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BMJ 2012; 344 doi: (Published 18 April 2012) Cite this as: BMJ 2012;344:e2750

Should ECG be used to detect heart disease in asymptomatic older adults?


In older people without overt heart disease resting electrocardiographic (ECG) abnormalities help predict future coronary events beyond traditional risk factors, such as age, sex, smoking, cholesterol, hypertension, and diabetes. This was found in a population based study of 2192 older adults from the US. At baseline, all participants were in their 70s and free of heart disease, but 276 (13%) had minor and 506 (23%) had major ECG abnormalities. In tune with the Minnesota code, minor ST-T changes were considered minor abnormalities, whereas major abnormalities were defined as Q-QS wave abnormalities, left ventricular hypertrophy, Wolff-Parkinson-White syndrome, complete bundle branch block or intraventricular block, atrial fibrillation or atrial flutter, or major ST-T changes.

Over eight years of follow-up, 351 people experienced acute myocardial infarction, death from coronary heart disease, or admission to hospital for angina or coronary revascularisation. The incidence of these outcomes was 17.2 per 1000 person years in those without ECG abnormalities at baseline, compared with 29.3 per 1000 person years and 31.6 per 1000 person years in those with minor and major abnormalities, respectively.

Beyond traditional risk factors, ECG abnormalities helped correctly reclassify 13.6% of people at intermediate risk, mainly by moving them to a lower risk category, for an overall net reclassification improvement of 7.4% (95% CI 3.1% to 19%). This is as many or more people than biomarkers such as C reactive protein or interleukin 6, but fewer than the recently developed coronary artery calcification score measured with computed tomography. In a recent study, this calcification score correctly reclassified a quarter of all participants, and more than half of those at intermediate risk.

The authors call for a trial to assess whether ECG should be done routinely in older adults. A linked editorial (p1530) points out that …

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