Generalist practitioners' self-rating and competence in electrocardiogram interpretation in South Africa

Background: Electrocardiogram (ECG) is the only practical, non-invasive method of recording and analysing cardiac abnormalities. It enables a primary healthcare (PHC) clinician to detect cardiac and non-cardiac abnormalities, some potentially life-threatening. Their early detection could save a patient's life. Aim: The aim of this study was to evaluate the competence of generalist practitioners in ECG interpretation. Setting: This study was conducted at the Annual Refresher Course, Council for Scientific and Industrial Research (CSIR), Pretoria. Methods: A cross-sectional study was conducted amongst 93 generalist practitioners, using a self-administered questionnaire containing 20 ECG tracings, commonly encountered in PHC. The tracings were categorised into primary ECG parameters, ECG emergencies and common ECG abnormalities. Competence was determined by the generalist practitioner's number of correctly interpreted ECG tracings. Data associations were computed using the Fisher's exact test. Statistical significance was set at p ≤ 0.05. Results: Correct heart rate calculation was achieved by 14/83 (16.9%), ECG rhythm by 7/83 (8.4%), acute antero-septal myocardial infarction (MI) by 29/83 (34.9%), atrial fibrillation by 19/83 (22.9%) and cute inferior MI by 22/83 (26.5%) generalist practitioners. No correlation was found between the practitioners' number of years in practice and competence in ECG interpretation (p > 0.05). The total number of correct answers achieved by all practitioners was 274/1860 (14.7%). Conclusion: The generalist practitioners had poor competency on ECG interpretation regardless of the number of years in practice. Their poor self-rating corresponded with the number of correct answers they provided. There is a need for continuous education in ECG interpretation

Prognostic performance of ECG abnormalities compared to vital signs in acutely ill patients in a resource-poor hospital in Uganda

Background There are few reports of electrocardiogram (ECG) findings and their prognostic value in acutely ill patients admitted to low resource hospitals in sub-Saharan Africa.Methods:We undertook an observational study of acutely ill medical patients admitted to a low-resource hospital in Uganda. Vital signs were used to calculate the National Early Warning Score (NEWS), and all ECGs were assessed using Tan et al.'s scoring system as described in Clin Cardiol 2009;32:82­86.Results There were 1361 ECGs performed, covering 68% of all acutely ill medical patients admitted to the hospital during the study. The most common ECG abnormality was a prolonged QTc interval (42% of all patients) and left ventricular hypertrophy (13.5%). Compared to the 519 patients (38%) with no Tan score abnormality, the 842 (62%) patients with one or more abnormalities were more likely to die in hospital (OR = 2.82; CI95% = 1.50­5.36) and within 30 days of discharge (OR = 2.46; CI95% = 1.50­4.08). There was no relationship between age and mortality; however, after adjustment by logistic regression, any NEWS ≥1 on admission, a Tan score of ≥1, and male sex all remained clinically significant predictors of both in-hospital and 30-day mortality.Discussion:The majority of acutely ill medical patients admitted in a low-resource hospital in sub-Saharan Africa had ECG abnormalities, of which prolonged QTc and left ventricular hypertrophy were most common. Those with any Tan score abnormality were twice as likely to die as those without an abnormality

L'ischémie myocardique silencieuse du diabétique au service de diabétologie du CHU de Yopougon Abidjan

objectif: identifier les aspects épidémiologiques et diagnostiques de l'ischémie myocardique silencieuse du diabétique à abidjan.Matériel et Méthode :cette rétrospective et descriptive s'est déroulée sur une année ( du 1er janvier au 31 Décembre 2016) dans le service de consultation d'endocrinologie diabétologie du chu de yopougon. Elle a porté sur l'analyse de 282 dossiers de patients diabétiques de type 2 ayant réalisés un electrocardiogramme de repos. Nous avons pris en compte certains faacteurs de risque cardiovasculaire tels que les dyslipidémies , l'HTA, lamicroalbuminurie, le tabagisme actuel et l'obésité abdominaleRésultats : Sur un total de 282 dossiers, 135 patients avaient un ECG de repos ischémique (47,87%) et 137 patients avaient un ECG de repos normal (48,58%). l'age moyen des patients était dde 56,35 +/- 11,83 ans; la durée d'évolution du diabète était de 11,05 +/- 6,5 ans avec un HBAC moyen de 7,5 +/-1,05 %. Les patients étaient asymptomatiques dans 92,90% des cas. L'association diabète et HTA étaient dans 78% des cas. L'ECG de repos ischémique était associé de facon significative à de nombreux facteurs de risque cardiovasculaires étudiés tels que l'obésité abdominale ( p=0,04);lamicroalbuminurie (p=0,03); le tabac (p=0,01); ladyslipidémie (p=0,02).conclusion:Ce trravail confirme la réalité de l'ischémie myocardique silencieuse chez le diabétique à Abidjan, comme en témoigne la prévalence de 51,41%

Valeur pronostique péri-opératoire des anomalies de la repolarisation ventriculaire découvertes sur l'ECG pré-opératoire au Centre Hospitalier et Universitaire de Cotonou

But : Le but de cette étude était de déterminer la valeur pronostique des anomalies de la repolarisation ventriculaire découvertes sur l'ECG réalisé avant la chirurgie non cardiaque. Méthode : Cette étude prospective effectuée sur une période de 10 mois a inclus des patients âgés de 18 ans au moins ayant réalisé un ECG préopératoire interprété par un cardiologue. Ces patients ont été suivis pendant l'intervention et jusqu'à H48 après. Les évènements cardiovasculaires anormaux étaient enregistrés pendant l'intervention et les deux premiers jours post-opératoires.Résultats : Quatre-vingt-dix-sept (97) patients ont été inclus. Les anomalies de la repolarisation ont été retrouvées chez 58,8% des patients. L'aspect d'ischémie sous-épicardique et la repolarisation précoce étaient les anomalies de la repolarisation les plus fréquentes avec des fréquences respectives de 42,3% et 14,4%. L'hypotension artérielle était l'évènement cardiovasculaire le plus retrouvé en per-opératoire devant la tachycardie sinusale, la poussée hypertensive, le choc cardiogénique et l'accélération de la fibrillation atriale. L'hypotension artérielle était le seul évènement cardiovasculaire péjoratif en per-opératoire, associé aux anomalies de la repolarisation avec un test statistiquement significatif (55,4% versus 32,5% ; p = 0,02). La période post-opératoire a été marquée par la survenue de deux (2) décès dans le groupe des patients ayant présenté une anomalie de repolarisation.Conclusion : L'ECG des patients subissant une chirurgie non-cardiaque contient des informations pronostiques importantes. Les résultats de notre étude montrent que l'ischémie sous-épicardique doit être considérée comme un facteur de risque indépendant d'hypotension per opératoire

The electrocardiogram made (really) easy: Using small-group tutorials to teach electrocardiogram interpretation to final-year medical students

Background. Since the 1990s; studies have reported the inability of medical schools to equip students with knowledge and skills to interpret an electrocardiogram (ECG). This has also been the case at the School of Medicine; University of the Free State; Bloemfontein; South Africa; with external examiners in the final examinations repeatedly commenting on the poor performance of students with regard to interpreting ECGs. Subsequently; the Department of Internal Medicine designed small-group tutorials using animations and analogies as methods to improve the ECG interpretation skills of students. Objectives. To improve students' ability to interpret ECGs and assess their perceptions of the tutorials. Methods. A questionnaire was administered to 67 final-year medical students after their internal medicine rotation in 2012. The objective of the question-naire was to obtain feedback on students' experiences and perceptions of ECG tutorials. Results. Although the results do not provide evidence that the abovementioned methods improved the students' competency to interpret ECGs; the limited findings from their perceptions might assist in the further use and improvement of such an approach to facilitate learning. Conclusion. This article highlights the responsive efforts and willingness of registrars in the Department of Internal Medicine to improve the teaching of a major and frequently used investigation such as the ECG; and how registrars formalised these two methods into tutorials

High prevalence of atrial fibrillation in stroke patients admitted to university of Gondar hospital, northwest Ethiopia

Purpose : Even though atrial fibrillation is a common risk factor of stroke which contributes to poor outcome, data concerning this association is scarce in African countries. This study assessed the prevalence of confirmed atrial fibrillation and its effect on outcome in stroke patients admitted to University of Gondar Hospital.Methods: A Hospital based cross-sectional study by record analysis was done from December 2014 to February 2015. All adult stroke patients with documented head CT scan and ECG results admitted to university of Gondar hospital during June 2010 to May 2013 were included. Relevant data including sociodemographics, type of stroke, and presence of atrial fibrillation was collected from patient charts using a data extraction form.Results: A total of 94 patients with mean age of 67.4±12.4 years and Female to male ratio of 1.13:1 were analyzed. The prevalence of AF was 28.7%. It occurred in 34% and 14% of ischemic and hemorrhagic strokes respectively. The in hospital case fatality of stroke associated with and without atrial fibrillation was 22.2% and 8% respectively while the rate of improvement at discharge was 34% and 68% respectively. Atrial fibrillation was associated with a low rate of improvement at discharge (OR= 0.28 CI: 0.1-0.78).Conclusion: Atrial fibrillation is common in stroke patients in our hospital, especially in the elderly population. It is associated with low rate of improvement at discharge. Appropriate screening and treatment of atrial fibrillation is invaluable for the primary and secondary prevention of stroke

Electrocardiographic Left Ventricular Hypertrophy among Gambian Diabetes Mellitus Patients

Background: The global prevalence of diabetes and its complications is increasing worldwide. Its role in coronary heart disease has been linked with the presence of left ventricular hypertrophy (LVH). The present study aims to determine the prevalence of electrocardiographic left ventricular hypertrophy (ECG-LVH) in adult diabetic subjects; its epidemiological and clinical correlates.Methods: A descriptive cross-sectional study involving 534 patients was conducted at the Edward Francis Small Teaching Hospital (formerly Royal Victoria Teaching Hospital); The Gambia. Four hundred and forty patients were included using a standard questionnaire. Anthropometry; laboratory investigations and electrocardiogram were carried out. We used the Lewis; Cornell; and Sokolow-Lyon Voltage criteria to define ECG-LVH. MinitabTM statistical software version 13.20 was used for analysis.Results: 146 (35.2) patients had ECG-LVH using all 3 criteria and this prevalence was higher among women being 116 (79.5). A generally high prevalence of overweight (155/37.4) and obesity (119/28.6) was observed among study participants; and both clinic-day systolic and diastolic blood pressure (BP) were significantly higher in those with ECG-LVH. Poor diabetes control was observed in both groups.Conclusion: There was a high prevalence of ECGLVH and it is especially so with combining multiple criteria; hence the need for screening. Clinic-day hypertension was associated with ECG-LVH hence the need for diagnosing and aggressive treatment of hypertension in patients with diabetes mellitus

Electrocardiographic Changes during Oesophagogastroscopy

Background: Oesophagogastroduodenoscopy (EGD) should be very safe, but there are many potential hazards,although the rate of serious complications is small. There are so many complications that can arise during this procedure.Most of these complications involve the respiratory or cardiovascular systems, especially in sick or sedated patients.The aim of this study was to determine the various electrocardiographic changes that can occur at different stages of diagnostic EGD and to determine their severity.Materials and Methods: The study is a descriptive one which was carried out at the endoscopy unit of Ladoke Akintola University of Technology Teaching Hospital, (LAUTECH), Osogbo, Osun State. Consecutive patients who were referred for oesophagogastroduodenoscopy (EGD) over a 3-month period and who consented to take part in the study were recruited. The electrodes of a portable electrocardiographic (ECG) machine (model Cardiovit AT_1ECG Machine) were attached to the patients accordingly and remained fixed till the end of the procedure. ECG recordings were done at baseline, postpremedication, during intubation and 5 minutes postprocedure. The results of the study were analyzed using simple descriptive statistical methods such as range, mean and standard deviation for continuous variables, and numbers and percentages for discreet variables.Results: Twenty-six (26) patients were studied, comprising 14 (53.8%) males and 12 (46.2%) females. The mean age of the patients was 47.19 ± 14.42 years. Three (11.5%) patients had tachycardia at the beginning of the procedure, while 13 (50%) patients developed tachycardia postpremedication and during the procedure, whereas 17 (65.4%) patients had tachycardia at the end of the procedure. Only one patient had bradycardia. Various ST-T wave abnormalities were observed at each stage of the procedure. Conduction abnormality was observed in 8 (30.8%), 9 (34.6%), 7 (26.9%) and 5 (19.2%) patients at rest, post-premedication, during the procedure and postprocedure respectively. Premature ventricular complexes (PVC) were observed in 4 (15.4%), 5 (19.2%), 4 (15.4%), and 4 (15.4%) patients at rest, postpremedication,during the procedure and post procedure respectively. Conclusion: This study has shown that, although ECG abnormalities do occur during EGD, these abnormalities are not severe enough to warrant specific interventions or discontinuation of the procedure

Electrocardiographic Abnormalities among Dialysis Naive Chronic Kidney Disease Patients in Ilorin Nigeria

Background: Chronic kidney disease (CKD) has an increased risk of not only end-stage renal disease (ESRD); but majority of moderate CKD patients do die from cardiovascular disease (CVD) before reaching ESRD. The prognosis of these patients is very poor in most developing countries because of late presentation; inadequate diagnostic facilities; and inability to pay for treatment. Knowledge about CVD in CKD is crucial because of unpredictable progressive nature of the disease and increased risk of premature death from cardiovascular events. We sought to determine prevalence and pattern of electrocardiographic abnormalities in dialysis naive CKD patients. Materials and Methods: This is a 10-year prospective cross-sectional study carried out at the University of Ilorin Teaching Hospital; Ilorin. Patients were recruited from the nephrology clinic and renal wards and all who met diagnostic criteria for stages 4 and 5 CKD were included. All had their standard 12-lead electrocardiogram (ECG) recorded and various findings were critically studied and interpreted independently by two consultant physician including a cardiologist. Data analysis was done using SPSS version 16. Results: Overall; 86of the patients had at least one form of ECG abnormality; with hypertension (HTN) and anemia being the main contributory factors. These include left ventricular hypertrophy (LVH) (27.6); left atrial enlargement (LAE) (21.6); combination of LVH and LAE (17.2); and ventricular premature contractions (6). Etiology of CKD appears to have influence on ECG changes as prevalence of LVH and LAE were high among hypertensive renal disease; chronic glomerulonephritis (CGN); and diabetic nephropathy patients. Conclusion: LVH and LAE were very common ECG abnormalities in our dialysis naive CKD patients. HTN; CGN; anemia; late presentation; and male gender appear to be the main risk factors for the ECG abnormalities. There is need for gender-specific intervention strategies directed at early detection and treatment of HTN; anemia; and underlying kidney disease; especially in resource poor nations where the burden of CKD is assuming epidemic proportion

Electromagnetic Energy Radiated from Mobile Phone Alters Electrocardiographic Records of Patients with Ischemic Heart Disease

Electromagnetic energy radiated from mobile phones did not show significant effect on the blood pressure; heart rate; and electrocardiographic (ECG) parameters in animals and humans. Aim: This study aimed to investigate the effect of radiofrequency of mobile phone on the electrocardiographic parameters in patients with history of ischemic heart disease; taking into consideration the gender factor . Subjects and Methods: A total number of 356 participants (129 males and 227 females) were admitted in this study. They were grouped into: subjects without cardiac diseases (Group I); patients with ischemic heart disease (Group II); and patients with history of cardiac diseases not related to myocardial ischemia (Group III). Electrocardiogram was obtained from each patient when the mobile phone was placed at the belt level and over precordium in turn-off mode (baseline) and turn-on mode for 40 sec ringing. The records of ECG were electronically analyzed. Results: Prolongation of QTc interval was significantly observed in male gender of Groups I and III (P 0.001). Male patients of Group II showed significant QTc interval prolongation (P

Heart Rate Variability

Over the last few decades; considerable evolutions were made in the diagnosis of cardiovascular diseases. Interpretive electrocardiography is one of the areas where the progress has been significant. This involves digital recording of cardiac signals at the body surface and subsequent computerized analysis. An important outcome of such analysis is heart rate variability (HRV); which is widely accepted to have prognostic significance in patients with cardiovascular diseases especially after acute myocardial infarction. This is because HRV represents one of the most helpful markers of autonomic balance and hence can predict the tendency to develop fatal arrhythmias. Recently; interest has grown in relating some diseases to abnormal autonomic nervous system (ANS) activity based on HRV studies; for example: hypertension; bronchial asthma; diabetes mellitus; irritable bowel syndrome; anxiety and so many other diseases. This actually reflects the vital role of the autonomic nervous system in maintaining health. Unfortunately; HRV is of little practice; if ever; by Sudanese doctors. Therefore; this review is intended to update the hysiological basis; determinants; common ways of measurements and some important clinical uses of HRV

Prevalence and Covariates of Electrocardiographic Left Ventricular Hypertrophy in Diabetic Patients in Tanzania : Cardiovascular Topics

Background : Left ventricular hypertrophy (LVH) has been demonstrated to be a powerful predictor of cardiovascular (CV) morbidity and mortality in diabetic as well as hypertensive patients. However; less is known about the prevalence of electrocardiographic LVH (ECG-LVH) and its relation to other CV risk factors in diabetic patients in sub-Saharan Africa. Therefore; the aim was to assess the prevalence of ECG-LVH in diabetic patients in Dar es Salaam; Tanzania; and its relation to other cardiovascular risk factors. Methods: Two hundred and thirty-seven consecutive patients attending the Muhimbili diabetic clinic were studied. ECGlvH was diagnosed by Sokolow-Lyon voltage and Cornell voltage-duration product criteria. Q waves; ST-segment deviation; T-wave abnormalities and intraventricular conduction defects were classified by the Minnesota codes. Blood pressure (BP); serum creatinine; cholesterol and triglyceride levels; and HbA1c and urinary albumin and creatinine concentrations were determined. Results: The prevalence of LVH in patients was 16by either ECG criteria; 12.2by Sokolow-Lyon and 5.1by Cornell product criteria. Patients with LVH had significantly higher systolic and mean BP and pulse pressure; and a higher prevalence of ST-segment abnormalities; T-wave inversion and albuminuria than those without LVH (all p 0.05). in multivariate logistic regression analysis; systolic BP was the only independent predictor of ECG-LVH. The prevalence of ECG-LVH increased by 15per 10 mmHg higher systolic BP [OR 1.151 (95CI 1.00921.314); p 0.05]. Clustering of cardiovascular risk factors differed significantly between type 1 and type 2 diabetes patients. On average; type 1 patients had 0.8 and type 2 had 2.2 additional CV risk factors. Conclusion: ECG-LVH was present in 16of diabetic patients in Tanzania. Systolic BP was the most important predictor of ECG-LVH. Clustering of CV risks was significantly higher in type 2 than in type 1 diabetics; demonstrating the need for systematic multiple risk-factor assessment in these patients

Electrocardiographic Left Ventricular Hypertrophy with Strain Pattern : Prevalence; Mechanisms and Prognostic Implications : Review Article

Background: Electrocardiographic left ventricular hypertrophy with strain pattern has been documented as a marker for left ventricular hypertrophy. Its presence on the ECG of hypertensive patients is associated with a poor prognosis. This review was undertaken to report the prevalence; mechanism and prognostic implications of this ECG abnormality. Materials and methods: We conducted a comprehensive search of electronic databases to identify studies relating to the title of this review. The search criteria were related to the title. Two of the reviewers independently screened the searches. Results: Results were described qualitatively. The data were not pooled because there were no randomised studies on the topic. The prevalence of ECG strain pattern ranged from 2.1 to 36. The highest prevalence was reported before the era of good antihypertensive therapy. The sensitivity as a measure of left ventricular hypertrophy ranged from 3.8 to 50; while the specificity was in the range of 89.8 to 100. Strain pattern was associated with adverse cardiovascular risk factors as well as increased all-cause and CV morbidity and mortality. ST-segment depression and T-wave inversion on the ECG was recognised as the strongest marker of morbidity and mortality when ECG-LVH criteria were utilised for risk stratification in hypertensive subjects. Conclusion: Electrocardiographic strain pattern identifies cardiac patients at higher risk of cardiovascular-related as well as all-cause morbidity and mortality

Electrocardiographic Abnormalities in Patients with Heart Failure : Cardiovascular Topics

Background : The morbidity and mortality from heart failure (HF) differ between patients with reduced ( 50) and with preserved ( 50) left ventricular ejection fraction (LVEF) on account of many factors; including abnormalities detected in the electrocardiogram (ECG). The aim of this study was to determine and compare the ECG abnormalities between HF patients with reduced and with preserved LVEF. Methods : The study was cross-sectional in design and carried out in Aminu Kano teaching hospital and Murtala Mohammed specialist hospital; Kano; Nigeria; from April 2005 to June 2006. We studied the resting electrocardiograms of all HF patients aged 15 years and older who were referred to the two centres for echocardiography. Results: A total of 113 patients were studied and 98.2of them had abnormal ECGs. Forty-two patients (37.2) had preserved LVEF while the remaining 71 (62.8) had reduced LVEF. Left ventricular hypertrophy ( LVH) was the commonest ECG abnormality; found among 55 patients (77.5) with reduced LVEF; and 21 patients (50) with preserved LVEF (p = 0.0026). The commonest arrhythmia was atrial fibrillation; found among 10 patients (14.1) with reduced LVEF and eight patients (19.1) with preserved LVEF (p = 0.486). Prolonged corrected QT interval was found among 30 (71.4) and 56 patients (78.9) with preserved and reduced LVEF; respectively (p = 0.370). Conclusion: Most of the patients with heart failure studied in Kano; Nigeria had abnormal electrocardiograms; and the most common abnormality was LVH

Pattern of ECG abnormalities in Nigerian hypertensive patients seen in University of Port Harcourt Teaching Hospital

Objective: The aim of the study was to document the pattern of EGG abnormalities in the hypertensive patients in Port Harcourt and to compare their prevalence with what obtains in the apparently normal population as documented in previous studies. Methods: The electrocardiographic profile of one hundred and thirty two consecutive hypertensive patients seen at the consultant medical clinic of the University of Port Harcourt Teaching Hospital were studied prospectively. All patients were above 15 years of age with blood pressures above 140/90 mmHg taken at more than two visits. As part of their investigations, twelve lead surface electrocardiograms were recorded. They were interpreted by either of the authors and data were analyzed by simple statistical methods. P value was taken as significant if up to or below 0.5. Results: The abnormalities identified were left ventricular hypertrophy(LVH)in37.1%, left axis deviation(LAD) in 30.3%, sinus tachycardia 25.0%,left atrial enlargement(LAE) in 21.2%, atrial fibrillation(AF) in 3.8%, right bundle branch block (RBBB) in 1.5% and left anterior hemi block (LAH) in 0.8%. There were no cases of myocardial infarction nor pathological Q waves. Conclusion: The study concluded that ECG abnormalities are prevalent in our hypertensive patients and given their prognostic significance, the surface ECG remains relevant as one of the first line investigations in these patients

Comparison of Araoye's criteria with standard electrocardiographic criteria for diagnosis of left ventricular hypertrophy in Nigerian hypertensives

Background: Left ventricular hypertrophy (LVH) is a major risk factor for cardiovascular morbidity and mortality. Various electrocardiographic (ECG) criteria for LHV give poorer performance in black subjects when compared with white subjects. Araoye proposed a code system for improved ECG diagnosis of LVH in blacks. The Araoye's criteria are yet to be validated in black subjects.Study design: Electrocardiograms and echocardiograms were obtained from 100 hypertensive subjects and 60 controls. ECG LVH was determined by the Araoye's code criteria; Sokolow-Lyon; Cornell voltage; and Romhilt-Estes point score. Echocardiographic LVH was defined by LV mass indexed for height at 97.5 percentile of the controls (126g.m-1 and 130g.m-1 in females and males respectively). Results: The prevalence of echocardiographic LVH indexed for height was 34and 1.67in the hypertensive and controls respectively while the prevalence of electrocardiographic LVH among the hypertensives were 18by Romhilt Estes score; 48by Sokolow-Lyon's criteria; 22by Cornell's criteria and 51by Araoye's criteria. The sensitivity and specificity respectively of the various electrocardiographic criteria were 65.7and 76.8for Sokolow-Lyon; 25.7and 88.8for Cornell's criteria 25.7and 92.8for Romhilt-Estes score and 71.4and 74.4for Araoye's criteria. Araoye's criteria did not differ significantly from Sokolow-Lyon criteria in identifying LVH but differed significantly from Cornell and Romhilt-Estes criteria. The number of positive codes in Araoye's criteria was significantly associated with the blood pressures; LV dimensions; and LV mass. Conclusion: The Araoye's code system for electrocardiographic diagnosis of LVH offer no comparative advantage over Sokolow-Lyon's criteria. However; the number of positive codes in Araoye's criteria identifies those individuals with more severe LVH