Interpretation of electrocardiograms in primary care

The recently published article by Begg and colleagues, ‘Electrocardiogram interpretation and arrhythmia management: a primary and secondary care survey’,¹ found that within primary care there was substantial error in the interpretation of electrocardiograms (ECGs) by healthcare professionals (HCPs), predominately comprising GPs, than secondary care cardiologists. Moreover, one-third of HCPs felt uncomfortable with interpreting ECGs. Begg and colleagues discuss the implications of unsafe ECG analysis and the wider impact on clinical practice. One proposed solution to this may be analysis of ECGs remotely by secondary care specialists.¹

Another recent survey determined the views of HCPs in primary care about screening for atrial fibrillation (AF).² There were similar findings between both surveys such as access to and interpretation of ECGs within practices. Taggar and colleagues also reported enthusiasm by GPs and nurses to up-skill in ECG interpretation.² These findings suggest that alternative models to improve accuracy of ECG interpretation warrant consideration, such as the development of validated, evidence-based ECG training programmes for primary care HCPs. The model suggested by Begg and colleagues could still be delivered within primary care using the hub and spoke/confederated working, with hub practices having the role of up-skilled ECG interpretation.

To minimise the increased burden on existing resources within primary or secondary care there is the potential to triage ECGs, referring only ECGs that are identified as abnormal. A systematic review compared the accuracy of different methods for interpreting 12-lead ECGs for AF diagnosis.³ Compared with ECGs interpreted by trained cardiac specialists, automated software analysis had greater specificity for AF diagnosis than other HCPs.³ Automated software therefore has the potential to be used as a triage tool to correctly identify normal ECGs that do not require further analysis; ECGs identified as abnormal would warrant further interpretation by a trained professional.

There is growing evidence suggesting that skills of primary care HCPs for interpreting 12-lead ECGs needs improving; there are a number of approaches to achieve this that warrant further investigation and evaluation.