SCHEDULE 34: PROTOCOL ON ELECTROCARDIOGRAMS ( ECG ) 1. Applicability This Protocol is applicable to Class 1, 2, and Class 3 applicants. 2. Resting ECG Resting ECG shall be perfmed at the following intervals: (1) Class 1 (a) at initial medical examination; (b) every 2 years between the age of thirty (30) and fifty (50); (c) annually after the age of fifty (50). (2) Class 2 (a) at initial medical examination; (b) first exam after the age of 40 (c) every 2 years after the age of fifty (50). (3) Class 3 (a) at initial medical examination; (b) every 2 years after the age of fifty (50). 3. Procedure f Resting ECG (1) A resting ECG shall be recded with the subject at rest in a warm environment. (2) The skin should be prepared with spirit abrasive, both. (3) Resting ECG is perfmed using a 12-lead standard ECG machine and chest leads should be placed accurately. (4) Leads V1 and V2 should be placed in the fourth inter-costal spaces on either side of the sternum. (5) Lead V4 is placed at the position of the apex of the nmal heart the fifth inter-costal space in the mid-clavicular line. (6) Lead V3 is placed midway between V2 and V4. Leads V5 and V6 are placed at the same level as V4 in the anteri and mid-axillary lines, respectively. 1
(7) The limb leads are placed on the right and left arms, and the right and left legs respectively. 4. Interpretation (1) All ECGs are to be interpreted by a DAME trained in ECG reading who would refer to a cardiologist specialist physician when in doubt. 5. Stress ECG 5.1 Indications f stress ECG (1) Stress ECG shall be perfmed in the following circumstances: (a) (b) (c) (d) Any abnmal resting ECG; The following indications should be considered in determining the necessity of a stress ECG: Hypertension, Smoking, Dyslipidaemia, Diabetes Mellitus, Raised BMI, waist circumference/abdominal obesity, family histy of early onset of cardiovascular disease. In accdance with the cardiovascular assessment algithm: f all applicants classified as Moderate, High Very High in accdance with the algithm; Provided that: (i) Stress ECG f moderate applicants may be perfmed by a DAME (ii) Stress ECG f High Very High applicants shall only be perfmed by a cardiologist a specialist physician. 6. Cardiovascular assessment (1) Cardiovascular assessment shall be done based on the South African Hypertension Guidelines. Cardiovascular assessment shall be done in accdance with the tables below. TABLE 1 MAJOR RISK FACTORS, TARGET ORGAN DAMAGE, AND ASSOCIATED CLINICAL CONDITIONS 2
MAJOR RISK FACTORS TARGET ORGAN DAMAGE ASSOCIATED CLINICAL CONDITIONS Levels of systolic and diastolic Left ventricular hypertrophy: Conary heart disease BP based on ECG Smoking Microalbuminuria: albumin/ Heart failure creatinine ratio 3 30 mg/mmol Dyslipidaemia Slightly elevated creatinine Chronic kidney disease: Total cholesterol >6.5 mmol/l, Men 115 133 μmol/l albumin OR creatinine ratio >30 Women 107 124 μmol/l creatinine ratio >30 mg/mmol mg/mmol LDL >4 mmol/l, OR HDL men <1 and women <1.2 mmol/l Diabetes mellitus Men >55 years Women >65 years Family histy of early onset of: cardiovascular disease Men aged <55 years Women aged <65 years Waist circumference abdominal obesity Men 102 cm Women 88 cm The exceptions are South Asians and Chinese: men >90 cm and women >80 cm Stroke transient ischaemic attack Peripheral arterial disease Advanced retinopathy Haemrhages OR Exudates Papilloedema TABLE 2 Stratification of to quantify prognosis Other BP (mmhg) facts Nmal High-nmal Stage 1 and disease SBP 120 SBP 130 139 Mild histy 129 DBP 85 89 hypertension SBP 140 159 Stage 2 Moderate hypertension SBP 160 179 Stage 3 Severe hypertension SBP >180 3
DBP 80 84 DBP 90 99 DBP 100 109 DBP >110 No other maj Average Average Low added Moderate added High added facts 1 2 maj Low added Low added Moderate Moderate added Very high facts added added 3maj Moderate High added High added High added Very high facts target-gan damage added added diabetes mellitus Associated Very high Very high Very high Very high added Very high clinical conditions added added added added * Legend Average Risk and Low Added Risk Bloods (Fasting Glucose, Fasting Lipogram, U&E-including Creatinine) Resting ECG: less than the age of 40 years Stress ECG: 40 years of age and above (to be done by a DAME) Moderate Added Risk Annual Stress ECG (done by a DAME-Designated Medical Examiner) Annual Bloods (U&E including Creatinine, Fasting Glucose, Fasting Lipo-gram) f all Classes Applicable Protocol f Co-mbidity 4
High Added Risk Stress ECG (to be done by a Cardiologist minimum stress level should be 85%) Annual Bloods (U&E including Creatinine, Fasting Glucose, Fasting Lipo-gram) Applicable Protocol f Co-mbidity Very High Added Risk Stress ECG (to be done by a Cardiologist minimum stress level should be 85%) Annual Bloods (U&E including Creatinine, Fasting Glucose, Fasting Lipo-gram) Applicable Protocol f Co-mbidity 7. Procedure f Stress ECG (1) Stress ECG is perfmed using a 12-lead standard ECG machine displaying at least 3 leads simultaneously and optimally filtered and damped. The leads should be placed as f a standard resting ECG except the limb leads are positioned on the shoulders and the iliac crests on each side. (2) Recdings should be made at rest in the erect and supine positions, and after hyperventilation f 10 seconds. The subject should be exercised to 85% of maximal heart rate symptom limitation, whichever comes first, and be expected to complete at least 3 stages (nine minutes) of the Bruce Protocol achieve an Oxygen uptake equivalent to 11 metabolic equivalents (METs). The age-predicted maximum heart rate is calculated by subtracting the age in years from 220 beats per minute (bpm). The test is most sensitive when taken to symptom limitation rather than any percentage of the age-predicted maximum. If exercise needs to be terminated due to symptom development, license holder should be referred to a cardiologist (if stress is perfmed by DAME). The reason f discontinuing the test should be recded together with the presence absence of any symptom. (3) Immediately post-stress, while the license holder is in the upright position, twelve (12) second recdings should be made at the following intervals: 0, 3, 5 and 7 minutes. If there is any indication, recdings can be taken at two (2) minute intervals up to 11 minutes. Any abnmalities on stress ECG shall be referred to a cardiologist, if the stress ECG is perfmed by a DAME. 5
(4) A standardized protocol such as the Bruce treadmill protocol 3 equivalent should be employed. The Bruce protocol is not the only one available but it is the most widely used. 8. Intervals (1) Stress ECG shall be perfmed in accdance with the cardiovascular assessment algithm. (2) Applicants classified as Moderate, High Very High shall have an annual stress- ECG (if some positive actions are taken to reduce mitigate the of those classified as moderate, an annual stress-ecg is probably not necessary, assuming the first one was negative). 6