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Rapid Responses: Rapid Responses published:
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Accuracy of Detection of Atrial Fibrillation calls for proper and rigid training of primary care practitioners
- Rodolfo Jr. L. Yuchongco (6 July 2007)
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Recognizing of atrial fibrillation (AF) on ECG in man: almost 100 years, but obviously not enough
- Goran Koracevic (20 July 2007)
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Re: Accuracy of Detection of Atrial Fibrillation calls for proper and rigid training of primary care practitioners
- Rajendra Kumar Yadava (16 August 2007)
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Are ECGs with interpretative software and electronic sphygomomanometers deskilling GPs in detecting Atrial Fibrillation?
- Matt Hoghton (28 August 2007)
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Atrial Fibrillation & Use of Technology
- Stephen Ward, Sally Chisholm Programme Director Lancashire & South Cumbria Cardiac Network (30 August 2007)
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Thoughts from General Practice
- Ralph Emmerson (5 September 2007)
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Re: Thoughts from General Practice
- Jonathan Mant (11 September 2007)
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Response from both Hospital and GP angles
- Ashish B Patel (10 October 2007)
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Rodolfo Jr. L. Yuchongco, Resident Physician Paranaque, Philippines 1700
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I commend the author for writing this informative article. It is very essential for general practitioners and practice nurses to screen and diagnose atrial fibrillation to prevent further complications like stroke. It is also an eye opener that a machine or software cannot replace training and experience of a cardiologist in the interpretation of Electrocardiograms. The authors were right to quote pulse palpation as one of their weakness which might increase the sensitivity of general practitioners to detect atrial fibrillation which is evident in the article of Cooke G. and colleagues. The authors also mentioned that access to other clinical information about the patient with the electrocardiogram is a weakness in their study because this might have an effect in the detection of atrial fibrillation. This was a result in the article of Anh D and colleagues, Accuracy of electrocardiogram interpretation by cardiologists in the setting of incorrect computer analysis, July, 2006. The study is very beneficial hovewer I would like to suggest that regular, proper and rigid training will be very helpful to improve the accuracy of primary care practitioners in diagnosing atrial fibrillation. Competing interests: None declared |
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Goran Koracevic, Assist. Prof. Department for Cardiovascular Diseases, Medical Faculty, Clinical Centre, 18000 Nis, Serbia,
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With all compliments for the study, results are expected in terms that there is no wonder in lower capability of GPs to recognize AF (in comparison to cardiologists). Likewise, cardiologists will always be below the diagnostic accuracy of dermatologists in the case of e.g. pemphigus. On the other hand, results are discouraging for doctors as professionals in general, because almost everyone expected better diagnostic skill. Moreover, results are probably particularly disappointing from the patients’ point of view, knowing how symptomatic and risky AF can be, especially if comorbidities coexist. AF has been very important, being the most common chronic arrhythmia, as well as the most common cardiac disorder in the United States (1), with huge 90 times gradient in prevalence (from from 0.1% in people <55 years of age to 9% in people over 80 years of age) (1). The personal experience suggest that by far the most common source of failure to recognize AF has been focusing on detection of “p” waves (and confusing them with flutter “F” or fibrillation “f” waves), without paying attention to rhythm irregularity. Since the first ECG in AF in man in 1909 by Rothberger and Winterberg (2), it is a pity that the probability that a positive diagnosis was correct was only 41% in the study of Mant et al. (3). 1.Abusaada K, Sharma SB, Jaladi R, Ezekowitz MD. Epidemiology and management of new-onset atrial fibrillation. Am J Manag Care. 2004;10(3 Suppl):S50-7. 2.Lip GYH , Atrial fibrillation in clinical practice, Martin Dunitz, 2001. 3.Mant J, Fitzmaurice D, Hobbs R, Jowett S, Murray E, Holder R, Davies M, Lip GYH. Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial. BMJ 2007: 39227.551713.AE. Competing interests: None declared |
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Rajendra Kumar Yadava, Specialist registrar in Geriatric Medicine Wrexham Maelor Hospital, Wrexham, United Kingdom LL13 9GD
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With due compliments, my personal experience suggests that listening to chaotic rhythm and varying first heart sound in cardiac auscultation is a very sensitive method to detect atrial fibrillation, which can be further corrobarated by 12 lead electrocardiagram. Your eyes see only what your mind knows. Pulse palpation alone can also miss atrial fibrillation with fast ventricuar conduction because of the pulse deiciet. Most doctors including junior doctors, have been trained adquately to listen to the heart sounds and find it easier to make the various cardiac diagnoses; when they use both palpation and ausculatation. So in that respect,listening to the heart makes one aware of the possible diagnosis, which in turn can help in quick and more accurate interpretation of the electrocardigrams. Competing interests: None declared |
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Matt Hoghton, GP Clevedon Medical Centre, Old Street Clevedon BS21 6DG
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With compliments to Dr Mant and his collaborators on their excellent study in accuracy of primary care staff diagnosing Atrial Fibrillation on ECG. I have a suspicion that GPs may have been deskilled in interpreting ECG since ECGs with interpretative software has been introduced into practices creating over reliance on the software result rather than reviewing the ECG "blind" before comparison .
I am also concerned that since the widespread use of electronic sphygmomanometers GPs may no longer be feeling the pulse routinely when taking blood pressures and may miss an irregular pulse. It remains important that the pulse is always taken when taking an electronic sphygmomanometer BP reading as the presence of an irregular rhythm may make the reading inaccurate 1. 1.Stewart MJ, Gough K and Padfield PL. The accuracy of automated blood pressure measuring devices in patients with controlled atrial fibrillation. Hypertens. 1995 Mar;13(3):297-300 Competing interests: None declared |
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Stephen Ward, Medical Director Central Lancashire PCT, Sally Chisholm Programme Director Lancashire & South Cumbria Cardiac Network
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We were interested to read the conclusions of the paper about the accuracy of diagnosing atrial fibrillation on electrocardiogram primary care practitioners and interpretative diagnostic software, particularly since the National Institute for Health and Clinical Excellence guideline 1 recommendation that electrocardiography is used to diagnose atrial fibrillation. A pilot study of the use of Cardiac Telemedicine in Primary Care, which was conducted in GP Practices and Walk in Centres in Lancashire and Cumbria during 2006, showed that both GPs and practice nurses valued readily accessible “expert” interpretation of ECGs to aid their clinical decision making. The service, which involves the transmission of a 12 lead ECG using a simple hand-held machine to a call centre staffed by experienced medical and cardiac nursing staff, provided a rapid interpretation service which was available 24 hours a day. Whilst not being used exclusively for identification of atrial fibrillation, the pilot demonstrated that, in 28% of cases the anticipated clinical outcome changed on the basis of the ECG interpretation. In 17% of patients GPs were then sufficiently confident to retain patients within primary care rather than referring them to hospital based care, as they previously expected to do. Likewise in 4% of patients unsuspected arrhythmias were found resulting in unanticipated referral. GPs reported the benefit they felt of having access to an interpretation service, recognising that accurate interpretation of an ECG is a skill difficult to maintain when no longer working in an acute setting. The report produced for service commissioners is available via the Lancashire and South Cumbria Cardiac Network Website. www.lsccardiacnetwork.nhs.uk. Competing interests: None declared |
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Ralph Emmerson, General Practitioner Imperial Rd, Matlock. DE4 5FE
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Mant et al give us much to think about and the results as published are disappointing for general practitioners. There are a few points in our defence though: The authors are correct that we would not routinely analyse 100 electrocardiograms especially without clinical information. It would be interesting to know if the electrocardiograms were read in the normal working day, if so when and how much protected time was offered. General practitioners are a heterogeneous group and it may be more appropriate to compare us with hospital physicians than with cardiologists. It is possible that the general practitioners selected did not all have an interest in cardiology and selecting general practitioners more specifically may have yielded different results. Indeed the authors state that the sensitivities of individual doctors varied from 50% to 100%, so some were at least as good as the cardiologists. Finally the summary of statistics table states that "uncertain diagnoses were counted as missed diagnoses for sensitivity and as not atrial fibrillation for specificity". Dealing with uncertainity is an area general practitioners are particularly good at. They would not have normally filed an uncertain electrocardiogram in the medical records but would have discussed it with a colleague either in the surgery or at the local hospital to come to a diagnosis. This usual process was not followed and the results do not therefore reflect normal practice. An idea of the number of uncertain diagnoses would put this in proportion. Competing interests: None declared |
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Jonathan Mant, Reader University of Birmingham, B15 2TT
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Point taken that a GP would not normally file an ECG with an 'uncertain' diagnosis. However, as shown in tables 1-3 of the unabridged paper, this only applied to 4 out of 1,454 12 lead ECGs, 8 out of 1,484 limb lead ECGs and 5 out of 1,457 single lead thoracic placement ECGs. Therefore, this assumption did not make any difference to the summary results for GP interpretation. Competing interests: None declared |
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Ashish B Patel, Specialist Registrar Geriatrics and GP Leicester General Hospital LE1 5WW
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Working as an SpR in Geriatric Medicine as well as being a GP, i am not surprised at the results of this excellent study. I feel that GP's need more training in basic general medicine, not just cardiology. With the ageing population GP's are caring for more and more elderly patients. Perhaps, the QOF system has fallen short in its aims should be rewarding GP's for detecting and diagnosing disease rather than numbers. Competing interests: None declared |
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