Arrhythmia is a common cardiovascular disorder characterized by abnormalities or disruptions in the normal electrical activation or contraction sequence of the heart. It is characterized by irregular heart rhythms, which can manifest as bradycardia (heart rate 60 beats/min) or tachycardia (heart rate $>$100 beats/min) [1]. Different types of arrhythmias exert varying impacts on patients: some have a favorable prognosis, while others may cause prominent palpitations, syncope, or even sudden cardiac death [2]. Additionally, the treatment costs for arrhythmias are substantial—for atrial fibrillation alone, the annual expenditure in the United States amounts to approximately 26 billion US dollars [3].

Currently, therapeutic and management strategies for arrhythmias include antiarrhythmic drugs, pacemakers, automated external defibrillators (AEDs), and radiofrequency ablation [4]. However, arrhythmias in high-risk populations (e.g., patients with hypertension, coronary heart disease, or the elderly) often occur paroxysmally and asymptomatically, making them highly prone to missed diagnosis via routine electrocardiogram (ECG). Therefore, early and accurate identification of such arrhythmias is crucial for improving patient prognosis [5].

Routine 12-lead ECG, with its short monitoring duration (only a few minutes), frequently fails to capture abnormal ECG signals, leading to missed diagnoses, delayed treatment, and increased risks of adverse cardiovascular events such as stroke and heart failure [6]. Although traditional Holter monitors enable 24-hour recording, their limited number of channels results in insufficient integrity and accuracy of signal acquisition, which cannot meet the needs of detecting early, subtle arrhythmias [7, 8].

High-channel 12-lead Holter ECG represents an advanced form of dynamic cardiac monitoring. It integrates the continuous recording capability of traditional monitors with the comprehensive spatial information provided by standard 12-lead ECG. Through optimized channel design, it can continuously collect more comprehensive dynamic ECG data over 24 hours, theoretically improving the detection rate of early arrhythmias [9]. Compared with modern devices like adhesive patch monitors, Holter systems offer superior multi-lead resolution for complex arrhythmias [10]. In this study, we retrospectively analyzed two types of ECG data from 300 high-risk individuals, compared the detection performance between the high-channel 12-lead Holter and routine 12-lead ECG, and further verified the clinical value of high-channel 12-lead Holter in the early identification of arrhythmias, aiming to provide practical evidence for cardiovascular management in high-risk populations.

Two researchers independently extracted data from the electronic medical record system. The extracted content included: (1) baseline data (sex, age, body mass index [BMI], smoking history, drinking history, type of underlying disease); and (2) ECG test data (reports from the routine 12-lead ECG examination, including examination time, type of arrhythmia, and interpretation results, and from the high-channel 12-lead Holter monitoring, including monitoring time, type of arrhythmia, episode frequency, duration, and symptom correlation records). After extraction, the two researchers cross-checked the data. In case of discrepancies, the final results were confirmed by reviewing original test images (waveforms stored in the ECG machine and Holter analyzer) and consulting clinical physicians to ensure data accuracy.

This study employed a paired design to compare arrhythmia detection between the routine ECG and high-channel 12-lead Holter monitoring. The results showed that Holter monitoring was significantly superior to routine ECG in terms of the overall arrhythmia detection rate and the detection of atrial fibrillation and frequent ventricular premature beat subtypes, which is consistent with the findings of previous studies [10, 13].

In the univariate logistic regression analyses, several clinical factors—especially smoking history, drinking history, hypertension, and heart failure—showed large odds ratios with relatively wide 95% confidence intervals, particularly for Holter-based detection. This pattern likely reflects the high-risk nature of our cohort (all patients met at least one high-risk criterion, and arrhythmia prevalence was high), which reduces the number of truly unexposed patients and can yield imprecise and apparently inflated estimates in univariate models, especially when outcomes are common. Age was not significantly associated with positive arrhythmia detection, which may seem inconsistent with clinical experience; however, our sample had a narrow age range (all $\ge$45 years; median 67 years) and strong correlations between age and comorbidities such as hypertension, coronary heart disease, diabetes, and heart failure. In this context, the per-year effect of age is likely attenuated, and the odds ratios for age were very close to 1.00, suggesting a relatively flat association within this already high-risk cohort. Taken together, these results should be regarded as exploratory associations rather than causal effects, and confirmation in larger, more heterogeneous populations with multivariable modelling is needed.

From the perspective of clinical significance, the advantages of high-channel 12-lead Holter monitoring stem from its core characteristics of “long-duration, dynamic monitoring”. Clinically, approximately 1/3 of atrial fibrillation cases are “paroxysmal atrial fibrillation”, and the duration of such episodes is often short (usually less than 24 hours). Due to the limited detection time, the missed diagnosis rate of routine ECG for paroxysmal atrial fibrillation can be as high as 30%–50% [14, 15]. In this study, high-channel 12-lead Holter monitoring additionally detected 20 cases of “Holter-only positive” atrial fibrillation. This finding strongly indicates that it can effectively compensate for the shortcomings of routine ECG in screening paroxysmal atrial fibrillation, providing a more accurate screening approach for patients with unexplained stroke or obvious palpitations but normal routine ECG results. This facilitates earlier definitive diagnosis and timely targeted treatment for such patients.

For frequent ventricular premature beats, their onset is closely associated with multiple factors, such as myocardial ischemia and autonomic nervous tension, exhibiting a significant feature of “temporal heterogeneity”—for example, the number of ventricular premature beats increases during physical activity but decreases at rest [16]. This dynamic variability, combined with underlying mechanisms like electrolyte imbalances or sympathetic activation, highlights Holter monitoring’s role in the quantitative assessment for interventions such as ablation [17]. By accurately assessing the load and characteristics of ventricular premature beats, clinicians can formulate more evidence-based treatment plans, avoiding over- or under-treatment.

While studies have demonstrated that adhesive patch-type electrocardiogram devices, by extending monitoring duration (e.g., to 72 hours), can significantly improve the detection rate of paroxysmal atrial fibrillation (PAF)—reportedly by 2.2 times compared to 24-hour Holter monitoring—their widespread clinical adoption must consider algorithm-enhanced accuracy and device cost [18, 19]. The single-lead design of many patch monitors may compromise signal quality, necessitating complementary advances in artificial intelligence (AI)-assisted analysis to ensure diagnostic reliability [20]. Therefore, despite the advantages of patch devices in extended monitoring and patient comfort, Holter monitoring remains a more widely adopted and logistically feasible option in routine clinical practice, particularly suitable for short- to medium-term monitoring scenarios [21].

However, this study also has certain limitations. First, the sample size is relatively small (only 300 subjects were included), which may affect the statistical power for low-incidence subtypes (e.g., atrioventricular block) and make it difficult to fully demonstrate the differences between high-channel 12-lead Holter and routine ECG in these subtypes. Second, the study did not conduct stratified analysis based on the severity of arrhythmias (e.g., CHA₂DS₂-VASc score for atrial fibrillation, Lown classification for ventricular premature beats), which limited the ability to further explore the detection advantages of high-channel 12-lead Holter for high-risk arrhythmias. Future studies could expand the sample size and conduct subgroup analysis incorporating arrhythmia severity to more comprehensively evaluate the clinical value of high-channel 12-lead Holter, thereby providing stronger evidence for its broader clinical application.

The high-channel 12-lead Holter significantly outperforms the routine 12-lead ECG in detecting arrhythmias in high-risk populations, particularly paroxysmal atrial fibrillation and frequent ventricular premature beats. Owing to its long-duration, dynamic monitoring capability, the high-channel 12-lead Holter provides an effective supplement to routine ECG for early identification of clinically significant arrhythmias in high-risk individuals and may support more timely risk stratification and intervention. Future studies with larger cohorts and stratified analyses across arrhythmia subtypes and severity will help further refine patient selection and monitoring strategies.

• This retrospective study demonstrates that the high-channel 12-lead Holter ECG significantly improves arrhythmia detection rates compared to the routine 12-lead ECG in high-risk populations, particularly for atrial fibrillation and frequent ventricular premature beats.

• Baseline risk factors such as smoking, hypertension, and heart failure are strongly associated with positive detections in univariate logistic regression, highlighting the need for targeted screening.

• The advantages of Holter monitoring lie in its extended monitoring capability, which captures paroxysmal events missed by short-duration methods, providing clinical value for early intervention.

• Limitations include sample size and lack of severity stratification, underscoring the need for future research with larger cohorts and subgroup analyses.

• Overall, Holter monitoring serves as an effective supplement to routine ECG, offering evidence-based support for cardiovascular risk management in high-risk populations.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

LH and XHJ designed the research study. XHJ and LH performed the research. XHJ and LH analyzed the data. LH drafted this article. Both authors contributed to the important editorial changes in the manuscript. Both authors read and approved the final manuscript. Both authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

This retrospective study was approved by the Ethics Committee of Zibo Central Hospital (approval number: 2025262). Case data were extracted from the hospital’s electronic medical record system, ECG database, and clinical diagnosis and treatment records. The protocol was reviewed by the Ethics Committee of Zibo Central Hospital, which confirmed eligibility for consent waiver. The waiver was granted because (i) analyses were performed on existing records that had been anonymized before investigator access; (ii) the study involved no more than minimal risk; and (iii) participants’ privacy was safeguarded through de-identification and secure data handling. The study was conducted in accordance with the Declaration of Helsinki.

Not applicable.

This research received no external funding.

The authors declare no conflict of interest.