11. Competency in Interpretation of 12-Lead Electrocardiograms:
A Summary and Appraisal of Published Evidence
• ECG Diagnosis correctly identified by non-cardiologist in 36-
96%
• Inappropriate management up to 11% of cases
• Even one cardiologist reading the same ECG on separate
occasions may have substantially different interpretations
Salerno et al AIM 2003
13. Accuracy of ECG Interpretation Improves with
EM Training
Hoyle et al EMA 2007
14. Improving Competency
• Review the ECG
– Look at the whole ECG
– Know what you are looking at
• Interpretation of the ECG
• Look at the patient with the ECG
Cruz et al MJA 2012
18. Smartphone ECG Interpretation
Can you just take a photo of the ECG and send it to me ?
Gonzales et al J Interv Cardiol. 2011
Bilgi et al Telemed J E Health. 2012
19.
20.
21. AliveCor EKG Case
• FDA Cleared December
2012
• Physician use only
• Issued by prescription
• Cost 200 USD
• Uploads single lead
rhythm to a cloud
server
27. Spotting lead reversal
• Abnormal axis
• Look at p wave morphology in limb leads
– Normal p waves
• Positive in leads I, II
• Negative in lead aVR
• Look at T wave in relation to p wave & QRS
complex
• Flat lead I, II or III
28. Source: Dr Stephen Smith
Dr Smith’s ECG Blog
http://hqmeded-ecg.blogspot.com.au/
29. Source: Dr Stephen Smith
Dr Smith’s ECG Blog
http://hqmeded-ecg.blogspot.com.au/
30. De Winter’s Hyperacute T Waves
• Acute LAD Occlusion
• 30 Patients
– (2% of Anterior MIs)
• ECG Features
– 1-3 mm ST depression V1-6 at J-point
– Tall positive symmetrical T waves
– ST Elevation aVR 1-2mm
• Did not progress to ST elevation
31. Third Universal Definition of MI
• New ST elevation at the J point in two
contiguous leads
• ≥0.1 mV in all leads other than leads V2–V3
where the following cut points apply:
– ≥0.2 mV in men ≥40 years
– ≥0.25 mV in men <40 years
– ≥0.15 mV in women.
Joint ESC/ACCF/AHA/WHF Task Force EHJ 2012
32. Source: Professor Martin Green, University of Ottawa Heart Institute, Ontario Canada
Dr Arieh Keren
33.
34. ‘Giant’ T Wave Inversion
• Deep symmetrically inverted T waves >5mm
• Raised ICP
– Associated with QT prolongation
– Rarely associated with STEMI-like changes
• Apical hypertrophic cardiomyopathy
– Yamaguchi syndrome
• Myocarditis
• Ischaemia
• Post-tachycardia
41. Web 2.0, FOAM & The ECG
• Provided a safe haven for ECG Enthusiasts
• Share and discuss interesting cases & ECGs
• Asynchronous learning
• Formation of networks & communities
• Large number of ECG related on-line resources
43. EKG Videos – Dr Amal Mattu
• ekgumem.tumblr.com
• Updated weekly
• Case based video
tutorials
44. Dr Smith’s ECG Blog
• http://hqmeded-ecg.blogspot.com.au/
• Extensive collection of
– ECG cases
– Topic Reviews
– Video lectures
– Article links
45. ECG of the Week
• jhcedecg.blogspot.com
• Locally sourced ECGs
• Updated weekly
• Incorporated into EM
education program
46. Acknowledgement & Thanks
• Dr Cameron Burrows
• Dr Arieh Keren
• Dr Shakeeb Razak
• Dr Colin Parker
• Prof Martin Green
• Dr Mike Cadogan
• Dr Chris Nickson
• Dr Ed Burns
• Kane Guthrie
• Dr Stephen Smith
47. References
• Salerno SM, Alguire PC,Waxman HS Competency in Interpretation of 12-Lead Electrocardiograms: A Summary and Appraisal of Published Evidence.
Ann Intern Med. 6 May 2003;138(9):751-760
• Cruz MF, Edwards J, Dinh MM, Barnes EH. The effect of clinical history on accuracy of electrocardiograph Interpretation among doctors working in
emergency departments. Med J Aust. 2012 Aug 6;197(3):161-5.
• Hoyle RJ, Walker KJ, Thomson G, Bailey M. Accuracy of electrocardiogram interpretation improves with emergency medicine training. Emerg Med
Australas. 2007 Feb;19(2):143-150.
• Gonzalez MA, Satler LF, Rodrigo ME, Gaglia MA Jr, Ben-Dor I, Maluenda G, Hanna N, Suddath WO, Torguson R, Pichard AD, Waksman R. Cellular
video-phone assisted transmission and interpretation of prehospital 12-lead electrocardiogram in acute st-segment elevation myocardial infarction. J
Interv Cardiol. 2011 Apr;24(2):112-8.
• Bilgi M, Gülalp B, Erol T, Güllü H, Karagün Ö, Altay H, Müderrisoğlu H. Interpretation of electrocardiogram images sent through the mobile phone
multimedia messaging service. Telemed J E Health. 2012 Mar;18(2):126-31.
• O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz
HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson
JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson
WG, Yancy CW; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline
for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425.
• Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial. Third universal
definition of myocardial infarction. Eur Heart J. 2012 Oct;33(20):2551-67.
• Pillarisetti J, Gupta K. Giant Inverted T waves in the emergency department: case report and review of differential diagnoses. J Electrocardiol. 2010
Jan-Feb;43(1):40-2.
• de Winter RJ, Verouden NJW, Wellens HJJ, Wilde AAM. A New Sign of Proximal LAD Occlusion. N Engl J Med. 2008 Nov;359(19):2071-2073.
• Maluli HA, Meshkov AB. A short story of the short QT syndrome. Cleve Clin J Med. 2013 Jan;80(1):41-7.
• Rokos IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, Stone GW. Appropriate cardiac cath lab activation: optimizing electrocardiogram
interpretation and clinical decision-making for acute ST-elevation myocardial infarction. Am Heart J. 2010 Dec;160(6):995-1003, 1003.e1-8.
Australasian College for Emergency Medicine Examination Handbook Learning and Examination Processes v02 March 2012College of Intensive Care Medicine of Australia & New Zealand – Objectives of advanced training and competencies CICM 2010 Section 6.6
Average pass rate over last 20 exam sittings is ~65%
Average pass rate over last 20 exam sittings is ~65%
Average pass rate over last 20 exam sittings is ~65%
Competency in Interpretation of 12-Lead Electrocardiograms: A Summary and Appraisal of Published EvidenceSalerno et al Ann Internal Medicine 2003Literature review – 41 articles 1976 - 2001
Khan et al. EMJ 2012Posterior myocardial infarction: are we failing to diagnose this?117 doctors – 33 interns 54 SHOs 30 Registrars10% Paramedics able to Dx PMIED & AAU Doctors 50:50Only half of the people knew you needed to perform posterior leads
Hoyle at al.Accuracy of electrocardiogram interpretation improves with EM trainingProspective cross sectional double blinded study EM traineesVictorian EM Trainees10 ECGsSenior 4th year / fellowship n=48 vs junior trainees n=74 n=122Accuracy of diagnosis of VT 43.8% senior trainee vs. 37.8% junior trainees
Gonzales Journal of Interventional Cardiology 2011 n=27Prehospital transmission of STEMI ECG using video phone high interphysician reliability compared with printed copyBilgi et al Telemedicine & e-Health 2012 n = 305MMS interpretation by cardiologist vs paper interpretation by cardiologist & EM physicianLess errors than EM dr with MMS and better consitency of interpretaiton with gold standardBoth studies used Nokia phones - Nokia E71 & Nokia N9 Screen resolution 240 x 320
Taken with Samsung Galaxy S3 – 1280 x 720 - Camera 8 MpiPhone 5 - 1136 x 640 – 8 Mp camera
58 year old maleAtypical chest painNorthern WADistance ~2500 km
Lead reversal LL LA
One case 2.5 hrs post symptoms
28 yr old male with palpatationsAF with pre-excitation