[Skip to Content]
[Skip to Content Landing]
Views 1,357
Citations 0
Original Investigation
Less Is More
July 10, 2017

Electrocardiograms in Low-Risk Patients Undergoing An Annual Health Examination

Author Affiliations
  • 1Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
  • 2Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
  • 3Institute for Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
  • 4Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  • 5University of Ottawa Medical School, Ottawa, Ontario, Canada
  • 6Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 7Schulich Heart Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
  • 8Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 9Sunnybrook Research Institute (SRI), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
  • 10Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
  • 11Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
  • 12Keenan Research Centre for Biomedical Science, St Michael’s Hospital, Toronto, Ontario, Canada
  • 13Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  • 14Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  • 15Department of Family and Community Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
  • 16Department of Medicine, University of Toronto, Toronto, Ontario, Canada
JAMA Intern Med. Published online July 10, 2017. doi:10.1001/jamainternmed.2017.2649
Key Points

Question  How frequently are electrocardiograms (ECG) ordered as part of an annual health examination (AHE) and what is the impact of an ECG on downstream cardiac testing?

Findings  In this population-based cohort study of 3 629 859 adult patients who had an AHE, 21.5% had an ECG within 30 days of an AHE. Those who had an ECG were 5 times more likely to have another cardiac test or consultation than those who did not.

Meaning  Electrocardiograms conducted on patients as part of an AHE are common and are associated with more cardiac tests and consultations.

Abstract

Importance  Clinical guidelines advise against routine electrocardiograms (ECG) in low-risk, asymptomatic patients, but the frequency and impact of such ECGs are unknown.

Objective  To assess the frequency of ECGs following an annual health examination (AHE) with a primary care physician among patients with no known cardiac conditions or risk factors, to explore factors predictive of receiving an ECG in this clinical scenario, and to compare downstream cardiac testing and clinical outcomes in low-risk patients who did and did not receive an ECG after their AHE.

Design, Setting, and Participants  A population-based retrospective cohort study using administrative health care databases from Ontario, Canada, between 2010/2011 and 2014/2015 to identify low-risk primary care patients and to assess the subsequent outcomes of interest in this time frame. All patients 18 years or older who had no prior cardiac medical history or risk factors who received an AHE.

Exposures  Receipt of an ECG within 30 days of an AHE.

Main Outcomes and Measures  Primary outcome was receipt of downstream cardiac testing or consultation with a cardiologist. Secondary outcomes were death, hospitalization, and revascularization at 12 months.

Results  A total of 3 629 859 adult patients had at least 1 AHE between fiscal years 2010/2011 and 2014/2015. Of these patients, 21.5% had an ECG within 30 days after an AHE. The proportion of patients receiving an ECG after an AHE varied from 1.8% to 76.1% among 679 primary care practices (coefficient of quartile dispersion [CQD], 0.50) and from 1.1% to 94.9% among 8036 primary care physicians (CQD, 0.54). Patients who had an ECG were significantly more likely to receive additional cardiac tests, visits, or procedures than those who did not (odds ratio [OR], 5.14; 95% CI, 5.07-5.21; P < .001). The rates of death (0.19% vs 0.16%), cardiac-related hospitalizations (0.46% vs 0.12%), and coronary revascularizations (0.20% vs 0.04%) were low in both the ECG and non-ECG cohorts.

Conclusions and Relevance  Despite recommendations to the contrary, ECG testing after an AHE is relatively common, with significant variation among primary care physicians. Routine ECG testing seems to increase risk for a subsequent cardiology testing and consultation cascade, even though the overall cardiac event rate in both groups was very low.

×