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PATIENT SAFETY••13 min read

Women Deserve an Accurate ECG

A clinical communication brief for EMTs, paramedics, nurses, and emergency leaders on AHA/ACC/HRS standards for accurate ECG acquisition in women.

Women Deserve an Accurate ECG

Communication brief for EMTs, paramedics, nurses, and emergency leaders based on AHA/ACC/HRS Standards.

Clear process. Clean signal. Correct decisions. Better outcomes.

Why this matters

The 12-lead ECG is the critical test for acute coronary syndrome. When it is delayed, noisy, misplaced, or recorded over clothing, the information can be inaccurate and the entire care pathway is weakened.

Women are less likely to receive a timely prehospital ECG and often wait longer for evaluation. These gaps contribute to missed myocardial infarction, delayed reperfusion, and worse outcomes.1,3,16,17

The standard is not complicated: expose the chest to use anatomy, prepare the skin, place leads accurately, and record in supine position.6

The standard action to obtain an accurate ECG is simple, verifiable, and non-negotiable.

  • Perform to the AHA/ACC standards6 every time
  • Explain the why to the patient
  • Verify correct lead placement
  • Document any deviation
  • Audit what teams actually do

Women experienced 42.5 minutes longer delays to first medical contact and 4.9 minutes longer door-to-balloon times according to a meta-analysis of over 705,000 STEMI patients. These issues led to nearly double the odds of in-hospital mortality (OR 1.91, 95% CI: 1.84–1.99), as well as higher rates of repeat myocardial infarction (OR 1.25), stroke (OR 1.67), and major bleeding (OR 1.82).4

Imboden et al. confirmed that male STEMI and NSTEMI patients had a median time-to-ECG that was 3.0 minutes shorter, and that males had a reduced likelihood of ECG delay (OR 0.64, 95% CI: 0.51–0.82); critically, after controlling for time-to-ECG, sex was no longer a significant predictor of PCI delay, underscoring that timely, accurate ECG acquisition is the key modifiable factor.5

The American Heart Association's 2026 scientific statement on ACS in premenopausal women explicitly recognizes that young women are particularly vulnerable to missed acute MI and inappropriate ED discharge due to underuse of diagnostic tests, including ECGs. These are not abstract statistics; they represent preventable deaths of real patients caused in part by substandard ECG acquisition practices.13

The standard of care in four actions

1. Expose the torso for anatomical indexingA shirt or bra is not an anatomical landmark. The precordial leads must be placed by their respective intercostal space and line of reference, not by clothing position.

3. Place electrodes directly on skinLeads placed over or around clothing, or shifted by breast tissue and undergarments, produce inconsistent tracings and unreliable serial comparison.15

2. Prepare the skinCleanse, dry/wipe, and reduce impedance and increase amplitudes by abrading the epidermis before electrode application. Good skin contact improves signal quality and reduces artifact.6

4. Record in supine position and motionlessBody position changes cardiac orientation and can alter ST-segment appearance.6 A sitting ECG and a supine ECG are not interchangeable. Supine up to 30 degrees is acceptable.

Common comments and the evidenced-based responses

Common comment Clear response Why it matters
“We do not have time to remove a bra.” The patient needs the diagnosis urgently, but urgency does not excuse inaccuracy. Electrodes must contact skin at prescribed anatomical landmarks. The AHA/ACC/HRS recommends electrodes be placed under the breast in women. A bra displaces leads from correct intercostal positions. Misplaced V1– V2 can simulate or mask anterior infarction by a 0.1 mV amplitude change per interspace of misplacement. Lead misplacement can mask or mimic infarction and delay cath lab activation.
“She is in public and will not want exposure.” Research shows 94% of women consent to a prehospital ECG regardless of paramedic gender.7 Use a drape, explain each step, and minimize exposure time. Modesty is protected with communication, not by compromising the diagnostic test. Dignity is protected by communication, not by compromising the test.
“It is fine to place electrodes around clothing.” No. Electrodes over or around clothing can lose skin contact, increase impedance, and generate artifact. Artifact is the most common cause of incorrect computer interpreted STEMI calls; both false positives and false negatives.8 Poor acquisition reduces both human and algorithmic interpretability.
“Sitting up or lying down…position doesn’t really matter” The standard diagnostic ECG is recorded supine. Body position changes cardiac position, which can shift ST-segment voltages by up to 0.3 mV; enough to mask or mimic ischemia. A prehospital ECG taken sitting and an ED ECG taken supine will look different for technical reasons, not clinical ones, undermining serial comparison.13 Technical differences can be mistaken for clinical change.
“I have never had to prep their skin before” This is rarely taught and almost never reinforced but is truly the standard of care. The AHA states: “skin preparation by cleaning and gentle abrasion before electrode application reduces noise and improves quality.”6 Cleanse, dry wipe, clip hair and abrade. This takes seconds. Skin prep improves signal quality, amplitudes, and decreases artifacts by conducting the signal more cleanly. Noisy signals produce unreliable interpretation.
“The hospital will just repeat it.” The entire point of a prehospital ECG is to activate the Cath lab BEFORE arrival. If your ECG is uninterpretable, the hospital starts from zero. That delay adds directly to total ischemic time. Prehospital ECG with hospital pre-notification is associated with reduced mortality.1,2,11 The first ECG shapes the next step in care.
“We already do high-quality ECGs every time.” Studies show misplaced electrode placement in pre-hospital patients up to 94% and up to 80% in hospital. The AHA recommends periodic retraining in skin preparation, proper electrode positioning, and proper patient positioning for all personnel who record ECGs.6 Quality requires audit, not assumption. Teams improve faster when expectations are measured.

The ultimate responsibility for correct ECG interpretation rests with the interpreting physician. Accordingly, the physician must be able to recognize abnormalities and artifacts arising from these technical variations.18

THE BIGGER PICTURE: ECG QUALITY AND EMERGENCY CARE INEQUALITIES

The issues mentioned above extend beyond STEMI. Every diagnostic ECG, whether for chest pain, syncope, arrhythmia, or other emergency indication, relies on the same basic acquisition principles.6,13,18 When these principles are overlooked, the resulting consequences include:

  • Missed STEMI (the initial ECG is non-diagnostic in 11% of patients eventually diagnosed with STEMI)12
  • False serial ECG discrepancies between prehospital and ED tracings12,13
  • Unnecessary cath lab activations due to artifact-induced false STEMI alerts8
  • Delayed identification of arrhythmias, conduction disease, and QT prolongation18
  • Decreased trust in prehospital clinical data by receiving physicians1

Women experiencing chest pain are less likely to receive prehospital aspirin, analgesia, IV access, timely ED evaluation, angiography, and CCU/ICU admission.3,4 The ECG serves as the initial test. When it is not conducted or conducted inadequately, every subsequent step in the care pathway is affected.1,3

What respectful, high-reliability behavior looks like

Provider script

“I need to place these leads directly on your skin to get the most accurate reading of your heart. I will explain each step, keep you covered as much as possible, and pause if you need me to.”

  • Provide informed consent
  • Use a sheet or drape when possible
  • Maintain matter-of-fact, professional language
  • Offer a chaperone when available
  • Document any limitation that prevents full standard acquisition

Drivers of behavior change

  • Make the AHA standard the default. Teams repeat what feels normal.
  • Reduce ambiguity. A short checklist outperforms vague reminders.
  • Use visible accountability. Audit creates attention; feedback creates change.
  • Frame the consequence. A shortcut can cost a diagnosis, not just quality points.
  • Reinforce identity. High-performing clinicians do not record “good enough” ECGs.

5-point ECG quality checkpoint

Checkpoint Expected standard Document if not done
Chest exposure Remove clothing from torso Reason for limitation
Skin preparation Cleanse, dry/wipe, abrade (clip hair when needed) Reason for deviation
Patient position Supine to 30 degrees when clinically feasible Reason patient not supine
Lead placement Placed by anatomical landmarks, including under/around breast tissue as needed Reason exact placement not possible
Communication Process explained respectfully; drape used when possible Reason if deferred

Leadership message for EMS and ED teams

  • Do not train staff to work around bras, shirts, or body habitus when those workarounds lower diagnostic quality.
  • The standard of care is torso exposure, skin preparation, accurate anatomical placement, and supine recording while patient is kept motionless.
  • The operational standard is to measure adherence, review misses, and coach to one consistent process across prehospital and hospital settings.
  • The equity standard is that all patients should receive high quality ECGs. Women should not receive a modified or lower-fidelity version of a diagnostic 12-lead ECG because of anatomy, sex, or provider bias.
  • The real question is not, “How fast can a tracing be printed?” The real question is, "How fast can an accurate ECG be obtained that clinicians and algorithms can trust?"

References

  1. Jacobs, A. K., Ali, M. J., Best, P. J., et al. (2021). Systems of care for ST-segment-elevation myocardial infarction: A policy statement from the American Heart Association. Circulation, 144(20), e310-e327. https://doi.org/10.1161/CIR.0000000000001025
  2. Rao, S. V., O'Donoghue, M. L., Ruel, M., et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes. Journal of the American College of Cardiology. Advance online publication. https://doi.org/10.1016/j.jacc.2024.11.009
  3. Dawson, L. P., Nehme, E., Nehme, Z., et al. (2023). Sex differences in epidemiology, care, and outcomes in patients with acute chest pain. Journal of the American College of Cardiology, 81(10), 933-945. https://doi.org/10.1016/j.jacc.2022.12.025
  4. Shah, T., Haimi, I., Yang, Y., et al. (2021). Meta-analysis of gender disparities in in-hospital care and outcomes in patients with ST-segment elevation myocardial infarction. The American Journal of Cardiology, 147, 23-32. https://doi.org/10.1016/j.amjcard.2021.02.015
  5. Imboden, M. T., Koltner, E., Bryant, J. H., et al. (2025). Sex disparities in acute myocardial infarction diagnosis and treatment. The American Journal of Cardiology. Advance online publication. https://doi.org/10.1016/j.amjcard.2025.09.013
  6. Kligfield, P., Gettes, L. S., Bailey, J. J., et al. (2007). Recommendations for the standardization and interpretation of the electrocardiogram: Part I. Journal of the American College of Cardiology, 49(10), 1109-1127. https://doi.org/10.1016/j.jacc.2007.01.024
  7. Wallen, R., Tunnage, B., & Wells, S. (2014). The 12-lead ECG in the emergency medical service setting: How electrode placement and paramedic gender are experienced by women. Emergency Medicine Journal, 31(10), 851-852. https://doi.org/10.1136/emermed-2013-202826
  8. Sandau, K. E., Funk, M., Auerbach, A., et al. (2017). Update to practice standards for electrocardiographic monitoring in hospital settings. Circulation, 136(19), e273-e344. https://doi.org/10.1161/CIR.0000000000000527
  9. Myers, J., Arena, R., Franklin, B., et al. (2009). Recommendations for clinical exercise laboratories: A scientific statement from the American Heart Association. Circulation, 119(24), 3144-3161. https://doi.org/10.1161/CIRCULATIONAHA.109.192520
  10. Schläpfer, J., & Wellens, H. J. J. (2017). Computer-interpreted electrocardiograms: Benefits and limitations. Journal of the American College of Cardiology, 70(9), 1183-1192. https://doi.org/10.1016/j.jacc.2017.07.723
  11. Chan, W. V., Pearson, T. A., Bennett, G. C., et al. (2017). ACC/AHA special report: Clinical practice guideline implementation strategies. Journal of the American College of Cardiology, 69(8), 1076-1092. https://doi.org/10.1016/j.jacc.2016.11.004
  12. Gulati, M., Levy, P. D., Mukherjee, D., et al. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Journal of the American College of Cardiology, 78(22), e187-e285. https://doi.org/10.1016/j.jacc.2021.07.053
  13. Kovacic JC, Reynolds HR, Alasnag M, et al. Acute Coronary Syndromes in Premenopausal Women: A Scientific Statement From the American Heart Association. Circulation. 2026. https://doi.org/10.1161/CIR.0000000000001416
  14. Lichtman JH, Leifheit-Limson EC, Watanabe E, Allen NB, Garavalia B, Garavalia LS, Spertus JA, Krumholz HM, Curry LA. Symptom recognition and healthcare experiences of young women with acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2015;8:S31–S38. https://doi.org/10.1161/CIRCOUTCOMES.114.001612
  15. Derkenne C, Jost D, Lefort H, Tourtier JP. Pathological ECG that seemed normal following electrode misplacement. BMJ Case Rep. 2017 Dec 5;2017:bcr2017221429. https://casereports.bmj.com/content/2017/bcr-2017-221429
  16. Lewis JF, Zeger SL, Li X, Mann NC, Newgard CD, Haynes S, Wood SF, Dai M, Simon AE, McCarthy ML. Gender Differences in the Quality of EMS Care Nationwide for Chest Pain and Out-of-Hospital Cardiac Arrest. Womens Health Issues. 2019;29:116–124. https://doi.org/10.1016/j.whi.2018.10.007
  17. McDonald N, Little N, Grierson R, Weldon E. Sex and Gender Equity in Prehospital Electrocardiogram Acquisition. Prehosp Disaster Med. 2022 Mar 9;37(2):1-7. https://doi.org/10.1017/s1049023x2200036x
  18. Kadish AH, Buxton AE, Kennedy HL, Knight BP, Mason JW, Schuger CD, Tracy CM, Winters WL Jr, Boone AW, Elnicki M, Hirshfeld JW Jr, Lorell BH, Rodgers GP, Tracy CM, Weitz HH; American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force; International Society for Holter and noninvasive electrocardiology. ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography. Circulation. 2001 Dec 18;104(25):3169-78. https://pubmed.ncbi.nlm.nih.gov/11748119/

Prepared as a concise provider communication brief. This document supports standards-based education and quality improvement and is not a substitute for local medical direction, scope of practice, or manufacturer instructions for use.

Tags

Patient SafetyECGEMSCardiologyWomen’s HealthClinical Standards

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