-
In programmatic cardiovascular risk management (CVRM) and diabetes care, the usefulness of electrocardiograms (ECGs) seems highest in consultations in which complaints of new onset were the reason to perform the ECG.
-
In the context of CVRM and diabetes care, general practitioners (GPs) perform moderately well in interpreting ECGs and managing patients following the ECG. From a previous study we know that GPs perform better in symptomatic patients.
-
Education targeted at GPs’ misinterpretations observed in this study—for example R‑wave abnormalities, previous myocardial infarction, atypical ST‑T abnormalities and conduction disorders—may further improve ECG interpretation in primary care.
Introduction
Methods
Design and setting
Data collection
Expert panel
Outcome and statistics
Ethical considerations
Results
Characteristics of the general practices and the included ECGs
The GPs’ indications, interpretations and management actions
Main categories | Subcategories | Number of ECG diagnoses | |
---|---|---|---|
Abnormal sinus node rhythms | 14 | ||
Sinus tachycardia (>100 beats/min) | 6 | ||
Sinus bradycardia (<50 beats/min) | 8 | ||
Sinus node arrhythmias | 9 | ||
Sinus node arrhythmia | 9 | ||
Sick sinus syndrome | 0 | ||
Other supraventricular rhythms | 37 | ||
Atrial fibrillation | 36 | ||
Atrial flutter | 1 | ||
Escape rhythms & premature complexes | 46 | ||
Premature atrial complexes (PACs) | 12 | ||
Ectopic atrial rhythm | – | ||
Premature ventricular complexes | 34 | ||
Atrial ventricular conduction abnormalities | 34 | ||
1st degree AV block | 33 | ||
2nd degree AV block type 2 | 1 | ||
Relevant intraventricular conduction abnormalities | 42 | ||
Left bundle branch block (LBBB) | 14 | ||
Right bundle branch block (RBBB) | 28 | ||
Less relevant intraventricular conduction abnormalities | 53 | ||
Incomplete right bundle branch block (iRBBB) | 27 | ||
Incomplete left bundle branch block (iLBBB) | 1 | ||
Left anterior fascicular block (LAFB) | 8 | ||
Intraventricular conduction delay | 17 | ||
Axis deviations | 79 | ||
Left axis (+90–+180 degrees) | 75 | ||
Right axis (−30–−90 degrees) | 4 | ||
Extreme axis (−90–+180 degrees) | – | ||
Low voltage (<0.5 mV in QRS amplitude) | 15 | ||
Chamber hypertrophy or enlargement | 10 | ||
Left atrial dilatation/hypertrophy | – | ||
Right atrial dilatation/hypertrophy | – | ||
Left ventricular dilatation/hypertrophy | 9 | ||
Right ventricular dilatation/hypertrophy | 1 | ||
Atypical ST‑T abnormalities | 31 | ||
Non-specific ST‑T abnormalities | 17 | ||
Scooped ST‑T | 2 | ||
Flat T waves | 10 | ||
Tall T waves | 2 | ||
Typical ST‑T abnormalities suggesting ischaemia or injury | 2 | ||
Acute or recent myocardial infarctions (MI) | 1 | ||
Acute or recent anterior MI | 1 | ||
(Suspected of) old myocardial infarctions | 45 | ||
Old MI (anterior/inferior/posterior/lateral/not otherwise specified) | 7 | ||
Pathologic Qs | 38 | ||
T‑wave inversion | 31 | ||
Pacemaker rhythm | 2 | ||
R‑wave abnormalities | 23 | ||
Slow R progression | 20 | ||
Tall R wave | 3 | ||
Prolonged QT interval | 3 | ||
Total | 477 |
ECGs performed for a specific indication during programmatic CVRM (n = 74) | Routine ECG at the start or in the course of programmatic CVRM (n = 778) | All ECGs (n = 852) | |
---|---|---|---|
New abnormalities found Total [95% CI] | 18 (24.3%) [16.0–35.2%] | 93 (12.0%) [9.9–14.4%] | 111 (13.0%) [10.9–15.5%] |
Management actions | |||
Referral to cardiologist | 5 (6.8%) | 13 (1.7%) | 18 (2.1%) |
Additional diagnostics | 3 (4.1%) | 14 (1.8%) | 17 (2.0%) |
Second ECG | 1 (1.4%) | 11 (1.4%) | 12 (1.4%) |
Medication alteration | 3 (4.1%) | 8 (1.0%) | 11 (1.3%) |
Reassurance | 1 (1.4%) | 1 (0.1%) | 2 (0.2%) |
Total [95% CI] | 13 (17.6%) [10.0–28.5%] | 47 (6.0%) [4.5–8.0%] | 60 (7.0%) [5.5–9.0%]a |
The expert panel’s assessment
Panel’s diagnostic ECG category (3-point scale) | Agreement on ECG interpretation | Agreement on management actions | ||
---|---|---|---|---|
Number (percentage) assessable for ECG interpretation | Number (percentage) assessable for management implications | Percentage [95% confidence interval] | Percentage [95% confidence interval] | |
– Normal | 41 (13.8%) | 41 (14.3%) | 90 [81–100] | 93 [84–101] |
– Borderline | 98 (33.0%) | 96 (33.4%)b | 67 [58–77] | 76 [67–84] |
– Pathologic | 158 (53.2%)a | 150 (52.3%) b | 61 [54–68] | 66 [58–74] |
Total | 297 (100%) a | 287 (100%) b | 67 [61–72] | 74 [68–79] |