Electrocardiography in primary care; is it useful?

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Abstract

Little is known about the value of electrocardiography in primary care. Aims: To assess whether electrocardiography (ECG) is a useful instrument, in addition to history taking and physical examination, in that it changes the general practitioner’s management of patients with suspected cardiovascular symptoms or disease. Methods and results: We performed a prospective study in a group practice of eight general practitioners in The Netherlands. During 2 years all ECGs that were recorded in these practices were studied. Two questionnaires were filled out by the general practitioners, one before and one after the ECG recording, to determine indication for electrocardiography, the general practitioner’s anticipated management before and after ECG results, and the subjective usefulness according to the applying doctor. All ECGs were reviewed by an experienced general practitioner working in the group practice and later on by a cardiologist. In addition, all clinical information, including the 6 months follow-up period, was scrutinised by both the cardiologist and general practitioner to establish the patients’ prognosis. A total of 301 ECGs was included in the analysis. Main indications for electrocardiography were chest pain (57%), and collapse or palpitation (30%). In 92 (30.6%; 95% CI 25.4–35.8) patients a change in management by the general practitioner occurred following the ECG results. Most prevalent changes were non-referral to a cardiologist, while referral was anticipated before the ECG results (34%), referral while the patient would not have been referred without ECG results (20%), and change in cardiovascular therapy (40%). In one of these cases only, this change could be considered unfavourable, since a subendocardial infarction, not detectable on the ECG, was missed. In patients with chest pain, a normal ECG (likelihood ratio (LR) 0.06) and an abnormal ECG (LR 13.3) were very useful to distinguish between patients likely or unlikely to experience cardiac events in the near future. The mean subjective usefulness, on a scale of 0–100, of the ECG evaluation according to the applying general practitioner was 77.5 (S.D. 14.4). There was good agreement in ECG interpretation between the experienced general practitioner, the cardiologist and a second general practitioner. Conclusion: Electrocardiography in addition to history taking and physical examination, may be an important tool in primary care. It can reduce considerably the number of unnecessary referrals.

Introduction

For decades, the usefulness of electrocardiography in general practice has been debated [1], [2], [3], [4], [5], [6]. The discussion has focused on the low prevalence of clinically important cardiological problems in general practice and the (lack of) skills in interpreting ECGs. Several studies concluded that the interpretative capacity of the general practitioner is limited, although the results of experienced general practitioners were better [4].

Earlier studies did show that a 12-lead ECG can improve the diagnostic accuracy in prehospital patients with stable chest pain [7] and in general practice patients with symptoms and signs suggestive of an arrhythmia [8]. Also in the diagnosis of heart failure due to left ventricular systolic dysfunction [9] or in diagnosing left ventricular hypertrophy [10], electrocardiography provides important information.

Studies aimed at determining whether the availability of an ECG facility leads to changes in patient management in general practice are necessary, since such studies are virtually lacking.

In a study including 301 consecutive patients, we assessed whether electrocardiography in addition to history taking and physical examination is potentially useful in primary care, in that it influences patient management by the general practitioner. In addition, electrocardiographic characteristics and change in management were related to cardiovascular events within 6 months of follow-up.

Section snippets

Design

In a group practice of five general practices with in total 14 000 patients, all successive electrocardiograms ordered by eight general practitioners during a 2-year period (November 1993–November 1995) were studied. In the first year of the study we used a one-channel ECG, type cardiofax (Nihon Kohden), in the second year a three-channel ECG, type PageWriter 200i (Hewlett Packard). The ECGs were made by two trained practice nurses.

The 12-lead ECGs were interpreted as soon as possible, but

Results

The mean age of the patients was 61.0 years (S.D. 14.4; range 16–88 years), and 163 (54%) were male. Chest pain (57%) and collapse or palpitations (30%) were mentioned most frequently as indications to perform an ECG (Table 1). In 94 (31%) patients the ECG showed a normal sinus rhythm. ST and/or T wave changes (18%), both non-specific and suggestive for myocardial ischemia, was the most prevalent ECG abnormality (Table 2).

In none of the 56 cases with discrepancies in the general practitioner’s

Discussion

In our study in primary care the main indications to perform an ECG were chest pain and collapse or palpitations. In 31% of the patients the ECG was normal. In one-third of the patients the general practitioner’s management of the patient changed following the ECG results. Most often this concerned changes in referral to a cardiologist, resulting in less hospital referrals. Only in one patient this change in management could be considered unfavourable, in that a subendocardial infarction, not

Acknowledgements

We thank the following general practitioners for their valuable contribution to the study: MW van den Broek, HHG De Jong, HJ Nederhorst, N Nicolay, BE van der Snoek, WAB Stalman and NJ de Wit. We thank HG Martijn, general practitioner for reviewing electrocardiograms.

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