Evaluation of general practitioners’ single-lead electrocardiogram interpretation skills: a case-vignette study

Abstract

Background Handheld single-lead electrocardiograms (1L-ECG) present a welcome addition to the diagnostic arsenal of general practitioners (GPs). However, little is known about GPs’ 1L-ECG interpretation skills, and thus its reliability in real-world practice. Objective To determine the diagnostic accuracy of GPs in diagnosing atrial fibrillation or flutter (AF/Afl) based on 1L-ECGs, with and without the aid of automatic algorithm interpretation, as well as other relevant ECG abnormalities. Methods We invited 2239 Dutch GPs for an online case-vignette study. GPs were asked to interpret four 1L-ECGs, randomly drawn from a pool of 80 case-vignettes. These vignettes were obtained from a primary care study that used smartphone-operated 1L-ECG recordings using the AliveCor KardiaMobile. Interpretation of all 1L-ECGs by a panel of cardiologists was used as reference standard. Results A total of 457 (20.4%) GPs responded and interpreted a total of 1613 1L-ECGs. Sensitivity and specificity for AF/Afl (prevalence 13%) were 92.5% (95% CI: 82.5–97.0%) and 89.8% (95% CI: 85.5–92.9%), respectively. PPV and NPV for AF/Afl were 45.7% (95% CI: 22.4–70.9%) and 98.8% (95% CI: 97.1–99.5%), respectively. GP interpretation skills did not improve in case-vignettes where the outcome of automatic AF-detection algorithm was provided. In detecting any relevant ECG abnormality (prevalence 22%), sensitivity, specificity, PPV and NPV were 96.3% (95% CI: 92.8–98.2%), 68.8% (95% CI: 62.4–74.6%), 43.9% (95% CI: 27.7–61.5%) and 97.9% (95% CI: 94.9–99.1%), respectively. Conclusions GPs can safely rule out cardiac arrhythmias with 1L-ECGs. However, whenever an abnormality is suspected, confirmation by an expert-reader is warranted.

Diagnostic accuracy of the PMcardio smartphone application for artificial intelligence–based interpretation of electrocardiograms in primary care (AMSTELHEART-1)

“…Adequate ECG interpretation is paramount to make adequate referral and/or treatment decisions, which means that GPs must have competence in ECG interpretation. Unfortunately the ECG interpretation skill of GPs is not on par with that of cardiologists, 17 , 18 , 19 , 20 , 21 with previous work indicating that GPs incorrectly assess 1 in 5 normal ECGs as abnormal. 22 We saw that PMcardio was especially reliable in assessing presence or absence of AF.…”

“… 22 We saw that PMcardio was especially reliable in assessing presence or absence of AF. Given the mixed evidence on GPs’ ability to assess AF on ECG signal, 17 , 20 , 21 , 22 PMcardio could be of particular use for AF diagnosis as well as AF management when combined with PMcardio’s guideline-directed treatment recommendation module.…”

“…6 , 26 However, even in this scenario adequate ECG interpretation remains questionable, with some studies suggesting an increase in sensitivity when combining GP interpretation with automatic algorithm software, while others do not. 17 , 18 The alternative is a (digital) cardiologist consultation service. This option is more reliable, but is more time consuming and costly.…”

Reliability of single-lead electrocardiogram interpretation to detect atrial fibrillation: insights from the SAFER Feasibility Study

“…A recent meta-analysis found pooled sensitivities and specificities of automated ECG diagnoses of 89% and 99% respectively in the community setting (24). The accuracy of manual diagnoses has varied greatly between previous studies, with sensitivities and specificities in comparison to reference 12-lead ECGs reported as: 77.4% and 73.0% (22), 90% and 79% (21), 76-92% and 84-100% (20), 89-100% and 85-88% (25), 92.5% and 89.8% (26), 93.9% and 90.1% (18), 100% and 94% (13), and 100% and 100% (27). In all of these studies, the single-lead ECGs were recorded under supervision.…”

Evaluation of the introduction of a single-lead ECG device and digital cardiologist consultation platform among general practitioners in the Netherlands

“…Such 1L-ECG devices showed to be highly accurate in diagnosing AF when interpreted by expert readers (Duarte et al ., 2019 ; Himmelreich et al ., 2019 ). While GPs safely ruled out AF (negative predictive value: 98.8%), they misclassified AF in about half of suspected cases (positive predictive value: 45.7%) (Karregat et al ., 2021 ). Therefore, 1L-ECG devices offer a promising tool for accessible and immediate ECG recordings, as long as GPs have access to an expert reader for consultation.…”