What’s new?
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Adherence of general practitioners (GPs) to guidelines recommending an electrocardiogram is high for suspected atrial fibrillation, suspected arrhythmia present during consultation, and bradycardia, but much lower for progressive heart failure and stable angina. GPs also adhere quite well to the recommendation not to record an electrocardiogram if arrhythmia is not present during consultation.
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Many GPs ignore the recommendation not to record an electrocardiogram in acute coronary syndrome, sports check-up and sudden death in a first-degree relative. In retrospect, GPs often acknowledged the low relevance of the results of a non-indicated electrocardiogram for their management decision.
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Diagnostic accuracy of the GPs is best for electrocardiograms showing atrial fibrillation, sick sinus syndrome or old myocardial infarction, and is weakest for left anterior fascicular block and incomplete right bundle branch block. Both of the latter electrocardiogram abnormalities also had most variability among cardiologists. Also, false abnormalities were described by GPs and—to a lesser extent—by cardiologists.
Introduction
Methods
Study design: a case vignette survey
Recruitment of participants
Online survey
Data analysis
Results
Characteristics of the participants
Indication setting
Title of case vignette | All participants (N = 70) | (a) All GPs (N = 58) | (b) GP-ECG (N = 8) | (c) GP+ECG (N = 50) | (d) Cardiologists (N = 12) | Fisher’s Exact test (c vs. d) | Fisher’s Exact test (b vs. c) | Fisher’s Exact test (a vs. d) |
---|---|---|---|---|---|---|---|---|
Indication for ECG by GP
a
| ||||||||
Suspected atrial fibrillation | 65 (93%) | 54 (93%) |
5
(62.5%)
|
49
(98%)
| 11 (92%) | 0.352 |
0.007
| 1.000 |
Bradycardia | 58 (83%) | 46 (79%) | 5 (62.5%) | 41 (82%) | 12 (100%) | 0.185 | 0.342 | 0.110 |
Suspected arrhythmia present during consultationc | 67 (96%) | 55 (95%) |
5
(62.5%)
|
50
(100%)
| 12 (100%) | / |
0.002
| 1.000 |
Progressive heart failure | 32 (46%) | 28 (48%) | 1 (12.5%) | 27 (54%) | 4 (33%) | 0.355 | 0.053 | 0.526 |
Stable angina | 41 (59%) | 32 (55%) | 4 (50%) | 28 (56%) | 9 (75%) | 0.335 | 0.302 | 0.335 |
Non-indication for ECG by GP
b
| ||||||||
Acute coronary syndrome | 46 (66%) | 37 (64%) |
1
(12.5%)
|
36
(72%)
| 9 (75%) | 1.000 |
0.002
| 0.526 |
Suspected arrhythmia not present during consultationc | 17 (24%) | 13 (23%) | 2 (25%) | 11 (22%) | 4 (33%) | 0.461 | 1.000 | 0.468 |
Screening after sudden death first-degree family member | 46 (66%) | 39 (67%) | 6 (75%) | 33 (66%) | 7 (58%) | 0.740 | 1.000 | 0.739 |
Pre-participation cardiovascular screening (‘sports check-up’) | 42 (60%) | 34 (59%) | 5 (62.5%) | 29 (58%) | 8 (67%) | 0.747 | 1.000 | 0.751 |
Diagnostic accuracy
Participant sub-group | ECG abnormality | ||||||
---|---|---|---|---|---|---|---|
Atrial fibrillation | SSS | Old infarction | iRBBB | LAFB | LBBB | PSVT (AVNRT) | |
GP+ECG
(N = 50) | 47/49 (96%) | 35/41 (85%) | 22/27 (82%) | 3/29 (10%) | 3/28 (11%) | 23/28 (82%) | 39/50 (71%) |
Cardiologists
(N = 12) | 11/11 (100%) | 12/12 (100%) | 4/4 (100%) | 3/8 (38%) | 2/8 (25%) | 9/9 (100%) | 12/12 (100%) |
Participant sub-group | ECG abnormality | ||||||
---|---|---|---|---|---|---|---|
Atrial fibrillation | SSSa | Old infarctionb | iRBBB or LAFB | LBBBc | PSVT (AVNRT) | Normal ECGd | |
GP+ECG
(N = 50) | 12/49 (25%) | 22/41 (54%) | 11/27 (41%) | 4/29 (14%) | 14/28 (50%) | 15/50 (29%) | 10/81 (12%) |
Cardiologists
(N = 12) | 4/11 (36%) | 3/12 (25%) | 1/4 (25%) | 1/8 (13%) | 1/9 (11%) | 0/12 (0%) | 2/20 (10%) |