Common ECG Issues Faced in Primary Care

Cardiology for the Non-Cardiologist 2018

Common ECG Issues Faced in Primary Care

Tim Prieur


Faculty Presenter Disclosure

Cardiology for the Non-Cardiologist

Faculty: Tim Prieur

No Relationships with Financial Sponsors


Disclosure of Financial Support

Cardiology for the Non-Cardiologist has received financial support from the following Pharmaceutical companies; Bayer, Bristol-Meyers Squibb/Pfizer, Servier, Novartis, Amgen, AstraZeneca and Merck in the form of unrestricted educational grants.

Potential Conflicts of Interest: none


Mitigating Potential Bias

• While we have received unrestricted educational grants from several pharmaceutical companies, most presentations have no mention of specific products and are unrelated to the supporting companies or their products. No specific presentations will be supported or sponsored by a specific company.

• Information on specific products will be presented in the context of an unbiased overview of all products related to treating patients.

• All scientific research related to, reported or used in this CME activity in support or justification of patient care recommendations conforms to the generally accepted standards.

• Clinical medicine is based in evidence that is accepted within the profession.


Objective

• To review ECGs which are commonly encountered in daily clinical practice

• Briefly discuss an approach to their management

• Focus on issues of: rhythm, conduction, markers of associated structural abnormality


National Focus to reduced the use of investigations where not clinically indicated

“Choose Wisely”

No national or international practice guidelines on the use of the ECG in clinical practice.


National focus to reduce the use of investigations where not clinically indicated

• Remember the dictum: “Never order an investigation that you are not sure on how you will use the results”… if you have a low clinical suspicion of an abnormality being present, do you need the investigation?

• The ECG will have the best discriminating value when a medium pre test probability of an abnormality being present exists.


What is the real “cost” an of ECG?

• Primary

• Secondary:➢Further investigations

➢Consultation

➢Secondary impact on the patient: employment, insurance, personal worry.


Examples and scenario's


Healthy 40 year old woman

Sinus rhythm, right atrial abnormality, Borderline ECG


Resulting Investigations

• Chest X ray

• Echocardiogram

• Telephone consult


Resulting Investigations

• Chest X ray $34.11

• Echocardiogram $250.31

• Telephone consult $85.63

TOTAL $447.40


• 50 year old male, low risk factor profile for cardiac health issues

• “Why have I never had one of those heart tracings”

• Would you do one at this point?


1. I would do an ECG.

2. I would not do an ECG, and explain why.


His ECG


What if he was a: actively smoking, diabetic, borderline hypertensive, with exertional

“breathlessness” and no previous cardiac symptoms, abnormal physical findings or

documented “cardiac events”?


1. I would do an ECG.

2. I would not do an ECG.


His ECG


Poor Discriminatory Value

- Early symptom/ECG positive study for inducible ischemia.

- Multi vessel CAD, including tight right coronary lesion.


One ECG, two scenarios, entirely different meaning


Same ECG in a:

- 20 year old female

- 60 year old male


Scenario's where a precordial ECG may have a discriminatory value.


78 year old, with “fatigue”

• What is the rhythm?

• Are there any other abnormal findings?

• ? Clinical approach


Would you:

1. Reassure the patient

2. Arrange cardiology consultation

3. Arrange your own investigations


If option 3

1. Echocardiogram

2. Holter monitor

3. Stress test or stress MPI

4. All three


What about this 78 year old?


• Is the clinical importance of the conduction findings any different?


Our last gentleman returns with fatigue for two weeks


• What are the clinical issues to be dealt with?


Clinical Issues in Atrial Fibrillation

• Is there associated structural heart disease?

• Rate vs. rhythm control with atrial arrhythmias.

• How do we calculate Anticoagulation/bleeding risk.

• Can J Cardiol 2012;28:125


Is this the same Rhythm?

• Are the management decisions similar/different from the previous patient


Another example


50 year old, chronic breathlessness

• What are the abnormal findings?

• Do they have any “localizing” features?


23 year old, “asymptomatic”, part of work application


• Are there any associated abnormal findings?


35 year old asymptomatic class 1 drivers physical

Is this ECG abnormal and if so, can he qualify at a class 1 level?


Remember CCS fitness to Drive App, found on the CCS website


75 year old male, recurrent pre syncope

• What is the abnormality?

• Does it have any predictive value?


Typical episode captured


80 year old, intermittent atrial flutter, now recurrent near syncope and syncope


80 year old, atrial flutter, hard to know what rate control agent in place

• What are the possible mechanisms of syncope?


Possible mechanisms

• Transient marked AV block when either in sinus rhythm, an abnormal atrial rhythm

• Sinus node dysfunction- primary when in sinus, or on termination of atrial arrhythmia.

• A previously unrecognized arrhythmia.




A second similar mechanism


50 year old, asymptomatic

• “Possible previous antero septal Myocardial Infarction”

• !?#*, now what?

• Are the findings “diagnostic?”


What about this one? Can this be explained by lead placement?


Another example the computer might give the same diagnosis of previous anterior MI.


55 year old, asymptomatic

• Is there evidence of previous infarction? Now what.


This one is diagnostic


24 hour holter, 50 year old, “palpitations”

• Now what?


Ask and stratify “ what is the likelihood of associated structural heart health issues?

• Is there otherwise a clinical suspicion of a significant cardiac heal issue?

• Additional screening investigations

- Echocardiogram

- Screen for ischemic heart disease.


In summary

• Is an ECG clinically indicated? If not, why should I order one.

• What is the pre test likelihood of a disorder causing an abnormality being present?

• Do I have a game plan in place if an abnormality is identified?

Common ECG Issues Faced in Primary Care

Documents