AHA/ACC/HRS Scientific Statement

Recommendations for the Standardization and Interpretation of the Electrocardiogram

Part II: Electrocardiography Diagnostic Statement List

A Scientific Statement From the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society

Endorsed by the International Society for Computerized Electrocardiology

Jay W. Mason, MD, FAHA, FACC, FHRS; E. William Hancock, MD, FACC; Leonard S. Gettes, MD, FAHA, FACC

Abstract —This 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

T hisguidelinesis the secondfor theofstandardization6 articles designedand interpretationto upgrade theof the ECG. The project was initiated by the American Heart Association and has been endorsed by the American College of Cardiology, the Heart Rhythm Society, and the International Society for Computerized Electrocardiography. The rationale for this upgrade and a description of the process are contained in Part I by Kligfield et al.

The listing contained in the present statement seeks to present a limited set of ECG diagnostic statements that are clinically useful and that do not create unnecessary overlap or contain

vague terminology. Some statements that are commonly used by electrocardiographers but that do not provide diagnostically or clinically useful information are not included. Some statements have been excluded to reduce the size of the statement set, so long as their meaning is well represented by included terms.

The Writing Group believes that the listing should be implemented as an available lexicon in report algorithms of the existing commercial electrocardiographs and that it should be used widely by ECG readers. The principal advantage of such use would be a worldwide improvement in uniformity of ECG interpretation. Such uniformity would promote better patient

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 College of Cardiology (www.acc.org). A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0390. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml? Identifier4431. A link to the “Permission Request Form” appears on the right side of the page.

© 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

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care. Additional advantages would be facilitation of the establishment of a uniform teaching curriculum in electrocardiography, availability of a uniform glossary of terms for research application, and promotion of research to better validate diagnostic criteria for the specific terms in the limited lexicon.

Although we recognize that each vendor of ECGs possesses a proprietary set of diagnostic statements and underlying criteria, we hope that this list of statements will be made available by each of them so that the reader can select it as the primary dictionary for use in interpreting all or some ECGs. We are also hopeful that the vendors will collaborate among themselves to align diagnostic criteria for this specific lexicon. This would not interfere with continued development of entirely independent, proprietary diagnostic software by each manufacturer.

Organization and Use

Four lists are included within this document. The main listing (Table 1), “Primary Statements,” displays 117 primary diagnostic statements under 14 categories. The majority of the primary statements are nondescriptive and convey clinical meaning without additional statements. The second listing (Table 2), “Secondary Statements,” provides additional statements that can be used to expand the specificity and clinical relevance of both descriptive and other primary diagnostic statements. These secondary statements are divided into 2 groups. Those that are preceded by “suggests” invoke clinical diagnoses likely responsible for the ECG observation(s). Those that are preceded by “consider” are intended to propose at least 1, but sometimes 1, potentially associated clinical disorder. This set of primary and secondary diagnostic statements constitutes what we might call the “core statement lexicon.”

The third list (Table 3) contains adjectives that can be used to modify the diagnostic statements. None of the modifiers change the meaning of the core statement but rather serve to refine the meaning. The list contains general modifiers, which can be used with many of the core statements, and specific modifiers assigned to a specific category of statements.

The fourth list (Table 4) is a short directory of comparison statements. It specifies 6 types of ECG changes that merit mention in the ECG interpretation and defines criteria to identify change within the 6 categories. Because so many

statements could be made in comparing individual ECGs to 1 previous ECGs, the Writing Group recommends use of these 6 statements to convey clinically important information that could influence patient care by the attending physician while preserving brevity and uniformity. On the other hand, the Writing Group encourages readers to add uncoded text as needed to the report to more fully compare tracings.

Tables 5, 6, and 7 establish rules for use of the primary, secondary, and modifier statements, alone or in combination. Table 8 is a set of commonly used statements that can, for the most part, be precisely reproduced by use of the primary and secondary statements and their modifiers. These statements are commonly used concatenations provided for the convenience of the reader.

Criteria for Diagnoses

This listing does not specify diagnostic criteria for any of the statements. A single set of diagnostic criteria underlying the core statements would have great benefits for patient care and research. Although the Writing Group does not believe that a uniform criterion set can be achieved at this time, we encourage ECG vendors and electrocardiography researchers and experts to collaborate on the development of a universally acceptable criteria set and a means for perpetually refining it. Several of the chapters in this statement support specific criteria for some of the core statements.

Myocardial Infarction Terminology

Advanced imaging techniques, including echocardiography and magnetic resonance, have demonstrated a need for change in existing terminology describing the cardiac location of myocardial infarction. New diagnostic statements for 6 common, distinct cardiac locations of myocardial infarction, documented by contrast-enhanced magnetic resonance, were recently recommended by a committee of the International Society for Holter and Noninvasive Electrocardiography. At the present time, the Writing Group considers the quantity of new data insufficient to recommend abandonment of existing terminology. Thus, traditional terms are listed in “Section M: Myocardial infarction” of the primary statement table (Table 1); however, we intend to revisit this issue when sufficient data have been developed.

Disclosures

Writing Group Disclosures

		Research	Other Research	Speakers’	Ownership	Consultant/
Writing Group Member	Employment	Grant	Support	Bureau/Honoraria	Interest	Advisory Board	Other
Jay W. Mason	Covance Cardiac Safety Services	None	None	None	None	None	None
Leonard S. Gettes	University of North Carolina	None	None	None	None	None	None
E. William Hancock	Stanford University Medical Center	None	None	None	None	Philips Medical Systems,*	None
						Covance Diagnostics*

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (1) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (2) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. *Significant.

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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
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.

References

1. Kligfield P, Gettes L, Bailey JJ, Childers R, Deal BJ, Hancock EW, van Herpen G, Kors JA, Macfarlane P, Mirvis DM, Pahlm O, Rautaharju P, Wagner GS. Recommendations for the standardization and interpretation of the electrocardiogram: part I: the electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Circulation. 2007;115:–.

2. Bogaty P, Boyer L, Rousseau L, Arsenault M. Is anteroseptal myocardial infarction an appropriate term? Am J Med. 2002;113:37–41.

3. Selvanayagam JB, Kardos A, Nicolson D, Francis J, Petersen SE, Robson M, Banning A, Neubauer S. Anteroseptal or apical myocardial infarction: a controversy addressed using delayed enhancement cardiovascular

magnetic resonance imaging. J Cardiovasc Magn Reson. 2004;6: 653–661.

4. Bayes de Luna A, Cino JM, Pujadas S, Cygankiewicz I, Carreras F, Garcia-Moll X, Noguero M, Fiol M, Elosua R, Cinca J, Pons-Llado G. Concordance of electrocardiographic patterns and healed myocardial infarction location detected by cardiovascular magnetic resonance. Am J Cardiol. 2006;97:443–451.

5. Bayes de Luna A, Wagner G, Birnbaum Y, Nikus K, Fiol M, Gorgels A, Cinca J, Clemmensen PM, Pahlm O, Sclarovsky S, Stern S, Wellens J, Zareba W; International Society for Holter and Noninvasive Electrocardiography. A new terminology for left ventricular walls and location of myocardial infarcts that present Q wave based on the standard of cardiac magnetic resonance imaging: a statement for healthcare professionals from a committee appointed by the International Society for Holter and Noninvasive Electrocardiography. Circulation. 2006;114:1755–1760.

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TABLE 1. Primary Statements

A.	Overall interpretation		G. Ventricular tachyarrhythmias
	1	Normal ECG	70	Ventricular tachycardia
	2	Otherwise normal ECG	71	Ventricular tachycardia, unsustained
	3	Abnormal ECG	72	Ventricular tachycardia, polymorphous
	4	Uninterpretable ECG	73	Ventricular tachycardia, torsades de
B.	Technical conditions			pointes
	10	Extremity electrode reversal	74	Ventricular fibrillation
	11	Misplaced precordial electrode(s)	75	Fascicular tachycardia
	12	Missing lead(s)	76	Wide-QRS tachycardia
	13	Right-sided precordial electrode(s)	H. Atrioventricular conduction
	14	Artifact	80	Short PR interval
	15	Poor-quality data	81	AV conduction ratio N:D
	16	Posterior electrode(s)	82	Prolonged PR interval
C.	Sinus node rhythms and arrhythmias		83	Second-degree AV block, Mobitz type I
	20	Sinus rhythm		(Wenckebach)
	21	Sinus tachycardia	84	Second-degree AV block, Mobitz type II
	22	Sinus bradycardia	85	2:1 AV block
	23	Sinus arrhythmia	86	AV block, varying conduction
D.	24 25 26 27 Supraventricular arrhythmias 30 31 32 33 34 35 36 37 38 39	Sinoatrial block, type I Sinoatrial block, type II Sinus pause or arrest Uncertain supraventricular rhythm Atrial premature complex(es) Atrial premature complexes, nonconducted Retrograde atrial activation Wandering atrial pacemaker Ectopic atrial rhythm Ectopic atrial rhythm, multifocal Junctional premature complex(es) Junctional escape complex(es) Junctional rhythm Accelerated junctional rhythm	87 88 89 I. Intraventricular and intra-atrial conduction 100 101 102 104 105 106 107 108 109 110	AV block, advanced (high-grade) AV block, complete (third-degree) AV dissociation Aberrant conduction of supraventricular beat(s) Left anterior fascicular block Left posterior fascicular block Left bundle-branch block Incomplete right bundle-branch block Right bundle-branch block Intraventricular conduction delay Ventricular preexcitation Right atrial conduction abnormality Left atrial conduction abnormality
	40	Supraventricular rhythm	111	Epsilon wave
	41	Supraventricular complex(es)	J. Axis and voltage
	42	Bradycardia, nonsinus	120	Right-axis deviation
E.	Supraventricular tachyarrhythmias 50	Atrial fibrillation	121 122	Left-axis deviation Right superior axis
	51	Atrial flutter	123	Indeterminate axis
	52	Ectopic atrial tachycardia, unifocal	124	Electrical alternans
	53	Ectopic atrial tachycardia, multifocal	125	Low voltage
	54	Junctional tachycardia	128	Abnormal precordial R-wave progression
	55	Supraventricular tachycardia	131	Abnormal P-wave axis
	56	Narrow-QRS tachycardia	K. Chamber hypertrophy or
F.	Ventricular arrhythmias 60	Ventricular premature complex(es)	enlargement 140	Left atrial enlargement
	61	Fusion complex(es)	141	Right atrial enlargement
	62	Ventricular escape complex(es)	142	Left ventricular hypertrophy
	63	Idioventricular rhythm	143	Right ventricular hypertrophy
	64	Accelerated idioventricular rhythm	144	Biventricular hypertrophy
	65	Fascicular rhythm
	66	Parasystole

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TABLE 1. Primary Statements, Cont’d

TABLE 2. Secondary Statements

TABLE 1. Primary Statements, Cont’d	TABLE 1. Primary Statements, Cont’d	TABLE 2. Secondary Statements
L. ST segment, T wave, and U wave 145 ST deviation 146 ST deviation with T-wave change 147 T-wave abnormality 148 Prolonged QT interval 149 Short QT interval 150 Prominent U waves 151 Inverted U waves 152 TU fusion 153 ST-T change due to ventricular hypertrophy 154 Osborn wave 155 Early repolarization M. Myocardial infarction 160 Anterior MI 161 Inferior MI 162 Posterior MI 163 Lateral MI 165 Anteroseptal MI 166 Extensive anterior MI 173 MI in presence of left bundle-branch block 174 Right ventricular MI N. Pacemaker 180 Atrial-paced complex(es) or rhythm 181 Ventricular-paced complex(es) or rhythm 182 Ventricular pacing of non–right ventricular apical origin 183 Atrial-sensed ventricular-paced complex(es) or rhythm 184 AV dual-paced complex(es) or rhythm 185 Failure to capture, atrial 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		Suggests 200 Acute pericarditis 201 Acute pulmonary embolism 202 Brugada abnormality 203 Chronic pulmonary disease 204 CNS disease 205 Digitalis effect 206 Digitalis toxicity 207 Hypercalcemia 208 Hyperkalemia 209 Hypertrophic cardiomyopathy 210 Hypocalcemia 211 Hypokalemia or drug effect 212 Hypothermia 213 Ostium primum ASD 214 Pericardial effusion 215 Sinoatrial disorder Consider 220 Acute ischemia 221 AV nodal reentry 222 AV reentry 223 Genetic repolarization abnormality 224 High precordial lead placement 225 Hypothyroidism 226 Ischemia 227 Left ventricular aneurysm 228 Normal variant 229 Pulmonary disease 230 Dextrocardia 231 Dextroposition
		CNS indicates central nervous system; ASD, atrial septal defect; and AV, atrioventricular.

AV indicates atrioventricular; MI, myocardial infarction.

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TABLE 3. Modifiers

General		Myocardial infarction, cont’d
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
317	(Specified) Lead(s)	350	Polymorphic
318	(Specified) Electrode(s)	Repolarization abnormalities
321	Nonspecific	360	0.1 mV
General: conjunctions		361	0.2 mV
302	Consider	362	Depression
310	Or	363	Elevation
320	And	364	Maximally toward lead
319	With	365	Maximally away from lead
322	Versus	366	Low amplitude
Myocardial infarction		367	Inversion
330	Acute	369	Postpacing	(anamnestic)
331	Recent

TABLE 4. Comparison Statements

Code	Statement	Criteria
400	No significant change	Intervals (PR, QRS, QTc) remain normal or within 10% of a previously abnormal value
		No new or deleted diagnoses with the exception of normal variant diagnoses
401	Significant change in rhythm	New or deleted rhythm diagnosis
		HR change20 bpm and50 or100 bpm
		New or deleted pacemaker diagnosis
402	New or worsened ischemia or infarction	Added infarction, ST-ischemia, or T-wave-ischemia diagnosis, or worsened ST deviation or
		T-wave abnormality
403	New conduction abnormality	Added AV or IV conduction diagnosis
404	Significant repolarization change	New or deleted QT diagnosis
		New or deleted U-wave diagnosis
		New or deleted nonischemic ST or T-wave diagnosis
		Change in QTc60 ms
405	Change in clinical status	New or deleted diagnosis from Axis and Voltage, Chamber Hypertrophy, or Enlargement
		primary statement categories or “Suggests” secondary statement category
406	Change in interpretation without significant change in	Used when a primary or secondary statement is added or removed despite no real change in
	waveform	the tracing; ie, an interpretive disagreement exists between the readers of the first and
		second ECGs

QTc indicates corrected QT interval; HR, heart rate; bpm, beats per minute; AV, atrioventricular; and IV, intraventricular.

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TABLE 5. General Use Rules

TABLE 6. Secondary–Primary Statement Pairing Rules

	TABLE 6. Secondary–Primary Statement Pairing Rules
1 Secondary statements must be accompanied by a primary statement 2 Modifiers must be accompanied by a primary statement 3 A primary statement may be accompanied by nothing, by 1 modifiers, by 1 secondary statements, or by both. 4 Each secondary statement can accompany only certain primary statements (see Table 6) 5 Each general modifier can accompany only certain primary statements (see Table 7) 6 Each specific modifier can accompany only primary statements within its category	Secondary Code May Accompany These Primary Codes
	200 145–147 201 21, 105, 109, 120, 131, 141, 145–147 202 105, 106, 145–146 203 109, 120, 125, 128, 131, 141, 143 204 147 205 145–147 206 145–147 207 149 208 147 209 142 210 148 211 147–148, 150 212 14, 154 213 82, 105–106, 121 214 124 215 42, 131, 145–147 220 145–147, 151 221 55, 56 222 55, 56 223 148, 149 224 128 225 22, 24–26, 37, 38 226 145–147 227 145–147 228 80, 105, 128, 155 229 109, 120, 122–123, 125, 128, 131, 141, 143 230 128, 131 231 128

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TABLE 7. General Modifier–Primary Statement Pairing Rules*

General	Modifier	May (May Not) Accompany These Primary Codes or May Be	May/
Code		Between Codes in These Categories or Groups of Categories	May Not	Location
301		1–20, 24–76, 81, 83–106, 108, 122–124	May not	b
302		1–3, 12–16, 80–82, 111–130, 145–152	May not	b, i
303		30, 31, 36, 37, 41, 60, 62, 63, 82, 107, 109, 110	May	a, b
304		21–26, 30–76, 80, 82–108, 124, 180–190	May	b
305		1–20, 27–76, 81, 85–106, 111, 122, 123, 148–150, 160–190	May not	b
306		1–20, 27–76, 81, 85–106, 111, 122, 123, 148–150, 160–190	May not	b
307		26, 30, 31, 36, 37, 41, 60–62, 185–190	May	b
308		26, 30, 31, 36, 37, 41, 60–62, 185–190	May	b
309		26, 30, 31, 36, 37, 41, 60–62, 185–190	May	b
310		C, D, E, F, G, N, H, I, J, K, L, M	May	i
312		1–3, 15, 80–82, 120–122, 128	May not	b
313		145–147	May	b
314		20–23, 33–35, 38–56, 63–76, 83–89, 180–184	May	b
315		1–3, 15, 80–82, 120–122, 128	May not	b
316		1–20, 27–76, 81, 85–106, 111, 122, 123, 148–150, 160–190	May not	b
317		C, D, E, F, G, N, H, I, J, K, L, M	May	i
318		C, D, E, F, G, N, H, I, J, K, L, M	May	i
319		C, D, E, F, G, N, 100, J, K, L, M	May	i
321		40, 55, 56, 145–147	May	b

b indicates before; a, after; and i, between.

*Not inclusive.

TABLE 8. Convenience Statements*

Code	Statement
500	Nonspecific ST-T abnormality
501	ST elevation
502	ST depression
503	LVH with ST-T changes
	Others to be added

LVH indicates left ventricular hypertrophy. *This table will be developed independently by each ECG laboratory.