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BMJ 2007;335:380 (25 August), doi:10.1136/bmj.39227.551713.AE (published 29 June 2007)
Jonathan Mant, reader1, David A Fitzmaurice, professor of primary care1, F D Richard Hobbs, professor and head of department1, Sue Jowett, research fellow2, Ellen T Murray, research fellow1, Roger Holder, head of statistics1, Michael Davies, consultant cardiologist3, Gregory Y H Lip, professor of cardiovascular medicine4
1 Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT, 2 Health Economics Facility, Health Services Management Centre, University of Birmingham, Birmingham B15 2RT, 3 Department of Cardiology, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, 4 University Department of Medicine, City Hospital, Birmingham B18 7QH
Correspondence to: D A Fitzmaurice d.a.fitzmaurice{at}bham.ac.uk
Design Prospective comparison with reference standard of assessment of electrocardiograms by two independent specialists.
Setting 49 general practices in central England.
Participants 2595 patients aged 65 or over screened for atrial fibrillation as part of the screening for atrial fibrillation in the elderly (SAFE) study; 49 general practitioners and 49 practice nurses.
Interventions All electrocardiograms were read with the Biolog interpretative software, and a random sample of 12 lead, limb lead, and single lead thoracic placement electrocardiograms were assessed by general practitioners and practice nurses independently of each other and of the Biolog assessment.
Main outcome measures Sensitivity, specificity, and positive and negative predictive values.
Results General practitioners detected 79 out of 99 cases of atrial fibrillation on a 12 lead electrocardiogram (sensitivity 80%, 95% confidence interval 71% to 87%) and misinterpreted 114 out of 1355 cases of sinus rhythm as atrial fibrillation (specificity 92%, 90% to 93%). Practice nurses detected a similar proportion of cases of atrial fibrillation (sensitivity 77%, 67% to 85%), but had a lower specificity (85%, 83% to 87%). The interpretative software was significantly more accurate, with a specificity of 99%, but missed 36 of 215 cases of atrial fibrillation (sensitivity 83%). Combining general practitioners' interpretation with the interpretative software led to a sensitivity of 92% and a specificity of 91%. Use of limb lead or single lead thoracic placement electrocardiograms resulted in some loss of specificity.
Conclusions Many primary care professionals cannot accurately detect atrial fibrillation on an electrocardiogram, and interpretative software is not sufficiently accurate to circumvent this problem, even when combined with interpretation by a general practitioner. Diagnosis of atrial fibrillation in the community needs to factor in the reading of electrocardiograms by appropriately trained people.
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