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Published on: February 26, 2013
Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians
Jorge Mario Davidenko1, Lisa Simonettta Snyder
1Department of Cardiology, St Joseph Hospital Health Center, Syracuse, NY, USA. davidenj@yahoo.com
Insights
Physician electrocardiogram (ECG) diagnosis of atrial fibrillation (AF) has notable error rates. Improving quality control for ECG interpretation can reduce misdiagnoses of this common arrhythmia.
Area of Science:
- Cardiology
- Medical Diagnostics
- Electrocardiography
Background:
- Atrial fibrillation (AF) research often focuses on treatment and prevention, with less attention to diagnostic accuracy.
- Physician accuracy in electrocardiogram (ECG) diagnosis of AF and sources of error remain understudied.
Purpose of the Study:
- To evaluate the accuracy of ECG diagnoses of atrial fibrillation (AF).
- To identify common causes of diagnostic errors in AF interpretation from ECGs.
Main Methods:
- A 10-month retrospective review of 35,508 ECGs from 28,356 patients.
- Cardiologist consensus served as the gold standard for final AF diagnosis.
- Analysis of incorrect AF diagnoses, categorizing them into Type I (overdiagnosis) and Type II (missed AF) errors.
Main Results:
- Incorrect AF diagnoses occurred in 219 out of 2809 studied cases (7.8%).
- Type I errors (137 cases) were associated with irregular rhythms and baseline artifact.
- Type II errors (82 cases) were linked to missed AF or confusion with other arrhythmias, with ventricular pacing increasing error likelihood.
Conclusions:
- Approximately 5 out of 900 weekly ECGs at the institution had incorrect AF interpretations.
- Targeting common error sources through quality improvement programs can decrease AF misdiagnosis rates.
- Reducing diagnostic errors in ECGs is crucial for preventing adverse patient outcomes.
Background:
The emphasis of most large studies has been placed on the treatment and prevention of atrial fibrillation (AF) and its complications. Little is known about the accuracy of physicians in the electrocardiographic (ECG) diagnosis of AF and the possible causes of the diagnostic errors.
Methods:
Over a period of 10 months, a total of 35508 ECGs (28356 patients) were overread in a 385-bed community hospital within 24 hours of the initial reading. Corrected ECGs were returned to the patient file. The gold standard for the final diagnosis was based on the consensus by the cardiologist readers.
Results:
In all, 35508 ECGs were reviewed. A total of 2809 cases of AF were studied. Incorrect diagnoses related to AF were found in 219 cases. Type I errors (overdiagnosis) occurred in 137 cases. Rhythms with irregular R-R intervals (sinus rhythm with premature atrial contractions and atrial tachycardia or flutter with variable atrioventricular conduction) were misdiagnosed as AF. The presence of low-amplitude atrial activity and/or baseline artifact significantly increased the likelihood of the erroneous diagnosis, whereas ventricular rates of 130 beats/min did not influence the rate of error. Type II errors (missed AF) occurred in 82 cases where AF was either missed or confused with atrial tachycardia/flutter. Finally, ventricular pacing significantly increased the likelihood of type II errors.
Conclusions:
In our institution, about 900 ECGs are read each week and 5 of them carry a wrong interpretation related to AF. More attention to common sources of errors as reinforced by an ongoing quality improvement program may reduce the rate of mistakes and thus prevent serious consequences.
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