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Avoiding Error in ECG Diagnosis

Misdiagnosis of both acute coronary syndrome and atrial fibrillation are common in clinical practice. This can have devastating consequences for patients. In this course, we emphasize the importance of recognizing ECG mimics of these conditions and emphasize the importance of overall clinical context in their diagnosis.

1.0 x AMA PRA Category 1 Credits™
Available on the Pro Plan



In this course, we deal with two of the most common errors in ECG diagnosis made in the acute setting, misdiagnosis of STEMI and misdiagnosis of atrial fibrillation. We show you how to recognize causes of ST elevation on the ECG unrelated to acute coronary syndrome. In particular, you will learn how to identify early repolarization pattern and male pattern ST segment elevation on the ECG, findings present in a proportion of healthy individuals in the absence of ischemic heart disease. We teach you how to recognize electrode misplacement, a potential source of artefact mimicking ECG changes associated with acute coronary syndrome. In this course, we emphasize the importance of the assessment of basic ECG features and overall clinical context in the diagnosis of atrial fibrillation. We test your ability to apply this approach. Evidence suggests that over-reliance on the computer interpretation reported on modern ECG readouts is a major contributing factor to both of the diagnostic errors dealt with in this course. We will discuss the diagnostic limitations of the ECG computer interpretation in clinical practice.


Planner and Author: Dr John Seery MB PhD

  • Consultant Physician at St. Vincent's University Hospital, Dublin, Ireland
  • Lecturer at the School of Medicine and Medical Science, University College Dublin, Ireland
  • Studied medicine at the University of Cambridge, United Kingdom
  • A Natural Sciences graduate of Trinity College Dublin, Ireland
  • PhD in Cell Biology from University College London, United Kingdom

Planner: Dr Karen Strahan PhD (University of Cambridge), Head of Editorial
Planner: Tommy O'Sullivan, CME Manager

Estimated Time to Complete

1.0 hours

Target Audience

  • Physicians
  • Nurses
  • Nurse Practitioners
  • Physician Assistants
  • Paramedics

Learning Objectives

Upon successful completion of this activity, you will be able to:

  • Identify ‘early repolarization pattern’ on the ECG
  • Identify ‘normal male pattern ST elevation’ on the ECG
  • Identify and correct electrode misplacement on the ECG
  • Identify an incorrect diagnosis of atrial fibrillation reported on the ECG computer interpretation

Course Content

  • Introduction
  • Benign ST Elevation
  • Electrode Misplacement
  • The Computer Interpretation
  • Quiz
  • Essential Reading

Release date


Expiration date


Instructions for Participation

Participants must complete the online activity during the valid period as noted above.
Follow these steps:

  1. View videos in sequence
  2. Read the papers on the essential reading list
  3. Complete the quiz
  4. Complete the activity evaluation form to provide feedback for continuing education purposes and for the development of future activities
  5. Download the Certificate of Completion

Relevant Financial Disclosures

Acadoodle adheres to the ACCME's Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CE activity, including faculty, planners, reviewers or others are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity.

Planners and faculty for this activity have no relevant financial relationships with commercial interests to disclose.


Lindow T et al. Erroneous computer-based interpretations of atrial fibrillation and atrial flutter in a Swedish primary healthcare setting. Scand J Primary Health Care. 2019;37(4):426-33.

Bae MH et al. Erroneous Computer Electrocardiogram Interpretation of Atrial Fibrillation and its Clinical Consequences. Clin Cardiol. 2012;35(6):348-53.

Kadish AH et al. ACC/AHA Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography. Circulation. 2001;104:3169-78.

Smulyan H. The Computerized ECG: Friend and Foe. Am J Med. 2019;132:153-60.

Pollak P and Brady W. Electrocardiographic Patterns Mimicking ST Segment Elevation Myocardial Infarction. Cardiol Clin. 2012;30:601-15.

Bourier et al. Early Repolarization Syndrome: Diagnostic and Therapeutic Approach. 
Front. Cardiovasc. Med. 5:169. doi: 10.3389/fcvm.2018.00169.

MacFarlane et al. The Early Repolarization Pattern: A Consensus Paper. J Am Coll Cardiol. 2015;66(4):470-7.

Brady WJ et al. The Diagnosis: Benign Early Repolarization. Emergency Medicine News. 2001;23(12): 30-6.

Hongo RH and Goldschlager N. Overreliance on Computerized Algorithms to Interpret Electrocardiograms. Am J Med. 2004;117:706-8.

Bogun F et al. Misdiagnosis of atrial fibrillation and its clinical consequences. Am J Med. 2004;117(9):636-42.

Additional Reading

Zakka P and Refaat M. Early Repolarization Syndrome. J Am Coll Cardiol. 2016

Pollak P and Brady W. Electrocardiographic Patterns Mimicking ST segment Elevation Myocardial Infarction. Cardiol Clin. 2012;30:601-15.

Bourier et al. Early Repolarization Syndrome: Diagnostic and Therapeutic Approach. 
Front Cardiovasc Med. 5:169. doi: 10.3389/fcvm.2018.00169.

Lynch R. ECG lead misplacement: A brief review of limb lead misplacement. African Journal of Emergency Medicine 2014;4(3):130-9.

Schlapfer J and Wellens HJ. Computer-Interpreted Electrocardiograms: Benefits and Limitations. J Am Coll Cardiol. 2017;70(9):1183-92.

Batcharov VN et al. Incorrect electrode cable connection during electrocardiographic recording. EP Europace. 2007;9(11):1081-90.

Seery JP and Ryan J. How to diagnose atrial fibrillation-top 5 tips.

ACCME Accreditation Statement

Acadoodle, Ltd is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

AMA Physician’s Recognition Award

Acadoodle, Ltd designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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