Interpretations of and management actions following ECGs in programmatic cardiovascular care in primary care: A retrospective dossier study.

BACKGROUND: The usefulness of routine electrocardiograms (ECGs) in cardiovascular risk management (CVRM) and diabetes care is doubted. OBJECTIVES: To assess the performance of general practitioners (GPs) in embedding ECGs in CVRM and diabetes care. METHODS: We collected 852 ECGs recorded by 20 GPs (12 practices) in the context of CVRM and diabetes care. Of all abnormal (n = 265) and a sample of the normal (n = 35) ECGs, data on the indications, interpretations and management actions were extracted from the corresponding medical records. An expert panel consisting of one cardiologist and one expert GP reviewed these 300 ECG cases. RESULTS: GPs found new abnormalities in 13.0% of all 852 ECGs (12.0% in routinely recorded ECGs versus 24.3% in ECGs performed for a specific indication). Management actions followed more often after ECGs performed for specific indications (17.6%) than after routine ECGs (6.0%). The expert panel agreed with the GPs' interpretations in 67% of the 300 assessed cases. Most often misinterpreted relevant ECG abnormalities were previous myocardial infarction, R­wave abnormalities and typical/atypical ST-segment and T­wave (ST-T) abnormalities. Agreement on patient management between GP and expert panel was 74%. Disagreement in most cases concerned additional diagnostic testing. CONCLUSIONS: In the context of programmatic CVRM and diabetes care by GPs, the yield of newly found ECG abnormalities is modest. It is higher for ECGs recorded for a specific reason. Educating GPs seems necessary in this field since they perform less well in interpreting and managing CVRM ECGs than in ECGs performed in symptomatic patients.

Interpretations of and management actions following electrocardiograms in symptomatic patients in primary care: a retrospective dossier study.

BACKGROUND: The electrocardiogram (ECG) has become a popular tool in primary care. The clinical value of the ECG depends on the appropriateness of the indication and the interpretation skills of the general practitioner (GP). OBJECTIVES: To describe the use of electrocardiography in primary care and to assess the performance of GPs in interpreting ECGs and making subsequent management decisions. METHODS: Three hundred ECGs, recorded during daily practice in symptomatic patients by 14 GPs who regularly perform electrocardiography, were selected. Corresponding data of the indications, interpretations and subsequent management actions were extracted from the associated medical records. A panel consisting of an expert GP and a cardiologist reviewed the ECGs and specified their agreement with the findings and actions of the study GPs. RESULTS: The most common indications were suspicion of a rhythm abnormality (43.7%), ischaemic heart disease (42.7%) and patient reassurance (14.3%). The study GPs interpreted 53.3% of the ECGs as showing no (new or acute) abnormality, whereas supraventricular rhythm disorders (12.3%), conduction disorders (7.7%) and repolarisation disorders (7.0%) were the most frequently reported pathological findings. Overall, the expert panel disagreed with the interpretations of the study GPs in 16.2% of cases, and with the GPs' management actions in 11.7%. Learning goals for GPs performing electrocardiography could be formulated for acute coronary syndrome, rhythm disorders, pulmonary embolism, reassurance, left ventricular hypertrophy and premature ventricular complexes. CONCLUSION: GPs who feel competent in electrocardiography performed well in the opinion of the expert panel. We formulated various learning objectives for GPs performing electrocardiography.

Competence of general practitioners in requesting and interpreting ECGs - a case vignette study.

BACKGROUND: Performing electrocardiography is common in general practice, but the quality of indication setting and diagnostic accuracy have been disputed. OBJECTIVES: To assess the competence of general practitioners (GPs) in their decision-making process with regard to recording and interpreting an electrocardiogram (ECG) and evaluating the relevance of the result for management. METHODS: An online case vignette survey was performed among GPs and cardiologists (in 2015). Nine cases describing situations for which Dutch clinical guidelines recommend or advise against recording an ECG were presented. In each case, the participant had to make choices on recording an ECG, interpreting it, and using the result in a management decision. The reference standard for each ECG diagnosis was set by the expert author team. RESULTS: Fifty GPs who interpret ECGs themselves, eight GPs who do not and 12 cardiologists completed the survey. Adherence to guidelines recommending an ECG was high for suspected atrial fibrillation, suspected arrhythmia present during consultation, including bradycardia, but much lower for progressive heart failure and stable angina. Diagnostic accuracy of GPs was best in atrial fibrillation (96%), sick sinus syndrome (85%) and old myocardial infarction (82%), but poor in left anterior fascicular block (16%) and incomplete right bundle branch block (10%). GPs often acknowledged the low relevance of the results of a non-indicated ECG. CONCLUSION: GPs do not fully adhere to Dutch cardiovascular guidelines on indications for recording ECGs. Diagnostic accuracy was high for atrial fibrillation, sick sinus syndrome and old myocardial infarction and poor for left anterior fascicular block and incomplete right bundle branch block.