Guidelines on ECG Interpretation

How did the idea for this website come about? Tell us about Dr. Alan Lindsay and the reasons you dedicated this website to him. When I first came to Salt Lake City in 1973 to be a member of the University of Utah School of Medicine, one of my teaching interests was the teaching of electrocardiography to students and residents. Shortly after I arrived here I met Dr. Alan Lindsay, who was a private practicing cardiologist who just happened to share a similar passion for teaching electrocardiography. Alan was somewhat older than me and had been in practice for quite some time; he was also part of a network of ECG teachers around the world. In fact, one of Alan s hobbies was to collect really interesting ECGs and send them around to various expert electrocardiographers both in this country and abroad; they shared a wonderful system of exchanging letters and ECGs. Alan and I taught a lot of seminars together we actually traveled several times to hospitals in Montana to teach physicians about electrocardiography. We did this for probably 10-15 years, and then in the mid 1980s, Alan developed severe prostate cancer, which ultimately took his life in 1987. In the remaining months of his life I promised him that after he died I would do something with his amazing collection of ECGs I would continue the teaching of electrocardiography. He had drawers and drawers full of folders filled with ECGs of every topic you can imagine, and when he died, I acquired all of those ECGs. I still have them in my office as well as the letters that he shared with other physicians around the world. Well, in 1987 the Internet had barely been introduced, but computers and the PC were widely used, so I worked with the library at the medical school (they re the ones who host this website now) and imaged almost a thousand of these ECGs. We put them on a video disk, which was the size of a long-playing record in those days. I also bought some interactive computer programs to interact with a video disk, which allows for an interactive teaching mode to enable you to interact with the video disk and go through a series of lessons. We did this for a couple of years until the Internet really took off and the video disk became obsolete. At that time I convinced the library affiliated with the Utah School of Medicine to build a website for me. When was the website launched? I don t remember exactly when the website started, but I m guessing it was in the early to mid 1990s. Was it initially started as a way for only local students to use? Since it was the Internet, my dream was that people all over the world would have access to it, and that has turned out to be true. I receive approximately 20 emails each week from people around the world physicians, students, nurses, and even engineers interested in electrocardiography so I can see that it is really an internationally appreciated website. Over the years I ve put some effort into adding to the website and including some simple quizzes, etc. However, I really wanted to honor Dr. Lindsay, more than just a physician but also as a renaissance man; he played the violin and also introduced me to chamber music. Who is this website designed for (e.g., the beginner EP student, etc.)? It s as clearly designed for beginning students as for health officers such as residents, but there are also topics on the website that are more advanced. For example, physicians in practice have emailed me that they ve found the website useful as well. So the website is for a mixed population of students. How often is the information on this website updated? What are some of the topics covered on this website? The last update was added last summer when I wrote a 75-page booklet for students. For example, one of the sections on the website is an outline on electrocardiography; I updated this outline with a document that I usually hand out to students and residents who work with me. It s also used by the ECG technicians in the various hospitals that I work in. I am the Director of Electrocardiographic Services for Intermountain Healthcare, so this booklet and website are used by all our staff in the field. So the last update was the document that is downloadable from the opening page of the website. Unfortunately, time constraints have prevented me from working on this on a day-to-day basis. However, I have a lot more material to add, not only from Dr. Lindsay s collection, but from my own collection of ECGs as well. Possibly this coming summer I ll have more time to work on the website. What are some of the heart rhythms covered on the website? It is a pretty thorough review of all ECG topics. For example, in the outline I start with an approach about how one should read 12-lead ECGs. The first section has to do with outlining the five steps one has to go through in interpreting the ECGs. The rest of the outline focuses on possible abnormalities that can be encountered in each of these steps; it s an exhaustive review of atrial and ventricular arrhythmias, conduction abnormalities, recognition of myocardial infarction or heart attack, hypertrophy or enlargement of the chamber, and abnormalities basically everything you want to look for in an electrocardiogram. Why was it important to offer this educational website on ECG interpretation? I wanted to share Dr. Lindsay s passion for teaching electrocardiography. I find that today s physicians and students who are in training are becoming increasingly less competent in interpreting electrocardiograms. There are a couple reasons for that. First, there is now so much more to learn about cardiology, including all the imaging modalities and magnetic resonance imaging, etc., so the study of electrocardiography has taken a back seat. The other major reason is that the computer has sort of taken much of the fun out of interpreting ECGs, since most ECGs now come with an automatic computer interpretation on it. Therefore, students and doctors in general might tend to cop out and just look at the computer interpretation and not really at all of the things that make up the ECG. When faced with an ECG that doesn t have a computer interpretation, they re stuck, because ECG is not really emphasized in medical school or training programs anymore. Thus, the purpose of this website is to get something together that is accessible and fun to look at that takes advantage of some teaching strategy approaches that I find interesting. I ve also included on this website an image index of ECG abnormalities that students can look at that are more interesting and complex. You ve been in the field for quite some time now. Is there an unusual ECG or case study that you can tell us about? Sure, I ve encountered a lot of unusual cases. For example, there is an increasing number of interesting ECGs that represent genetic abnormalities of cell membranes in the heart. They are abnormalities in proteins that make up the membrane of a heart cell; these protein abnormalities that affect the movement of sodium and potassium in and out of the heart cell affect the shape and duration of the ST segment and t-wave of the ECG. Included in these abnormalities is Long QT syndrome. Sometimes these types of abnormalities can be induced in people who don t have them on their resting ECGs. For instance, one might have an idiosyncratic reaction to a particular medication such as a commonly used antibiotic. Medication can often bring out these abnormalities in people who don t have symptoms while they re not taking the medication. Therefore, these abnormalities are interesting in that they re precursors to arrhythmias that can cause sudden death. We can recognize on the ECG where the arrhythmia occurred. That being said, there was one particular case of an abnormality seen in a female who presented to the emergency room. This patient had accidentally overdosed on an antidepressant medication; the abnormality later found was Brugada syndrome, a kind of genetic abnormality. This patient was someone who had nothing else wrong with her heart, and yet the abnormality could have caused sudden death. There was no family history; it was a drug-induced abnormality. For more information, please visit: http://library.med.utah.edu/kw/ecg/intro.html