Circulation. 2007;115:1325-1332
Published online before print February 23, 2007,
doi: 10.1161/CIRCULATIONAHA.106.180201
(Circulation. 2007;115:1325-1332.)
© 2007 American Heart Association, Inc.
AHA/ACC/HRS Scientific Statements |
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
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Abstract
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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.
Key Words: AHA Scientific Statements • electrocardiography • computers • diagnosis
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Introduction
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This is the second of 6 articles designed to upgrade the guidelines
for the standardization and interpretation of 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.
1
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 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.
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Organization and Use
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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.
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Criteria for Diagnoses
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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.
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Myocardial Infarction Terminology
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Advanced imaging techniques, including echocardiography
2 and
magnetic resonance,
3,4 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.
5 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.
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Acknowledgments
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Disclosures
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Footnotes
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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?Identifier=4431. 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.
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References
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- 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: –.
- Bogaty P, Boyer L, Rousseau L, Arsenault M. Is anteroseptal myocardial infarction an appropriate term? Am J Med. 2002; 113: 37–41.[CrossRef][Medline]
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- 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.[CrossRef][Medline]
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- 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.[CrossRef][Medline]
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- 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.[Free Full Text]
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Abstract
Introduction