AHA/ACC/HRS Scientific Statement: Recommendations For The Standardization and Interpretation of The Electrocardiogram
AHA/ACC/HRS Scientific Statement: Recommendations For The Standardization and Interpretation of The Electrocardiogram
AHA/ACC/HRS Scientific Statement: Recommendations For The Standardization and Interpretation of The Electrocardiogram
Jay W. Mason, MD, FAHA, FACC, FHRS; E. William Hancock, MD, FACC;
Leonard S. Gettes, MD, FAHA, FACC
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AbstractThis statement provides a concise list of diagnostic terms for ECG interpretation that can be shared by students,
teachers, and readers of electrocardiography. This effort was motivated by the existence of multiple automated
diagnostic code sets containing imprecise and overlapping terms. An intended outcome of this statement list is greater
uniformity of ECG diagnosis and a resultant improvement in patient care. The lexicon includes primary diagnostic
statements, secondary diagnostic statements, modifiers, and statements for the comparison of ECGs. This diagnostic
lexicon should be reviewed and updated periodically. (Circulation. 2007;115:1325-1332.)
Key Words: AHA Scientific Statements electrocardiography computers diagnosis
Other members of the Standardization and Interpretation of the Electrocardiogram Writing Group include James J. Bailey, MD; Rory Childers, MD;
Barbara J. Deal, MD, FACC; Mark Josephson, MD, FACC, FHRS; Paul Kligfield, MD, FAHA, FACC; Jan A. Kors, PhD; Peter Macfarlane, DSc; Olle
Pahlm, MD, PhD; David M. Mirvis, MD, FAHA; Peter Okin, MD, FACC; Pentti Rautaharju, MD, PhD; Borys Surawicz, MD, FAHA, FACC; Gerard
van Herpen, MD, PhD; Galen S. Wagner, MD; and Hein Wellens, MD, FAHA, FACC.
The American Heart Association, the American College of Cardiology, and the Heart Rhythm Society make every effort to avoid any actual or potential
conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel.
Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might
be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on October 26, 2006, by the American
College of Cardiology Board of Trustees on October 12, 2006, and by the Heart Rhythm Society on September 6, 2006.
This article has been copublished in the March 13, 2007, issue of the Journal of the American College of Cardiology and in the March 2007 issue of
Heart Rhythm.
Copies: This document is available on the World Wide Web sites of the American Heart Association (www.americanheart.org) and the American
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2007 American Heart Association, Inc., the American College of Cardiology Foundation, and the Heart Rhythm Society.
Circulation is available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.106.180201
1325
1326 Circulation March 13, 2007
care. Additional advantages would be facilitation of the estab- statements could be made in comparing individual ECGs to
lishment of a uniform teaching curriculum in electrocardiogra- 1 previous ECGs, the Writing Group recommends use of
phy, availability of a uniform glossary of terms for research these 6 statements to convey clinically important information
application, and promotion of research to better validate diag- that could influence patient care by the attending physician
nostic criteria for the specific terms in the limited lexicon. while preserving brevity and uniformity. On the other hand,
Although we recognize that each vendor of ECGs possesses a the Writing Group encourages readers to add uncoded text as
proprietary set of diagnostic statements and underlying criteria, needed to the report to more fully compare tracings.
we hope that this list of statements will be made available by Tables 5, 6, and 7 establish rules for use of the primary,
each of them so that the reader can select it as the primary secondary, and modifier statements, alone or in combination.
dictionary for use in interpreting all or some ECGs. We are also Table 8 is a set of commonly used statements that can, for the
hopeful that the vendors will collaborate among themselves to most part, be precisely reproduced by use of the primary and
align diagnostic criteria for this specific lexicon. This would not secondary statements and their modifiers. These statements are
interfere with continued development of entirely independent, commonly used concatenations provided for the convenience of
proprietary diagnostic software by each manufacturer. the reader.
core statements would have great benefits for patient care and
tic statements under 14 categories. The majority of the primary
research. Although the Writing Group does not believe that a
statements are nondescriptive and convey clinical meaning
uniform criterion set can be achieved at this time, we
without additional statements. The second listing (Table 2),
encourage ECG vendors and electrocardiography researchers
Secondary Statements, provides additional statements that can
and experts to collaborate on the development of a univer-
be used to expand the specificity and clinical relevance of both
sally acceptable criteria set and a means for perpetually
descriptive and other primary diagnostic statements. These
refining it. Several of the chapters in this statement support
secondary statements are divided into 2 groups. Those that are specific criteria for some of the core statements.
preceded by suggests invoke clinical diagnoses likely respon-
sible for the ECG observation(s). Those that are preceded by Myocardial Infarction Terminology
consider are intended to propose at least 1, but sometimes 1, Advanced imaging techniques, including echocardiography2
potentially associated clinical disorder. This set of primary and and magnetic resonance,3,4 have demonstrated a need for
secondary diagnostic statements constitutes what we might call change in existing terminology describing the cardiac loca-
the core statement lexicon. tion of myocardial infarction. New diagnostic statements for
The third list (Table 3) contains adjectives that can be used 6 common, distinct cardiac locations of myocardial infarc-
to modify the diagnostic statements. None of the modifiers tion, documented by contrast-enhanced magnetic resonance,
change the meaning of the core statement but rather serve to were recently recommended by a committee of the Interna-
refine the meaning. The list contains general modifiers, which tional Society for Holter and Noninvasive Electrocardiogra-
can be used with many of the core statements, and specific phy.5 At the present time, the Writing Group considers the
modifiers assigned to a specific category of statements. quantity of new data insufficient to recommend abandonment
The fourth list (Table 4) is a short directory of comparison of existing terminology. Thus, traditional terms are listed in
statements. It specifies 6 types of ECG changes that merit Section M: Myocardial infarction of the primary statement
mention in the ECG interpretation and defines criteria to table (Table 1); however, we intend to revisit this issue when
identify change within the 6 categories. Because so many sufficient data have been developed.
Disclosures
Reviewer Disclosures
Research Other Research Speakers Ownership Consultant/
Reviewer Employment Grant Support Bureau/Honoraria Interest Advisory Board Other
Jonathan Abrams University of New Mexico None None None None None None
Leonard S. Dreifus Hahnemann University, School of Medicine None None None None None Merck
Endpoint
Committee
Mark Eisenberg McGill University None None None None None None
Nora Goldschlager University of California, San Francisco None None St. Jude; Medtronic None None None
Peter Kowey Lankenau Hospital and Main Line Health None None Medifacts Cardionet Medifacts None
Frank Marcus University of Arizona None None None None None None
Thomas M. Munger Mayo Clinic St. Jude None None None None None
Medical, Bard
Electrophysiology
Robert J. Myerburg University of Miami None None None None None None
David Rosenbaum Case Western Reserve University None None None None None None
Richard Schofield University of Florida None None None None None None
Downloaded from http://circ.ahajournals.org/ by guest on February 14, 2017
Samuel Shubrooks Beth Israel Deaconess Medical Center None None None None None None
Cynthia Tracy George Washington University None None None None None None
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit.
21 Sinus tachycardia 84
2:1 AV block
22 Sinus bradycardia 85
AV block, varying conduction
23 Sinus arrhythmia 86
AV block, advanced (high-grade)
24 Sinoatrial block, type I 87
AV block, complete (third-degree)
25 Sinoatrial block, type II 88
AV dissociation
26 Sinus pause or arrest 89
27 Uncertain supraventricular rhythm I. Intraventricular and intra-atrial
D. Supraventricular arrhythmias conduction
100 Aberrant conduction of supraventricular
30 Atrial premature complex(es)
beat(s)
31 Atrial premature complexes,
Left anterior fascicular block
nonconducted 101
Left posterior fascicular block
32 Retrograde atrial activation 102
Left bundle-branch block
33 Wandering atrial pacemaker 104
Incomplete right bundle-branch block
34 Ectopic atrial rhythm 105
Right bundle-branch block
35 Ectopic atrial rhythm, multifocal 106
Intraventricular conduction delay
36 Junctional premature complex(es) 107
Ventricular preexcitation
37 Junctional escape complex(es) 108
Right atrial conduction abnormality
38 Junctional rhythm 109
Left atrial conduction abnormality
39 Accelerated junctional rhythm 110
Epsilon wave
40 Supraventricular rhythm 111
41 Supraventricular complex(es) J. Axis and voltage
Right-axis deviation
42 Bradycardia, nonsinus 120
Left-axis deviation
E. Supraventricular tachyarrhythmias 121
Right superior axis
50 Atrial fibrillation 122
Indeterminate axis
51 Atrial flutter 123
Electrical alternans
52 Ectopic atrial tachycardia, unifocal 124
Low voltage
53 Ectopic atrial tachycardia, multifocal 125
Abnormal precordial R-wave progression
54 Junctional tachycardia 128
Abnormal P-wave axis
55 Supraventricular tachycardia 131
56 Narrow-QRS tachycardia K. Chamber hypertrophy or
enlargement
F. Ventricular arrhythmias
140 Left atrial enlargement
60 Ventricular premature complex(es)
141 Right atrial enlargement
61 Fusion complex(es)
142 Left ventricular hypertrophy
62 Ventricular escape complex(es)
143 Right ventricular hypertrophy
63 Idioventricular rhythm
144 Biventricular hypertrophy
64 Accelerated idioventricular rhythm
65 Fascicular rhythm
66 Parasystole
Mason et al Standardization and Interpretation of the ECG, Part II 1329
160 Anterior MI
214 Pericardial effusion
161 Inferior MI
215 Sinoatrial disorder
162 Posterior MI
Consider
163 Lateral MI
220 Acute ischemia
165 Anteroseptal MI
221 AV nodal reentry
166 Extensive anterior MI
222 AV reentry
173 MI in presence of left bundle-branch
223 Genetic repolarization abnormality
block
224 High precordial lead placement
174 Right ventricular MI
225 Hypothyroidism
N. Pacemaker
226 Ischemia
180 Atrial-paced complex(es) or rhythm
227 Left ventricular aneurysm
181 Ventricular-paced complex(es) or rhythm
228 Normal variant
182 Ventricular pacing of nonright ventricular
apical origin 229 Pulmonary disease
183 Atrial-sensed ventricular-paced 230 Dextrocardia
complex(es) or rhythm 231 Dextroposition
184 AV dual-paced complex(es) or rhythm CNS indicates central nervous system; ASD, atrial septal defect; and AV,
185 Failure to capture, atrial atrioventricular.
186 Failure to capture, ventricular
187 Failure to inhibit, atrial
188 Failure to inhibit, ventricular
189 Failure to pace, atrial
190 Failure to pace, ventricular
AV indicates atrioventricular; MI, myocardial infarction.
1330 Circulation March 13, 2007
TABLE 3. Modifiers
General Myocardial infarction, contd
301 Borderline 332 Old
303 Increased 333 Of indeterminate age
304 Intermittent 334 Evolving
305 Marked Arrhythmias and tachyarrhythmias
306 Moderate 340 Couplets
307 Multiple 341 In a bigeminal pattern
308 Occasional 342 In a trigeminal pattern
309 One 343 Monomorphic
310 Frequent 344 Multifocal
312 Possible 345 Unifocal
313 Postoperative 346 With a rapid ventricular response
314 Predominant 347 With a slow ventricular response
315 Probable 348 With capture beat(s)
316 Prominent 349 With aberrancy
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6 Each specific modifier can accompany only primary statements within 206 145147
its category 207 149
208 147
209 142
210 148
211 147148, 150
212 14, 154
213 82, 105106, 121
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214 124
215 42, 131, 145147
220 145147, 151
221 55, 56
222 55, 56
223 148, 149
224 128
225 22, 2426, 37, 38
226 145147
227 145147
228 80, 105, 128, 155
229 109, 120, 122123, 125, 128, 131, 141, 143
230 128, 131
231 128
1332 Circulation March 13, 2007
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