Electrocardiography was introduced by Willem Einthoven with the first published electrocardiogram (ECG) in 1902.1 It is the most commonly used test for the diagnosis of heart disease2, contributing significantly to the diagnosis and management of cardiac arrhythmias and acute myocardial ischemic syndromes, which account for the majority of cardiac catastrophes.3 An ECG is safe, easy to administer, and available at a minimal cost.2
Electrocardiograms are interpreted not only by cardiologists, but also by other specialists, including family physicians. Although computerized interpretation of ECG data is widely available and is improving, it is not reliable enough to obviate the need for physician over-reading and confirmation.4,5,6 Therefore, family physicians must maintain competence in ECG interpretation.
According to the October 2016 AAFP Member Profile, 89% of active American Academy of Family Physicians (AAFP) members perform ECGs in the office7, and it is well established that ECG interpretation is within the scope of family medicine. The diagnosis and management of cardiovascular disorders is routinely taught in family medicine residency programs. The AAFP’s recommended cardiovascular medicine curriculum guidelines for family medicine residents state: “Core cognitive ability and skill may be obtained through longitudinal or block rotations, or cardiology experiences in intensive care and cardiac care units. Residents will obtain substantial additional cardiology experience throughout the three years of experience in the family medicine practice, on their family medicine inpatient service, and through internal medicine experiences. During this time, it would be a reasonable goal to accomplish proficiency in ECG interpretation and [cardiopulmonary resuscitation (CPR)].” 8
Electrocardiography is indicated for patients who present with chest pain, palpitations, dizziness, or syncope, and for those who have symptoms that may indicate risk of sudden death or myocardial infarction.2,9
In 2001, the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine (ACC/AHA/ACP-ASIM) Task Force on Clinical Competence released a statement on electrocardiography and ambulatory electrocardiography. This statement (which had not been updated as of September 2017) notes the wide variety of indications for ECG: “There are numerous potential clinical uses of the 12-lead ECG. The ECG may reflect changes associated with primary or secondary myocardial processes (e.g., those associated with coronary artery disease, hypertension, cardiomyopathy, or infiltrative disorders), metabolic and electrolyte abnormalities, and therapeutic or toxic effects of drugs or devices. Electrocardiography serves as the gold standard for the noninvasive diagnosis of arrhythmias and conduction disturbances, and it occasionally is the only marker for the presence of heart disease.”2
Electrocardiography is not indicated for screening of healthy subjects who do not have symptoms of heart disease, hypertension, or other risk factors for the development of heart disease. The U.S. Preventive Services Task Force (USPSTF) states that for asymptomatic adults at low risk for coronary heart disease (CHD) events, the incremental information offered by an ECG is “highly unlikely to result in changes in risk stratification that would prompt interventions and ultimately reduce CHD-related events.”10 Under the Choosing Wisely campaign—a national effort to reduce waste in the health care system and avoid unnecessary or harmful tests and treatment—the AAFP recommends that physicians should not order annual ECGs or any other cardiac screening for low-risk patients who do not have symptoms.11 This recommendation is based on evidence that shows false-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment, and misdiagnosis, so potential harms of routine annual ECG screening exceed the potential benefit.
Training for ECG interpretation begins in medical school and is continued in the family medicine residency program curriculum. The Accreditation Council for Graduate Medical Education (ACGME) requires that family medicine residency training include specific subspecialty training to ensure competence in the care of the cardiology patient in family medicine, which would include training in the interpretation of ECGs.12 AAFP policy states that procedural skills training in the family medicine residency should comprise a number of components, including knowledge of clinical indications and contraindications, and performance under supervision.13 Specific to training for ECG interpretation, the ACC/AHA/ACP-ASIM Task Force on Clinical Competence states that physicians should gain basic knowledge of electrocardiographic technology, cardiac anatomy, and cardiac physiology, and learn how to recognize diagnostic patterns on a 12-lead tracing.2 The number of studies needed to obtain competence in ECG interpretation has not been established.2,3
The depth of ECG experience a family medicine resident requires will depend on his or her expected practice needs, especially in terms of practice location, available facilities, and accessibility of consultants.8 Physicians who wish to undergo more extensive training may find a preceptor by contacting local hospitals to identify medical staff members who have expertise in ECG interpretation. Other resources for finding a preceptor include local family medicine residency programs, AAFP chapters, and medical societies.
Testing a physician’s knowledge of indications for ECG and ECG interpretation is a part of the general testing for certification by the American Board of Family Medicine (ABFM).14 Primary certification and recertification examinations include questions on topics such as arrhythmia interpretation, diagnosis of ischemia/myocardial infarction, and structural issues (e.g., accessory pathways). The number of questions about ECG interpretation varies from examination to examination.
Maintaining competence in ECG interpretation requires ongoing practice.2 However, the amount of continuing experience in ECG interpretation needed to maintain proficiency has not been extensively studied. Proficiency in ECG interpretation may be determined by monitoring a physician’s interpretations or administering a test. It is the AAFP’s position that if local tests are utilized to establish current competence, the use of such tests should apply equally to all physicians, regardless of specialty.15
The AAFP recommends that family physicians document all significant training and experience so that it is recorded and can be reported in an organized fashion.16
The process for credentialing and delineation of family medicine privileges varies among organizations. It is the position of the AAFP that clinical privileges should be based on the individual physician’s documented training and/or experience, demonstrated abilities, and current competence.17 AAFP policy states, “On the basis of their training in family medicine, family physicians should have the education, training, and experience to read electrocardiograms and should therefore be eligible for privileges to interpret [ECGs].”18
The AAFP’s stance is in line with the policies of other organizations with influence in the area of credentialing and privileging:
The AAFP supports the establishment of a family medicine department in every hospital departmentalized by specialty. 21 The department of family medicine should have the right to recommend directly to the appropriate committee all privileges that fall within the scope of family medicine, including ECG interpretation. Neither the assent nor the approval of any other department should be required.
Because privileges for family physicians often overlap those in other clinical departments, there may be some confusion about which department is responsible for recommending privileges. For example, a family physician may request “cardiology” privileges in the department of family medicine that would overlap those of the department of cardiology. The family medicine department should determine the criteria for and recommend privileges commensurate with the core curriculum and training offered in a family medicine residency program.21
Resources on hospital privileging, including information about avoiding privileging disputes and answers to frequently asked questions about hospital credentialing and privileging, are available from the AAFP.
The AAFP recommends that payment for the interpretation of ECGs be available for all eligible physicians who have competence in ECG interpretation, regardless of the physician's specialty.
B. Quality assurance
Family medicine departments should have an ongoing peer review process in place that monitors patient outcomes to ensure that family physicians maintain their competence in ECG interpretation.
C. Public health implications
Family physicians are the first—and sometimes the only—point of contact for many patients within the health care system. Expanding and improving family physicians' skills in ECG interpretation could improve access to cardiovascular care for patient populations in need.
D. Research agenda
The research agenda for ECG interpretation should focus on the following:
E. Relationships with other organizations
The AAFP, the ACC, and the ACP should cooperate to develop quality improvement programs for ECG interpretation.
(March Board 2001) (2018 COD)