Accuracy of Interpretation of Preparticipation Screening Electrocardiograms

doi:10.1016/j.jpeds.2011.05.014

The Journal of Pediatrics

Volume 159, Issue 5, November 2011, Pages 783-788

https://doi.org/10.1016/j.jpeds.2011.05.014 Get rights and content

Objective

To evaluate the accuracy of pediatric cardiologists’ interpretations of electrocardiograms (ECGs).

Study design

A series of 18 ECGs that represented conditions causing pediatric sudden cardiac death or normal hearts were interpreted by 53 members of the Western Society of Pediatric Cardiology. Gold-standard diagnoses and recommendations were determined by 2 electrophysiologists (100% concordance).

Results

The average number of correct ECG interpretations per respondent was 12.4 ± 2.2 (69%, range 34%-98%). Respondents achieved a sensitivity of 68% and a specificity of 70% for recognition of any abnormality. The false-positive and false-negative rates were 30% and 32%, respectively. Based on actual ECG diagnosis, sports participation was accurately permitted in 74% of cases and accurately restricted in 81% of cases. Respondents gave correct sports guidance most commonly in cases of long QT syndrome and myocarditis (98% and 90%, respectively) and least commonly in cases of hypertrophic cardiomyopathy, Wolff-Parkinson-White syndrome, and pulmonary hypertension (80%, 64%, and 38%, respectively). Respondents ordered more follow-up tests than did experts.

Conclusions

Preparticipation screening ECGs are difficult to interpret. Mistakes in ECG interpretation could lead to high rates of inappropriate sports guidance. A consequence of diagnostic error is overuse of ancillary diagnostic tests.

Section snippets

Methods

This study was an online questionnaire-based study investigating the accuracy of pediatric cardiologists’ interpretations of ECGs. We selected 18 12-lead ECGs from the ECG database at Lucile Packard Children’s Hospital. The 18 ECGs included 8 from patients with normal hearts and 10 from patients with conditions that commonly underlie SCD (1 with long QT syndrome (LQTS); 4 with hypertrophic cardiomyopathy (HCM); 2 with Wolff-Parkinson-White syndrome (WPWs); 1 with pulmonary arterial hypertension

Results

We emailed the survey link to 212 pediatric cardiologists. Although 97 respondents began the survey, only 53 finished it. Incomplete surveys were excluded. The rate of participation was 25%. The participants included 53 pediatric cardiologists, most of whom had been practicing for 5 to 15 years (43%) in university-based (47%) practices where 43% read more than 100 ECGs per month (Table).

The mean score for correct ECG interpretation was 12.4 (69%) ± 2.2 of the total possible 18 (range, 7-17),

Discussion

ECGs demonstrating diseases that underlie SCD are difficult to interpret, even for pediatric cardiologists; their accuracy rate in this study was 69%. We found that the accuracy rate did not differ significantly in respondents, despite variations in length of time practicing pediatric cardiology, number of ECGs read per month, or practice type. These findings are in agreement with other studies showing that the accuracy of ECG interpretation ranges from 53% to 96%.12, 13, 14, 15, 16, 17 Others

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Of the 121 actively working individuals in the department, 96 (97.3 %) finished the questionnaire, and 85 (77.3 %) were valid for final evaluation. The participants' mean age was 30.4 ± 6.92 years, 76.5 % juniors and 23.5 % seniors. 83.5 % of the participants perceived their current ECG evaluation knowledge as none or limited. For participants' ability to evaluate an ECG, higher scores were achieved when determining if the ECG was normal or abnormal, with a mean score percentage of 79.32 % ± 23.27. However, the scores were lower when trying to reach the diagnosis, with a mean score percentage of 43.02 % ± 27.48. There was a significant negative correlation between the participant's age and answering the normality question correctly (r = −0.277, p = 0.01); and a significant positive correlation between answering the diagnosis question correctly and the desired level of knowledge and the intention to attend a workshop about ECG evaluation, r = 0.355 (p = 0.001), and r = 0.223 (p = 0.04), respectively. Only 56.5 % of the participants desired to get more knowledge, and 81.2 % were interested in attending ECG evaluation workshops.
Orthopaedic surgeons showed sufficient knowledge when determining the normality of ECG trace papers; however, they could not reach the proper diagnosis, and Junior surgeons performed slightly better than their senior peers. Most surgeons are willing to attend ECG evaluation and interpretation workshops to improve their knowledge level.
The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions
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To assess the impact of participation in an educational presentation on electrocardiogram (ECG) interpretation in children on pediatric practitioners' ability to accurately interpret ECGs.
Pediatric healthcare providers at a pediatric clinic with >65 000 visits/year were eligible to participate. A 1-hour ECG educational module that provided a systematic approach to ECG interpretation was presented to 8 providers who consented (6 pediatricians, 2 pediatric nurse practitioners). A test on 11 ECGs (normal, normal-variant, and abnormal ECGs) was given before and 2 weeks after the educational module. Outcomes included correct interpretation of each ECG as normal or abnormal and correct identification of specific ECG findings. Data analysis was descriptive and included χ² and Student t test.
Mean score (SD) for correct interpretation of ECGs as normal or abnormal improved from 35% (48%) (95% CI 25.0-45.4) to 77% (42%) (95% CI 68.3-86.2) after the ECG educational module (P < .001). Mean (SD) pretest score for correct identification in the normal ECG category improved from 45% (50%) (95% CI 28.9-61.1) to 68% (47%) (95% CI 52.3-82.7) (P = .003). In the abnormal ECG category, correct identification improved from 31% (47%) (95% CI 17.6-44.9) to 83% (5%) (95% CI 72.4-94.3) after the module (P < .001).
Education of pediatric practitioners on ECG interpretation significantly improves their ability to distinguish normal from abnormal and to identify specific abnormalities. Limitations included small sample size and short-term follow-up.

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: A.D. receives fellowship support from Medtronic. The other authors declare no conflicts of interest.

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Original ArticleAccuracy of Interpretation of Preparticipation Screening Electrocardiograms

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Am Heart J

J Am Coll Cardiol

Lancet

Ann Emerg Med

Am Heart J

Am J Cardiol

Acta Psychol (Amst)

Am J Cardiol

J Am Coll Cardiol

J Electrocardiol

Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006

Circulation

Sudden death in young competitive athletes: clinical, demographic, and pathological profiles

JAMA

Nontraumatic sports death in high school and college athletes

Med Sci Sports Exerc

Sudden death in young athletes

N Engl J Med

An electrocardiogram should not be included in routine preparticipation screening of young athletes

Circulation

Original Article
Accuracy of Interpretation of Preparticipation Screening Electrocardiograms