Electrocardiography in primary care; is it useful?
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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