ABSTRACT
Objectives:
To provide the first nationwide assessment of licensed physicians’ competence in electrocardiogram (ECG) interpretation and emergency myocardial infarction (MI) management in Saudi Arabia and to identify specialty-specific gaps that could inform targeted educational strategies.
Methods:
An analytical cross-sectional survey was conducted from September 11, 2025 to October 15, 2025 via Google Forms. Eligible participants included consultants, fellows, residents, and general physicians across cardiology, internal medicine, emergency medicine, family medicine, general surgery, anesthesia, and intensive care medicine. A validated, self-administered questionnaire captured demographics, ECG knowledge triggers, interpretation of seven key ECG findings, and prior workshop attendance. Each correct response was coded as 1/0, summed, and scaled to a 0–100 composite score. Data were analyzed in R (v4.3.2) using Kruskal–Wallis tests with Bonferroni-adjusted Dunn post-hoc comparisons (P < 0.0083).
Results:
Of 364 respondents, 69.3% were general physicians and 61.8% had attended an ECG workshop. Cardiologists achieved the highest median interpretation scores, whereas general physicians and surgical specialties performed significantly lower (P < 0.001). Workshop attendance was associated with higher scores. ST-elevation recognition demonstrated the highest accuracy, whereas reciprocal change identification was poorest.
Conclusions:
Competency gaps in ECG interpretation and MI management remain substantial, particularly among general physicians. Mandatory ECG modules in residency programs, expansion of continuing medical education requirements, and tele-ECG over-read systems are urgently needed to standardize acute cardiac care and improve reperfusion timelines.
Keywords: Cross-sectional study, electrocardiogram interpretation, emergency cardiac care, myocardial infarction, physician competency, Saudi Arabia, tele-electrocardiography
Introduction
Misinterpretation of electrocardiograms (ECGs) continues to compromise the timely management of myocardial infarction (MI), leading to delayed reperfusion and increased mortality.[1] Acute coronary occlusion induces irreversible myocardial necrosis within minutes, and even minor delays in recognition can push patients beyond the therapeutic window.[2] The 2023 European Society of Cardiology (ESC) guidelines emphasize the need to perform a 12-lead ECG within 10 minutes of presentation and to immediately activate reperfusion pathways to improve survival.[1] Likewise, focused updates from the American College of Cardiology and American Heart Association reaffirm that rapid ECG-based decision-making remains the cornerstone of STEMI care.[3]
Global data demonstrate significant variability in physicians’ accuracy when interpreting ischemic ECG changes. A systematic review reported widespread deficiencies in ECG interpretation competency across multiple healthcare settings, despite advances in training methods.[4] Within Saudi Arabia, evidence remains limited and fragmented. A study in the Makkah region showed that medical students and interns achieved a median score of only 35.3% in ECG interpretation, while another national-level survey of medical interns found that just 61.9% correctly identified MI-related ECG changes, even after advanced life-support training.[5,6] These findings, although informative, are localized and small-scale, highlighting the absence of a comprehensive national assessment.
Effective MI management extends beyond ECG interpretation to coordinated emergency response. Among Saudi emergency medical service (EMS) providers, ECG interpretation accuracy averaged only 43.3%, underscoring prehospital diagnostic delays.[7] Such operational gaps likely contribute to avoidable treatment delays and poorer patient outcomes.
The urgency of addressing these deficits is amplified by the cardiovascular risk landscape in Saudi Arabia. The Global Burden of Disease 2019 study reported that ischemic heart disease remains the leading cause of death nationally.[8] Moreover, national surveys indicate that approximately 65% of Saudi adults are overweight or obese and nearly 95% have insufficient physical activity, while diabetes affects about 22% of adults.[9,10] These risk factors contribute to earlier onset of MI in Gulf populations, where registry data show presentation occurs 10–15 years earlier compared to Western cohorts.[11] Collectively, these findings highlight the urgent need to optimize physician competency and system-level preparedness.
From a practical perspective, this study provides actionable insights for both clinicians and patients. For healthcare practitioners, identifying specialty-specific gaps in ECG interpretation and emergency myocardial infarction management can guide the development of targeted training programs, continuing medical education initiatives, and competency-based assessments, particularly for general physicians and non-cardiology specialties who often serve as first-contact providers. For patients, improving physicians’ ability to promptly recognize ischemic ECG changes and initiate appropriate management has the potential to reduce diagnostic delays, optimize reperfusion timelines, and ultimately improve clinical outcomes. By linking diagnostic competency with emergency decision-making, this study supports system-level efforts to enhance the quality and consistency of acute cardiac care.
To our knowledge, no existing research has simultaneously evaluated licensed physicians’ ECG interpretation proficiency and their adherence to emergency MI protocols on a national scale in Saudi Arabia. Therefore, this study aims to provide the first nationwide assessment of physicians’ competence in ECG interpretation and emergency MI management. By identifying strengths and weaknesses, the findings will inform targeted educational programs, support national policy initiatives, and ultimately enhance acute cardiac care outcomes.
Materials and Methods
Study design and participants
This analytical cross-sectional study targeted licensed physicians in Saudi Arabia who are routinely engaged in ECG interpretation. Eligible participants included consultants, fellows, residents, and general practitioners across cardiology, internal medicine, emergency medicine, family medicine, general surgery, anesthesia, and intensive care medicine. Physicians not involved in ECG interpretation were excluded to ensure a clinically relevant sample. Cardiologists served as the comparator group given their advanced training and expected proficiency. A total of 364 physicians met the eligibility criteria, completed the survey, and were included in the analysis.
Ethical considerations
Ethical approval for this study was obtained from the Institutional Review Board of the College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia (IRB No. 853/2025; approval date: 10 September 2025). Participation was entirely voluntary, and electronic informed consent was integrated into the first page of the online survey. Respondents were explicitly informed about the study objectives, confidentiality of data, and their right to withdraw prior to submission. No personal identifiers were collected.
Sample size and sampling
The minimum required sample size (n = 384) was calculated using OpenEpi, assuming 50% expected prevalence of correct ECG interpretation, 95% confidence level, and 5% margin of error. The survey link was distributed via institutional mailing lists, professional WhatsApp groups, and social media platforms. A total of 364 complete responses were obtained, corresponding to 94.8% of the target sample and yielding an actual margin of error of 5.1%.
Study instrument
Data were collected using a structured, self-administered questionnaire developed in English and deployed via Google Forms. The instrument captured sociodemographic information (role, specialty, years of experience, region of practice), physicians’ knowledge of key clinical triggers for ECG, interpretation of seven key ECG findings, and self-reported confidence and preferences for improving ECG competence. The questionnaire incorporated seven representative ECG tracings; one tracing (Lateral STEMI) was adapted from an open-access ECG resource (Life in the Fast Lane). The image is licensed for noncommercial educational use and contained no patient identifiers.[12]
Content validity was established through independent review by two cardiologists and one internal medicine consultant (S-CVI/Ave > 0.85). Face validity was confirmed through a pilot test with 25 physicians outside the final sample, leading to minor revisions for clarity and relevance. Internal consistency of the ECG interpretation section demonstrated acceptable reliability (Cronbach’s α = 0.72), supporting the use of a composite score to quantify interpretation competence.
Data collection
The survey was administered via Google Forms and was open from September 11, 2025 to October 15, 2025. The link was disseminated electronically with periodic reminders to maximize participation. Responses were automatically recorded and exported to Microsoft Excel for cleaning and quality control.
Data analysis
Data were analyzed using R (v4.3.2, RStudio IDE). Categorical variables were summarized as frequencies and percentages, and continuous variables as medians with interquartile ranges (IQRs). Each of the seven ECG interpretation items was coded as 1 (correct) or 0 (incorrect), and a composite score was calculated and scaled to a 0–100 range. Between-group comparisons were conducted using the Kruskal–Wallis test, followed by Dunn’s post-hoc pairwise tests with a Bonferroni-adjusted significance threshold (P < 0.0083) to control for type I error.
Results
Out of 364 respondents, the majority were general physicians (69.3%) with less than 2 years of clinical experience (60.4%), practicing in the Western Region of Saudi Arabia (23.9%), and most (61.8%) had attended an ECG interpretation workshop [Table 1].
Table 1.
Demographics Characteristics of Respondents (n=364)
| Demographics | Response | Frequency (n=364) | Percentage |
|---|---|---|---|
| Current Role or Position | Consultant | 38 | 10.4% |
| Fellowship | 33 | 9.1% | |
| General Physician | 216 | 69.3% | |
| Residency | 77 | 21.1% | |
| Current Specialty or Residency Training | Cardiology | 30 | 8.2% |
| Emergency Medicine | 26 | 7.1% | |
| Family Medicine | 27 | 7.4% | |
| General Surgery | 21 | 5.8% | |
| General Physician | 198 | 54.4% | |
| ICU/Critical Care | 25 | 6.9% | |
| Internal Medicine | 37 | 10.2% | |
| Years of Clinical Experience | 2-5 years | 80 | 22.0% |
| Less than 2 years | 220 | 60.4% | |
| More than 5 years | 64 | 17.6% | |
| Region of Saudi Arabia you are Currently Practicing | Central Region | 75 | 20.6% |
| Eastern Region | 60 | 16.5% | |
| Northern Region | 79 | 21.7% | |
| Southern Region | 63 | 17.3% | |
| Western Region | 87 | 23.9% | |
| Attended a Workshop Related to ECG Interpretation | No | 139 | 38.2% |
| Yes | 225 | 61.8% |
Figure 1 illustrates the reported time window for streptokinase use in acute MI as perceived by respondents. Nearly half of respondents (n = 178, 48.9%) knew the correct time window of administering streptokinase, while 113 respondents (31.0%) believed that it should be administered within 3 hours.
Figure 1.
Reported Time Window for Streptokinase Use in Acute Myocardial Infarction (AMI) as Perceived by Respondents (n = 364)
Table 2 summarizes the respondents’ knowledge of symptoms indicating the need of performing ECG categorized by medical residency. Chest pain was almost universally recognized as an indication across all residencies, with 100% of cardiology and over 90% in most other groups identifying it correctly. Shortness of breath and shoulder pain were also recognized; however, in ICU/critical care, only 52% and 80% identified shortness of breath and shoulder pain, respectively, as ECG indications. General surgery residents were the highest in recognizing jaw pain and back pain, as indicated by 90.5% and 90.0%, respectively, whereas ICU/critical care residents showed lower recognition of both jaw pain and back pain (32% and 60%) selected “Not Indicated,” respectively. Epigastric pain was commonly identified by emergency medicine residence, 88.5%, as indication of ECG. The highest recognition of both sweating and syncope came from general surgery residents, 95.2% and 90.5%, respectively.
Table 2.
Respondents’ knowledge of symptoms indicating the need for performing an ECG by residency (n=364)
| Symptoms indicating the need of ECG | Cardiology (n=30) | Emergency Medicine (n=26) | Family Medicine (n=27) | General Physician (n=198) | General Surgery (n=21) | ICU/Critical Care (n=25) | Internal Medicine (n=37) | |
|---|---|---|---|---|---|---|---|---|
| Chest Pain | I don’t know | 0 (0.0%) | 1 (3.8%) | 2 (7.4%) | 6 (3.0%) | 1 (4.8%) | 0 (0.0%) | 1 (2.7%) |
| Indicated | 30 (100.0%) | 25 (96.2%) | 23 (85.2%) | 185 (93.4%) | 19 (90.5%) | 24 (96.0%) | 36 (97.3%) | |
| Not indicated | 0 (0.0%) | 0 (0.0%) | 2 (7.4%) | 7 (3.5%) | 1 (4.8%) | 1 (4.0%) | 0 (0.0%) | |
| Shortness of Breath | I don’t know | 0 (0.0%) | 0 (0.0%) | 1 (3.7%) | 19 (9.6%) | 0 (0.0%) | 3 (12.0%) | 2 (5.4%) |
| Indicated | 22 (73.3%) | 23 (88.5%) | 20 (74.1%) | 136 (68.7%) | 17 (81.0%) | 13 (52.0%) | 28 (75.7%) | |
| Not indicated | 8 (26.7%) | 3 (11.5%) | 6 (22.2%) | 43 (21.7%) | 4 (19.0%) | 9 (36.0%) | 7 (18.9%) | |
| Shoulder Pain | I don’t know | 2 (6.7%) | 3 (11.5%) | 0 (0.0%) | 19 (9.6%) | 0 (0.0%) | 0 (0.0%) | 1 (2.7%) |
| Indicated | 26 (86.7%) | 22 (84.6%) | 22 (81.5%) | 146 (73.7%) | 18 (85.7%) | 20 (80.0%) | 29 (78.4%) | |
| Not indicated | 2 (6.7%) | 1 (3.8%) | 5 (18.5%) | 33 (16.7%) | 3 (14.3%) | 5 (20.0%) | 7 (18.9%) | |
| Jaw Pain | I don’t know | 2 (6.7%) | 1 (3.8%) | 3 (11.1%) | 26 (13.1%) | 2 (9.5%) | 1 (4.0%) | 4 (10.8%) |
| Indicated | 18 (60.0%) | 21 (80.8%) | 18 (66.7%) | 125 (63.1%) | 19 (90.5%) | 16 (64.0%) | 25 (67.6%) | |
| Not indicated | 10 (33.3%) | 4 (15.4%) | 6 (22.2%) | 47 (23.7%) | 0 (0.0%) | 8 (32.0%) | 8 (21.6%) | |
| Back Pain | I don’t know | 1 (3.3%) | 1 (3.8%) | 7 (25.9%) | 42 (21.2%) | 1 (4.8%) | 2 (8.0%) | 7 (18.9%) |
| Indicated | 27 (90.0%) | 19 (73.1%) | 16 (59.3%) | 86 (43.4%) | 19 (90.5%) | 8 (32.0%) | 20 (54.1%) | |
| Not indicated | 2 (6.7%) | 6 (23.1%) | 4 (14.8%) | 70 (35.4%) | 1 (4.8%) | 15 (60.0%) | 10 (27.0%) | |
| Epigastric Pain | I don’t know | 2 (6.7%) | 1 (3.8%) | 3 (11.1%) | 36 (18.2%) | 1 (4.8%) | 4 (16.0%) | 3 (8.1%) |
| Indicated | 21 (70.0%) | 23 (88.5%) | 20 (74.1%) | 117 (59.1%) | 17 (81.0%) | 19 (76.0%) | 26 (70.3%) | |
| Not indicated | 7 (23.3%) | 2 (7.7%) | 4 (14.8%) | 45 (22.7%) | 3 (14.3%) | 2 (8.0%) | 8 (21.6%) | |
| Sweating | I don’t know | 2 (6.7%) | 2 (7.7%) | 1 (3.7%) | 35 (17.7%) | 1 (4.8%) | 3 (12.0%) | 5 (13.5%) |
| Indicated | 28 (93.3%) | 22 (84.6%) | 20 (74.1%) | 122 (61.6%) | 20 (95.2%) | 21 (84.0%) | 27 (73.0%) | |
| Not indicated | 0 (0.0%) | 2 (7.7%) | 6 (22.2%) | 41 (20.7%) | 0 (0.0%) | 1 (4.0%) | 5 (13.5%) | |
| Syncope | I don’t know | 0 (0.0%) | 1 (3.8%) | 2 (7.4%) | 40 (20.2%) | 0 (0.0%) | 4 (16.0%) | 7 (18.9%) |
| Indicated | 24 (80.0%) | 23 (88.5%) | 22 (81.5%) | 133 (67.2%) | 19 (90.5%) | 18 (72.0%) | 28 (75.7%) | |
| Not indicated | 6 (20.0%) | 2 (7.7%) | 3 (11.1%) | 25 (12.6%) | 2 (9.5%) | 3 (12.0%) | 2 (5.4%) | |
Table 3 shows the management options for AMI among residencies. While most specialties correctly Identified aspirin/clopidogrel as AMI management with the highest recognition among internal medicine, 86.5% other management options showed significant variation, especially with ICU/critical care residents having the lowest selection of both heparin and morphine (48.0% and 16.0%, respectively). Moreover, emergency medicine residents most frequently select oxygen inhalation (73.1%), and general surgery residents show the strongest support for streptokinase (81.0%).
Table 3.
Management options for acute myocardial infarction perceived (AMI) by residency (n=364)
| Management Options for AMI | Cardiology (n=30) | Emergency Medicine (n=26) | Family Medicine (n=27) | General Physician (n=198) | General Surgery (n=21) | ICU/Critical Care (n=25) | Internal Medicine (n=37) |
|---|---|---|---|---|---|---|---|
| Aspirin/Clopidogrel | 23 (76.7%) | 21 (80.8%) | 22 (81.5%) | 161 (81.3%) | 15 (71.4%) | 17 (68.0%) | 32 (86.5%) |
| Heparin | 16 (53.3%) | 13 (50.0%) | 13 (48.1%) | 77 (38.9%) | 15 (71.4%) | 12 (48.0%) | 22 (59.5%) |
| Morphine | 16 (53.3%) | 16 (61.5%) | 16 (59.3%) | 105 (53.0%) | 12 (57.1%) | 4 (16.0%) | 26 (70.3%) |
| Oxygen Inhalation | 8 (26.7%) | 19 (73.1%) | 15 (55.6%) | 99 (50.0%) | 14 (66.7%) | 13 (52.0%) | 20 (54.1%) |
| Primary Angioplasty | 18 (60.0%) | 14 (53.8%) | 19 (70.4%) | 99 (50.0%) | 12 (57.1%) | 15 (60.0%) | 26 (70.3%) |
| Streptokinase | 17 (56.7%) | 10 (38.5%) | 16 (59.3%) | 96 (48.5%) | 17 (81.0%) | 15 (60.0%) | 27 (73.0%) |
| I don’t know | 3 (10.0%) | 0 (0.0%) | 2 (7.4%) | 15 (7.6%) | 0 (0.0%) | 3 (12.0%) | 4 (10.8%) |
Table 4 shows the ECG interpretation total score by residencies. Cardiology residents had the highest median ECG interpretation score (71.4, IQR 57.14–82.14) with a statistically significant difference, while general physicians and general surgery residents had the lowest median scores (42.9). A statistically significant difference was found across residencies (P = 0.0001). When compared to cardiology residents, general physicians had a significantly reduced ECG interpretation score (adjusted P = 0.0076).
Table 4.
ECG interpretation total score by residency (cardiology as comparator)
| Residency | Median score | IQR lower | IQR upper | Adjusted P |
|---|---|---|---|---|
| Kruskal–Wallis Test | *0.0001 | |||
| Cardiology | 71.43 | 57.14 | 82.14 | NA |
| Emergency Medicine | 71.43 | 42.86 | 85.71 | 1.000 |
| Family Medicine | 57.14 | 14.29 | 71.43 | 0.2676 |
| General Physician | 42.86 | 28.58 | 71.43 | a0.0076 |
| General Surgery | 42.86 | 42.86 | 71.43 | 0.7762 |
| ICU/Critical Care | 71.43 | 42.86 | 85.71 | 1.000 |
| Internal Medicine | 57.1 | 42.86 | 71.43 | 1.000 |
*Significant at P<0.001. aindicates statistically significant difference compared with cardiology. Bold values indicate statistical significance
Table 5 shows the ECG interpretation total score by professional role. Residents had the highest median ECG interpretation score (71.4, IQR 42.86–71.43), while consultants, fellows, and general physicians had lower median scores, and a statistically significant difference was observed across the roles (P = 0.0004).
Table 5.
ECG Interpretation Total Score by Different Roles
| Role | Median score | IQR lower | IQR upper | P |
|---|---|---|---|---|
| Consultant | 57.14 | 42.86 | 71.43 | *0.0004 |
| Fellowship | 42.86 | 28.57 | 71.43 | |
| General Physician | 42.86 | 28.57 | 71.43 | |
| Residency | 71.43 | 42.86 | 71.43 |
*Significant at P<0.001
Figure 2 displays the confidence in interpreting ECG reported among residencies. The respondents of internal medicine, 29.7% (11), reported “Confident,” and emergency medicine, 42.3% (11), reported “Moderately confident,” expressing higher confidence compared to cardiology and general physicians.
Figure 2.
Self-Reported Confidence in ECG Interpretation in Clinical Practice by Residency (n = 364)
Figure 3 displays the preferred method to improve ECG interpretation skills. ICU/Critical care residents preferred “Continuous Medical Education” as a method to improve ECG interpretation by 64% (16) as well as emergency medicine and internal medicine by 46.2% (12) and 37.8% (14), respectively, while 38.1% (8) of general surgery preferred “Cardiology Rotation” and 40% of cardiology preferred “workshops.”
Figure 3.
Preferred Methods for Improving ECG Interpretation Skills by Residency (n = 364)
Continuing medical education was the most commonly preferred method, followed by workshops and cardiology rotations [Figure 4].
Figure 4.
Preferred methods for improving ECG interpretation skills among physicians (n = 364)
Figure 5 Perceived time window for streptokinase administration in acute myocardial infarction by specialty. Marked variation was observed across specialties in knowledge of the appropriate streptokinase administration window.
Figure 5.
Perceived Time Window for Streptokinase Administration in Acute Myocardial Infarction by Specialty (n = 364).
Discussion
This nationwide analytical cross-sectional study provides the first national assessment of physicians’ ECG interpretation competence and adherence to emergency MI management guidelines in Saudi Arabia. The study detects clear specialty-related differences in ECG interpretation performance and decision-making accuracy. These findings indicate that exposure, training structure, and clinical role likely shape ECG competence across specialties, which is consistent with prior international and regional observations.[13,14,15]
The study findings align with previous Saudi evidence showing limited ECG competence among medical trainees and early-career physicians, including frequent misinterpretation of important arrhythmias and incomplete recognition of critical ischemic patterns.[13,14] Comparable work from Pakistan also reports higher competency among emergency physicians than general practitioners and shows that workshop attendance, rather than years of practice, predicts performance.[15] These parallels suggest that structured reinforcement and specialty-specific training influence ECG proficiency more than experience alone. The present study expands this evidence by evaluating diagnostic and therapeutic decision-making simultaneously, providing a more detailed understanding of competency patterns than previously available in the Saudi context.
Differences in clinical recognition may reflect variations in exposure to acute coronary syndromes, distribution of on-call responsibilities, and familiarity with STEMI protocols. Pattern-recognition skills strengthen with repeated practice and feedback, which are more available in cardiology and emergency medicine settings. ICU physicians’ lower recognition of atypical symptoms may relate to competing clinical priorities within intensive-care workflows. These interpretations align with broader cardiovascular literature that emphasizes early diagnosis as a determinant of treatment timelines and outcomes.[1,2,3,11] National data indicate prolonged delays in first-medical-contact to reperfusion pathways and suboptimal pre-hospital ECG acquisition,[16] underscoring the importance of early clinical identification. Observations of outcome differences across patient groups in tertiary centers further emphasize the relevance of timely diagnosis.[17]
The study has several implications for clinical training and health-system planning. Specialty-specific gaps highlight the need for targeted reinforcement among general physicians and surgeons, who serve as first-contact providers in many settings. Emergency and ICU physicians may benefit from focused education on atypical ACS presentations to reduce diagnostic uncertainty. Integrating tele-ECG support systems in peripheral hospitals could improve access to expert interpretation. Expanding pre-hospital ECG acquisition within EMS workflows, as recommended by international guidelines,[1,2,3] may shorten key ischemic intervals. Periodic ECG competency assessments may help maintain long-term proficiency.
This study has important strengths. It includes a large national sample representing multiple specialties and clinical roles, uses a validated instrument with strong content validity and internal consistency, and combines assessment of interpretation accuracy and treatment decision-making. These features allow detailed characterization of competency gaps across the healthcare system.
Several limitations must be addressed. Convenience sampling may introduce selection bias, and online administration may allow respondents to consult external resources. Unequal representation across specialties may limit direct comparison. The study assesses theoretical performance rather than real-time clinical behavior. Multivariable adjustment for potential confounders was not possible due to design constraints. Despite these limitations, the detection of significant differences across specialties and strong internal reliability support the validity of the findings.
Future research should evaluate simulation-based ECG curricula through multicenter randomized trials that measure clinically meaningful outcomes, such as door-to-balloon time and mortality. Qualitative research may clarify workflow barriers to timely activation of reperfusion pathways. Longitudinal studies may determine whether periodic competency renewal improves sustained performance. International comparisons, including data from Malaysia showing persistently low undergraduate competence,[18] suggest that early curriculum reform may be warranted.
Conclusion
This nationwide cross-sectional study demonstrates critical gaps in ECG interpretation and emergency myocardial infarction management among physicians in Saudi Arabia, with general physicians and non-cardiology specialties showing the lowest competency. Cardiologists consistently outperformed other groups, underscoring the need for targeted, specialty-specific educational interventions. Attendance at structured ECG workshops was associated with significantly higher interpretation scores, confirming the value of focused training. These findings highlight an urgent mandate to integrate mandatory ECG interpretation modules into residency curricula, expand continuing medical education requirements, and implement tele-ECG over-read systems to reduce diagnostic delays. Collectively, such measures could standardize acute cardiac care pathways, shorten reperfusion times, and ultimately improve survival outcomes at the national level.
List of abbreviations
ECG – Electrocardiogram
MI – Myocardial Infarction
STEMI – ST-Elevation Myocardial Infarction
EMS – Emergency Medical Services
IQR – Interquartile Range
PCI – Percutaneous Coronary Intervention
CME – Continuing Medical Education
IRB – Institutional Review Board
CVI – Content Validity Index.
Declarations
Author contributions
All authors participated in the concept, Design, analysis, interpretation of data, writing, and manuscript review. They have seen and approved the final version of the manuscript.
Institutional review board statement
The study was approved by the IMSIU Research Ethics Committee (project number 853/2025; approval date, 10 September 2025). All writing is done following the ethical principles of the Declaration of Helsinki. The survey link included a brief study description and a more detailed explanation on the front page. Participants were told that completion of the survey constituted consent. All participant consent and data were collected in complete confidence throughout the study.
Informed consent statement
Informed consent was obtained from all subjects involved in the study.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
- 1.Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44:3720–826. doi: 10.1093/eurheartj/ehad191. [DOI] [PubMed] [Google Scholar]
- 2.Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of ST-segment elevation myocardial infarction. Eur Heart J. 2018;39:119–77. doi: 10.1093/eurheartj/ehx393. [DOI] [PubMed] [Google Scholar]
- 3.Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 ACC/AHA/SCAI focused update on primary PCI for STEMI. Circulation. 2016;133:1135–47. doi: 10.1161/CIR.0000000000000336. [DOI] [PubMed] [Google Scholar]
- 4.Fent G, Gosai J, Purva M. Teaching the interpretation of electrocardiograms: Systematic review of educational trials. BMJ Open. 2015;5:e006955. doi: 10.1016/j.jelectrocard.2014.12.014. [DOI] [PubMed] [Google Scholar]
- 5.Mandourah AJ, Alqurashi KA, Alshareef AM, Alharbi AA, Alzahrani SA. Evaluation of ECG interpretation among medical students in the Makkah region. Niger J Clin Pract. 2025:28. doi: 10.4103/njcp.njcp_261_24. [DOI] [PubMed] [Google Scholar]
- 6.Al Mousa AM, Alhubail FM, Almulhim M, AlBeladi BA, Almulhim NA, Almulhim AA, et al. ECG interpretation competency of medical interns in Saudi Arabia. Cureus. 2023;15:e37557. doi: 10.7759/cureus.37557. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Alalwan MA, Alharbi AA, Alghamdi AS, Alotaibi NH, Almutairi FA, Alqahtani MA, et al. ECG interpretation by EMS providers in Saudi Arabia. PLoS One. 2023;18:e0285604. [Google Scholar]
- 8.Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. Global burden of cardiovascular diseases, 1990–2019. J Am Coll Cardiol. 2020;76:2982–3021. doi: 10.1016/j.jacc.2020.11.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Al-Hanawi MK, Keetile M. Socio-demographic correlates of NCD risk factors among Saudi adults. Front Med (Lausanne) 2021;8:605912. doi: 10.3389/fmed.2021.605912. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Memish ZA, El Bcheraoui C, Tuffaha M, Robinson M, Daoud F, Jaber S, et al. Diabetes mellitus in Saudi Arabia:prevalence from a national survey. Ann Saudi Med. 2014;34:465–70. [Google Scholar]
- 11.AlHabib KF, Hersi A, AlFaleh H, AlNemer K, Alsaif S, Taraben A, et al. The Gulf RACE registry: Acute coronary syndrome presentation and outcomes in the Middle East. Circulation. 2009;120:1207–14. [Google Scholar]
- 12.Life in the Fast Lane. Lateral STEMI ECG Library. [[Last accessed on 2025 Aug 28]]. Available from: https://litfl.com/lateral-stemi-ecg-library/
- 13.Alghamdi SAA, Almuntashiri AH, Aljuaeed MS, Mohamed MA. Electrocardiography misreading among sixth-year medical students and interns in Taif University. Int J Community Med Public Health. 2018;5:4225–30. [Google Scholar]
- 14.Alsadi M, Ahmed AM, Almousa S, Homoud E, Almutairi R, Alkhalifah B, et al. Competency differences in interpreting ECG strips among medical students, interns, and residents. KAIMRC Rep. 2023;12:45–52. [Google Scholar]
- 15.Ahmad F, Sohail AA, Danish SH, Iqbal Z, Shahid M. Interpretation of ECG and emergency management of MI: A survey among doctors. Pak J Med Dent. 2020;9:93–9. [Google Scholar]
- 16.Alhabib KF, Kinsara AJ, Alghamdi S, Al-Murayeh MA, Al-Amri HS, Al-Mallah MH, et al. STARS-1: Saudi AMI registry main results. PLoS One. 2019;14:e0216551. doi: 10.1371/journal.pone.0216551. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Khaled S, Almalki M, Shalaby G, Alharbi A, Alotaibi A, Almutairi H, et al. Epidemiological variation of acute myocardial infarction relevant to in-hospital outcomes in Saudi Arabia. J Saudi Heart Assoc. 2020;32:1–10. doi: 10.37616/2212-5043.1139. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Ou KQ, Hassan MM, Jad R, Rahman A, Lee TH. Electrocardiogram competency among undergraduate medical students in Malaysia. Asian J Clin Med Res. 2024 [Google Scholar]