The RCPsych Article of the Month for December is ‘What training should psychiatrists have to interpret six- and 12-lead electrocardiograms?‘. The blog is written by author George Crowther and published in BJPsych Bulletin.

Electrocardiogram (ECG) interpretation is not classically the psychiatrists’ natural habitat; yet, psychiatrists are required to obtain and interpret ECGs in certain clinical scenarios. For example, taking a person’s ECG when they are admitted to a psychiatric inpatient ward, in memory clinics or prior to starting high dose or intramuscular antipsychotics. Traditionally, this has been done using 12 lead (12L) traces. Although the procedure is painless, it can cause embarrassment (owing to exposure) and feel frightening to the uninformed. Further, many psychiatric settings are not equipped to perform the test. Novel 6 lead (6L) handheld ECG recorders are rapidly gaining popularity among clinicians and the public. They are portable, simple to use, and do not require the patient to expose themselves. In September 2023 the National Institute for Health and Care Excellence (NICE) published guidance on their use for measuring QTc interval in adults receiving antipsychotic medication, and they may become a common sight in the future. However, a 6L or 12L device is only beneficial if the results are interpreted and applied accurately by the user.

We conducted an online survey and ECG interpretation test with 183 psychiatric prescribers. They were asked about their confidence interpreting ECGs and how regularly their training was updated. Participants were then shown ten ECGs in sequence. They had 1 minute to analyse the ECG and answer questions about whether the trace was normal or abnormal, what abnormalities, if any, the trace showed, and whether they would prescribe antipsychotic or acetylcholinesterase inhibitor medication to a patient with that trace. Participants were shown five common rhythms: normal sinus rhythm (good quality trace), normal sinus rhythm (poor quality trace), atrial fibrillation, QT prolongation and complete heart block. For each rhythm, they were shown a 12L trace and a 6L trace.

The results showed that participants’ confidence in ECG interpretation was generally low, and the majority (75%) did not regularly attend ECG interpretation training updates. Although most were able to identify normal ECG traces (63% in 12L and 81% 6L), the majority were not able to diagnose an abnormal trace. The impact of interpretation on prescribing practice was striking, with antipsychotics and acetylcholinesterase inhibitors being both withheld overcautiously and prescribed in cases of potentially life-threatening arrhythmias. There was relative agreement between the 6L and 12L traces suggesting that the interpretation errors were at the level of the interpreter, not the type of machine used.

These findings suggest that whatever ECG recorder is used, if prescribers are unable to confidently interpret the traces because of lack of training, the patient may either be denied treatment unnecessarily or end up suffering harm. We recommend that psychiatrists are required to update their ECG reporting skills as part of revalidation.

This paper caught my interest as a clinician who often prescribes, amongst other things, antipsychotics and stimulant medication. I therefore often find myself requesting new ECGs, or hunting down those most recently completed, to assist with prescribing decisions. In their online survey, the authors found that 75% of prescribers do not have updated ECG interpretation skills, only 22% are confident interpreting ECGs, and most were unable to identify serious arrhythmias. Clearly, this may have important clinical implications, including prescribing when caution is required, or withholding medication in the face of an over-cautious approach. Given the variations in ECG skills that their survey has helped uncover, their call for a renewed focus on training as part of revalidation is well made, and I think their views deserve to be highlighted further here in this RCPsych article of the month blog. 

Andrew Forrester
Editor-in-Chief, BJPsych Bulletin