performed during an exercise training cb& and the subsequent 24 hours, which included activities at work and home. SIUy-five percent (13) of the 20 patients had abnonnal findings on recordings. Of the 20 patients studied, 40 percent (eight) had arrhythmias detected by ambulatory recording that had not been detected either by resting or exercise electrocardiograms. Three patients with ven-

I nstant

tricular ectopia (multifo~ premature ventricular beats, couplets, and bigeminy) had exercise activities temporarOy curtaDed and therapy with antiarrhythmic drop begun, with subsequent resoIutiOll or Improvement. Two other patients (with recorded heart rates of 160 beats per minute) were InstnJcted to carefully momtor their heart rate in order to not exceed the target mulmum. We conclude that 24-bour continuous electrocardiographic monitoring Is beneftclalln evaluating patients in cardiac exercise programs and frequently inftuences the m8D8lement of such patients.

electrocardiographic studies have been used in cardiac exercise programs as a method of evaluating arrhythmias and the response of the heart rate during exercise activity in patients who have had myocardial infarctions.! This type of monitoring affords "spot-check" analysis of the heart rate and rhythm before and after various exercise activities in groups of outpatients. Because of the limited and variable results in this type of evaluation, the question is unanswered regarding the responses of cardiac rate and rhythm in such patients during activities at home and work, as well as their supervised exercise training activities. The study herein described was undertaken to obtain continuous ambulatory tape recordings of electrocardiographic rate and rhythm during a cardiac exercise class and the associated 24-hour period of activity at home and at work in a sele~ed group .of patients engaged in an outpatient gymnasium program for patients with coronary atherosclerotic disease at Georgia Baptist Medical Center in Atlanta.

Twenty patients with coronary atherosclerotic disease, as manifested by the postinfarctional state, angina. pectoris, or angiographic documentation of coronary atherosclerosis (or a combination of the three), were chosen for evaluation. These patients all had previous documentation of arrhythmias or symptoms of possible arrhythmias (dizziness, near-syncope, or palpitations). Continuous ambulatory recordings utilizing a 24-hour recorder (Avionics 4(0) were begun at the onset of the exercise class on a given day of the exercise training program and were continued for th~ subsequent 24 hours after the training session, including activities at work and home. The conventional V 5 manubrium lead system was used, as the data being sought were primarily heart rate and rhythm. Detailed diaries were kept of the training sessions to denote specifio times when exercises for relaxation, calisthenic exercises, walle-jog activities, and activities with aerobic games were done. In addition, other activities were recorded accurately at home or at work, specifically symptoms or events referable to the cardiovascular system. The records were analyzed using a scanner ( Avionics Research Products Electrocardioscanner 650) at a scanning speed of ~ times normal.

°From the Depamnents of Medicine, Georgia Baptist Medical Center and Emory University SchoOl of Medicine, Atlanta. °·Director of Internal Medicine and Professor of Medicine ( Cardiology) . tDirector, Preventive Cardiology Clinic and Clinical Assis.tant Professor of Medicine. Manuscript 'received Feb~ 18; revision accepted June 8. Reprint requesta: Dr. Fletcliet-, 300 Boulevard NE, Atlanta 30312

Twenty subjects with various manifestations of atherosclerotic cardiovascular disease were studied; the age range was from 27 to 73 years, with a mean age of 52 years. All were white. Eleven of 20 had had previous myocardial infarction, seven had angina pectoris (five of these had diffuse intimal coronary

CHEST, 71: 1, JANUARY, 1977

MATERIALS AND METHODS

REsuLTS

CONTINUOUS AMBULATORY ECG MONITORING 27

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N

(yr)

(Obitruction) -

Aapirin

Procaine Oricin of CCA Old A8MI (100%); RCA at amide (Proneetyl) 20m (100%) hydrochloride;

12

12

1.

29

9,"1

10,14

21

23

diuepun; iIoIorbide dinltn.te; warfariD eodium

DiaoDn;

Not done

BR-60-180;

...

..-,

frequent. pvc. atrial bipminy;occ. IioaalPVC

~;

BR-60-130;

HR-60-I5O; BR-62-180; ooupleta after multiformed aerci8e; PVc. fal8e-poeitive

rare PVC

BR-60-160; Deptive

BR-56-160; neptive

paUIM

PVCe; sinus

HR-52-1SO;

occasional

HR-70-160; poeitive with coitus

Died a cIa1a after neordbta. belen analyaia

t.ioIlof much of ectoplc beMa; arrhyt.bmia lmproYeCl

in..-l to IpD q4b, with reeoIu-

Procaine amide (ProDMtyl) hydrocbloride

Nochanp

Nochanp

Nochanp

Couneeled to use prophylactic nitroe1ycerin with coitu.; leas analna

No change

BR-52-140;

DePtiw

Noebanp

Nochanp

Nocban&e

Ib unchanpd

(ProDeItyl) hydrocbJorlde mcr..ed to 7SO me q4h, with IeeI ectopic beats; eurciIe

Procaine amide

and ReIultat

Moc:tificatioD

ofProcram

BR-&&-llO; neptive

pvc.

BR-58-I5O; ocouional

BR-60-130; PVOI (more at nicbt)

BR-60-I*»; PVOI in hipminy and ooupleta with coitus

ECOt

AmbuJat«y

eeJA, CoroDary artery; CCA, cIrcum8a OOI'ODAI'J artery; LAD, left anterior deIoeDdinc coronary artery; LeA, left. COI'OD&l7 artery; and RCA, richt COIODary artery.

11,68

dicosin

Old IMI

HR-71-160;

Lesion in pros- Normal lma1 LAD (06%)

None

12

7

Not done

DePtiw;

HR-60-15O; neptlve

Normal

8,33

BR-60-1.w; poaitive

Normal RCA at ori&in (total); middle CCA (SO%); diqon&l braDch 01 LAD (50%)

Warfarin

eodiurn

36

36

7, .9

(100%)

HR-80-140; positive

Severe and PD- Normal eralcn.ue; all major CAl

Warfarin lOCtium; clofibrate

11

18

S, .3

HR-70-I30; poeitift

LeA (90%); Old IMI CCA"(90%); proximal LAD (90%); maqlnaI branch of CA (90%)

Clofibrate; iIoeorbide dinitrate

22

24

5,60

BR-70-IIO; neptive

Antaior and Inferior lIchemia

RCA and proslmal CCA (total); LAD (90%)

88

4,14

Uoeorbide dinitrate; hydrocblorotbiuide

88

38

3,46

88

12

48

2, &9

BR-71-I5O; neptlve

fa1le-poeitive

BR-7~ISO;

BR-71-1ao; IMlptive

of 8tudyt~

Old IMI

IMI

BOG--

Not done

proximal and middle LAD (90%); distal CCA (total)

LCA(~);

DiI-. diIMIe of RCA; maiD

Diuepam

Dip.

RestiDI

Esera.eEOO

duriDa Period

PVOI; DE; old IMI

8