AHA/ACC/HRS SCIENTIFIC STATEMENT
Recommendations for the Standardization and Interpretation of the ElectrocardiogramPart 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 and
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
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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Disclosures
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Writing Group Disclosures
| Writing Group Member |
Employment |
Research Grant |
Other Research Support |
Speakers' Bureau/Honoraria |
Ownership Interest |
Consultant/ Advisory Board |
Other |
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| 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,*
Covance Diagnostics* |
None |
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| * Significant. |
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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.
Reviewer Disclosures
| Reviewer |
Employment |
Research Grant |
Other Research Support |
Speakers' Bureau/Honoraria |
Ownership Interest |
Consultant/ Advisory Board |
Other |
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| 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 Medical, Bard Electrophysiology |
None |
None |
None |
None |
None |
| 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 |
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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.
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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 Foundation, 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.
When citing this document, the American Heart Association, the American College of Cardiology Foundation, and the Heart Rhythm Society request that the following citation format be used: Mason JW, Hancock EW, Gettes LS. 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 Foundtion; and the Heart Rhythm Society. J Am Coll Cardiol 2007;49:1128–35.
This article has been copublished in the March 13, 2007, issue of Circulation and in the March 2007 issue of Heart Rhythm.
Copies: For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints{at}elsevier.com.
Permissions: 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.
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References
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1. Kligfield P, Gettes L, Bailey JJ, et al. 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 J Am Coll Cardiol 2007;49:1109-1127.[Abstract/Free Full Text]2. Bogaty P, Boyer L, Rousseau L, Arsenault M. Is anteroseptal myocardial infarction an appropriate term? Am J Med 2002;113:37-41.[CrossRef][Web of Science][Medline] 3. Selvanayagam JB, Kardos A, Nicolson D, et al. Anteroseptal or apical myocardial infarction: a controversy addressed using delayed enhancement cardiovascular magnetic resonance imaging J Cardiovasc Magn Reson 2004;6:653-661.[CrossRef][Web of Science][Medline] 4. Bayes de Luna A, Cino JM, Pujadas S, et al. Concordance of electrocardiographic patterns and healed myocardial infarction location detected by cardiovascular magnetic resonance Am J Cardiol 2006;97:443-451.[CrossRef][Web of Science][Medline] 5. Bayes de Luna A, Wagner G, Birnbaum Y, et al. 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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Top
Abstract
Organization and Use