Role of the surface electrocardiogram in developing countries

The surface electrocardiogram (ECG) is a basic cardiac investigation delivering information not only regarding heart rhythm but also regarding ischemic disease, effects of hypertension, congenital syndromes, and cardiomyopathies. These may determine decisions regarding follow-up investigations or treatment. The ECG fulfils several characteristics of a good screening test: it is rapid, is noninvasive, requires minimal technical expertise to perform, and is inexpensive. However, its interpretation requires highly trained physicians. In industrialized nations, the test is performed routinely in outpatient clinics and hospitals frequently in conjunction with further cardiac imaging. Developing nations confront a different situation. Urbanized segments may access ECG testing similarly to industrialized countries. However, in a country such as India, 80% of population is rural and poor. Less than 30% of physicians are rurally located, and most are primary care physicians. Access to medical care is limited by sparse and underresourced medical facilities and personnel, poorer socioeconomic status, ignorance of disease, and lack of motivation to seek health care. The ECG may be the only affordable cardiac test for this population, but poor communications (transport, telephone) hamper access. Initiatives to overcome these obstacles are being undertaken in some model situations. For example in Bangalore, India, use of mobile vans equipped with satellite terminals (aided by the Indian Space Research Organization) permits transmission of ECGs from rural points to central urban hospitals for physician interpretation. The physician community has responsibilities of improving the diagnostic yield from the ECG. Rural communities have a different spectrum of diseases with lesser coronary artery disease and greater incidence of valvular disease. The ECG has different roles in these diseases. (In contrast, urban communities in the same country experience diseases of industrialized nations.) Electrocardiogram interpretation also needs to account for different "normal" values in different ethnic groups: there is a surprising dearth of such data in groups other than African Americans. This is essential for interpretation of abnormality. Development of additional sophisticated analyses from ECG data may guide more selective use of expensive and invasive therapies. For example, risk stratification for defibrillator implant may be enhanced by use of T-wave alternans and heart rate variability. In China, ischemia monitoring with 12-lead Holters is performed due to lack of availability of a chest pain clinic. Innovative measures in electrocardiography are required for improving health care delivery in developing nations.