14 February 2012
In the UK, the exercise electrocardiogram (ECG) is the most common initial test for the evaluation of stable chest pain and has been used widely for almost half a century. However, recent NICE guidelines recommend that it should not be used to diagnose or exclude stable angina in patient assessments. New research published in the BMJ Open finds that the test has other uses that transcend its technical contribution to diagnosis.
The study, led by Professor Gene Feder from the University of Bristol, evaluated the role of exercise ECGs in 89 consultations between clinicians and patients across three chest pain clinics.
The researchers report that the functions of the exercise ECG go beyond its diagnostic function and can help clarify symptoms and other aspects of the clinical history by engaging the patient in the diagnostic process while providing a context for guidance on reversible cardiovascular risk factors. For example, the act of walking on the treadmill created an additional opportunity for dialogue between clinician and patient and engagement of the patient in the diagnostic process through precipitation and further elaboration of symptoms.
In addition, the exercise ECG facilitated reassurance in relation to exercise capacity and tolerance, providing a platform for behavioural and lifestyle advice particularly when exercise was promoted by the clinician.
In patients with new onset stable chest pain, the exercise ECG has a role in articulating the clinical history through stimulating symptoms such as chest pain and breathlessness, and prompting additional narrative details about their symptoms. The study suggests that through physical engagement the exercise ECG can facilitate communication between patient and clinician which, even if not improving diagnostic accuracy, does enhance subsequent reassurance.
Dr Helen Cramer, the lead author, from the University’s School of Social and Community Medicine, said: ”As chest pain clinic services are re-configured without the test, in line with UK national (NICE) guidance, the exercise ECG will have a diminishing role in the diagnosis of angina. However, many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients and need to be considered in the re-design of chest pain assessment services without that test. In particular, the supervised exercising of patients, even if this does not explicitly inform diagnostic decision or prognostic judgements, should form part of the assessment process.”
The National Institute for Health Research (NIHR)-funded study, entitled ‘Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise electrocardiograms in evaluating stable chest pain’ is published in the BMJ Open.