Cardiology · Medical Literature
Abstract: 14-Day ECG Patch vs 24-Hour Holter Monitoring for Detection of Clinically Significant Arrhythmias: A Systematic Review and Meta-Analysis.
Abstract
Prolonged ambulatory ECG monitoring is hypothesized to improve detection of paroxysmal arrhythmias compared with standard 24-hour Holter monitoring. This systematic review and meta-analysis evaluated whether 14-day single-lead adhesive ECG patch monitoring enhances detection of clinically significant arrhythmias versus conventional Holter monitoring. Following PRISMA guidelines, PubMed, Scopus, and Embase were searched. Studies comparing 14-day ECG patch with Holter monitoring (primarily 24-72 hours) in ambulatory adults with suspected paroxysmal arrhythmia were included. Primary outcomes were detection rates of atrial fibrillation/flutter (AF), major arrhythmias, atrioventricular block, sinus pause, ventricular tachycardia, and supraventricular tachycardia. Risk of bias was assessed using ROBINS-I and RoB 2. Risk ratios (RR) with 95% confidence intervals were pooled using random-effects models in Review Manager (RevMan). Heterogeneity was evaluated with I² statistics, and sensitivity/subgroup analyses performed. The protocol was registered on PROSPERO (CRD420251248305). Six studies met inclusion criteria. Primary analyses showed substantial heterogeneity for most outcomes. No significant differences were observed for AF (RR 0.43, 95% CI 0.05-3.51), major arrhythmias (RR 0.41, 95% CI 0.16-1.01), atrioventricular block (RR 1.10, 95% CI 0.42-2.90), sinus pause (RR 1.09, 95% CI 0.47-2.49), ventricular tachycardia (RR 0.62, 95% CI 0.03-11.98), or supraventricular tachycardia (RR 0.39, 95% CI 0.11-1.44). Sensitivity analyses excluding one influential study often resolved heterogeneity and shifted results, favoring Holter monitoring for AF, major arrhythmias, and ventricular tachycardia, or the 14-day patch for supraventricular tachycardia. Subgroup analysis by patient type showed no significant interaction. Fourteen-day ECG patch monitoring showed no overall statistically significant superiority over 24-hour Holter monitoring for detecting clinically actionable arrhythmias. High heterogeneity and strong sensitivity to individual studies reflecting variability in devices, populations, and designs shows key limitations in current evidence. Larger, high-quality, standardized randomized trials are essential to clarify if extended patch monitoring offers true diagnostic advantages.
Clinical relevance
This meta-analysis addresses a critical evidence gap regarding whether extended 14-day adhesive ECG patch monitoring offers a meaningful diagnostic advantage over conventional 24-hour Holter monitoring for ambulatory adults with suspected paroxysmal arrhythmias — a population in whom missed diagnoses carry significant stroke, syncope, and sudden death risk. Despite widespread clinical adoption of longer-duration patch monitors, robust comparative evidence has been lacking. The findings are immediately relevant to cardiologists and electrophysiologists making device-selection decisions for arrhythmia workup.
Key findings
1. No statistically significant difference in atrial fibrillation/flutter detection was observed between 14-day ECG patch and Holter monitoring (RR 0.43, 95% CI 0.05–3.51), with wide confidence intervals indicating substantial uncertainty. 2. Detection of major arrhythmias did not significantly differ between modalities (RR 0.41, 95% CI 0.16–1.01), with the upper confidence limit approaching but not crossing unity. 3. Atrioventricular block detection rates were statistically equivalent (RR 1.10, 95% CI 0.42–2.90), with no advantage demonstrated for either monitoring strategy. 4. Sinus pause detection showed no significant difference (RR 1.09, 95% CI 0.47–2.49), and ventricular tachycardia detection was similarly non-significant (RR 0.62, 95% CI 0.03–11.98), though the latter CI was exceptionally wide, reflecting very limited data. 5. Supraventricular tachycardia detection was not significantly different in primary analysis (RR 0.39, 95% CI 0.11–1.44); however, sensitivity analyses excluding one influential study resolved heterogeneity and suggested a trend favoring the 14-day patch for SVT detection. 6. Sensitivity analyses were highly influential: excluding a single study frequently resolved substantial heterogeneity (I² not reported per outcome) and shifted directional findings, with some analyses favoring Holter for AF, major arrhythmias, and VT — underscoring the fragility of pooled estimates across only 6 included studies.
Practice implications
Clinicians should not assume that prescribing a 14-day adhesive ECG patch confers statistically superior arrhythmia detection over 24-hour Holter monitoring based on current pooled evidence; device selection should continue to be individualized based on symptom frequency, patient adherence factors, cost, and clinical pre-test probability of paroxysmal arrhythmia. The high inter-study heterogeneity driven by variability in devices, patient populations, and study designs means that existing literature cannot yet support a universal protocol change favoring extended patch monitoring. Until larger, standardized randomized controlled trials are available, clinicians should document clinical rationale when selecting extended monitoring and remain vigilant for future high-quality RCT data that may redefine the diagnostic pathway.