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Objective. To investigate the application effect of 24 h dynamic electrocardiogram in the diagnosis of asymptomatic myocardial ischemia with arrhythmia in elderly patients with coronary heart disease. Methods. A total of 206 elderly patients suspected of coronary heart disease (CHD) with asymptomatic myocardial ischemia and arrhythmia were selected as the research subjects. 24 h dynamic electrocardiogram and conventional electrocardiogram examinations were conducted. Coronary angiography was used as the gold standard to observe the performance of the two examination methods in the diagnosis of asymptomatic myocardial ischemia with arrhythmia in elderly patients with CHD. Results. Coronary angiography showed 174 positive cases and 32 negative cases among the 206 patients. The diagnostic results of a conventional electrocardiogram showed 150 positive cases and 20 negative cases. Its sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 86.21%, 62.50%, 82.52%, 92.59%, and 45.45%, respectively. The diagnostic results of 24 h dynamic electrocardiograms showed 168 positive cases and 29 negative cases. Its sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 96.55%, 96.63%, 95.63%, 98.25%, and 82.86%, respectively. The above results indicated that 24 h dynamic electrocardiogram was significantly better (P < 0.05). The detection rate of arrhythmia types by 24-hour dynamic electrocardiogram was significantly higher than that of conventional electrocardiogram (P < 0.05). Conclusion. 24 h dynamic electrocardiogram is helpful for the diagnosis of asymptomatic myocardial ischemia with arrhythmia in elderly patients with CHD and can improve the detection rate, thereby providing a basis for clinical diagnosis and treatment. [ABSTRACT FROM AUTHOR]