Accuracy of Computer Interpretation

Author(s)	J.S.S.G. de Jong, MD
Moderator	J.S.S.G. de Jong, MD
Supervisor
some notes about authorship

Modern ECG equipment often includes some form of algorithm that performs a computer interpretation of the electrocardiogram. It is useful to have some insight into the reliability and pitfalls of computer interpretation so as to be able to assess the value of these interpretations.

First of all, it is important to realize that the algorithm used often interprets the raw ECG-signal, i.e., the signal before it is filtered. This means that the ECG that is printed by the machine is not the ECG that is interpreted by the machine. Therefore one has to be very careful in making sure that the signal is 'clean' as possible by:

• cleaning the skin with e.g. alcohol before placing the electrodes
• shaving skin when necessary
• using contact spray or electrodes with contact gel
• carefully checking the electrodes position

Different manufacturers of ECG equipment have produced different algorithms for ECG interpretation. Not surprisingly, the accuracy of algorithms therefore differs. One study comparing nine computer algorithms with eight cardiologists found that overall the per cent of correct classifications of computer programs was 69.7% as compared to 76.3% for the cardiologists.[1] However, this study was performed in 1991 and algorithms have developed since. Some 'self learning' algorithms have been developed that improve themselves by learning from adjustments that cardiologists make to their diagnosis.

Much attention has been aimed at the diagnosis of acute cardiac ischemia. This can be challenging if subtle ST segment shifts are present, and ST segment shifts can also be present in healthy persons. A systematic review on the subject found a sensitivity of 76% (95% CI, 54% to 89%) and a specificity of 88% (95% CI, 67% to 96%) for the correct interpretation of acute cardiac ischemia by a computer algorithm. For acute myocardial infarction the sensitivity was 68% (95% CI, 59% to 76%) and the specificity 97% (95% CI, 89% to 92%).[2] One study investigating the Marquette 12SL system in the diagnosis of patients eligible for thrombolytic therapy found a sensitivity of 61.5% and specificity of 100%. The authors conclude that reliance on computer interpretation would result in inappropriate underuse of thromobolytic therapy.[3]

A recent scientific statement by a consortium of AHA/ACC and the HRS advises to be prudent when using computer interpretations. The official recommendation reads: "Computer-based interpretation of the ECG is an adjunct to the electrocardiographer, and all computer-based reports require physician overreading. Accurate individual templates should be formed in each lead before final feature extraction and measurement used for diagnostic interpretation." [4]

References

1. Willems JL, Abreu-Lima C, Arnaud P, van Bemmel JH, Brohet C, Degani R, Denis B, Gehring J, Graham I, and van Herpen G. The diagnostic performance of computer programs for the interpretation of electrocardiograms. N Engl J Med. 1991 Dec 19;325(25):1767-73. DOI:10.1056/NEJM199112193252503 |
2. Ioannidis JP, Salem D, Chew PW, and Lau J. Accuracy and clinical effect of out-of-hospital electrocardiography in the diagnosis of acute cardiac ischemia: a meta-analysis. Ann Emerg Med. 2001 May;37(5):461-70. DOI:10.1067/mem.2001.114904 |
3. Massel D, Dawdy JA, and Melendez LJ. Strict reliance on a computer algorithm or measurable ST segment criteria may lead to errors in thrombolytic therapy eligibility. Am Heart J. 2000 Aug;140(2):221-6. DOI:10.1067/mhj.2000.108240 |
4. Kligfield P, Gettes LS, Bailey JJ, Childers R, Deal BJ, Hancock EW, van Herpen G, Kors JA, Macfarlane P, Mirvis DM, Pahlm O, Rautaharju P, Wagner GS, American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology, American College of Cardiology Foundation, Heart Rhythm Society, Josephson M, Mason JW, Okin P, Surawicz B, and Wellens H. Recommendations for the standardization and interpretation of the electrocardiogram: part I: The electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation. 2007 Mar 13;115(10):1306-24. DOI:10.1161/CIRCULATIONAHA.106.180200 |
5. Kudenchuk PJ, Ho MT, Weaver WD, Litwin PE, Martin JS, Eisenberg MS, Hallstrom AP, Cobb LA, and Kennedy JW. Accuracy of computer-interpreted electrocardiography in selecting patients for thrombolytic therapy. MITI Project Investigators. J Am Coll Cardiol. 1991 Jun;17(7):1486-91. DOI:10.1016/0735-1097(91)90636-n |
6. Mason JW, Hancock EW, Gettes LS, American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology, American College of Cardiology Foundation, Heart Rhythm Society, Bailey JJ, Childers R, Deal BJ, Josephson M, Kligfield P, Kors JA, Macfarlane P, Pahlm O, Mirvis DM, Okin P, Rautaharju P, Surawicz B, van Herpen G, Wagner GS, and Wellens H. Recommendations for the standardization and interpretation of the electrocardiogram: part II: Electrocardiography diagnostic statement list: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation. 2007 Mar 13;115(10):1325-32. DOI:10.1161/CIRCULATIONAHA.106.180201 |