ECG Criteria

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ECG Criteria
  ▸  Axis Deviation
  ▸  Conduction Disturbance
  ▸  Chamber Abnormality
  ▸  Miscellaneous

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Left Axis Deviation

Criteria

  • QRS axis between -30º and -90º
  • Dominant S wave (S > R) in lead II and aVF

Causes

Right Axis Deviation

Criteria

  • QRS axis between +90º and +180º
  • Dominant S wave (S > R) in lead I and aVL

Causes

  • Right ventricular strain

Northwest Axis (No Man's Land)

Criteria

  • QRS axis between -90º and -180º

Causes

Left Anterior Fascicular Block

Criteria

  • Frontal plane axis between -45° and -90°.
  • qR pattern in lead aVL.
  • R peak time ≥ 45 ms in lead aVL.
  • QRS duration < 120 ms.[1]

Left Posterior Fascicular Block

Criteria

  • Frontal plane axis between +90° and +180°.
  • Owing to the more rightward axis in children up to 16 years of age, this criterion should only be applied to them when a distinct rightward change in axis is documented.
  • rS pattern in leads I and aVL.
  • qR pattern in leads III and aVF.
  • QRS duration < 120 ms.[2]

Left Bundle Branch Block

Complete LBBB Criteria

  • QRS duration ≥ 120 ms (≥ 100 ms in children 4 to 16 years of age; ≥ 90 ms in children < 4 years of age).
  • Broad notched or slurred R wave in leads I, aVL, V5, and V6 and an occasional RS pattern in V5 and V6 attributed to displaced transition of QRS complex.
  • Absence of q waves in leads I, V5, and V6 (or a narrow q wave in aVL in the absence of myocardial pathology).
  • R peak time ≥ 60 ms in leads V5 and V6 but normal in leads V1, V2, and V3 (when small initial r waves can be discerned).
  • ST and T waves opposite in direction of QRS deflections.[3]

Incomplete LBBB Criteria

  • QRS duration 110 - 120 ms (90 - 100 ms in children 4 to 16 years of age; 80 - 90 ms in children < 4 years of age).
  • Presence of left ventricular hypertrophy pattern.
  • R peak time ≥ 60 ms in leads V4, V5, and V6.
  • Absence of q wave in leads I, V5, and V6.[4]

Right Bundle Branch Block

Complete RBBB Criteria

  • QRS duration ≥ 120 ms (≥ 100 ms in children 4 to 16 years of age; ≥ 90 ms in children < 4 years of age).
  • rsr', rsR', or rSR' in leads V1 or V2.
  • The R' or r' deflection is usually wider than the initial R wave.
  • In a minority of patients, a wide and often notched R wave pattern may be seen in lead V1 and/or V2.
  • S wave of greater duration than R wave or ≥ 40 ms in leads I and V6.
  • R peak time ≥ 50 ms in lead V1 but normal in leads V5 and V6.[5]

Incomplete RBBB Criteria

  • QRS duration 110 - 120 ms (90 - 100 ms in children 4 to 16 years of age; 80 - 90 ms in children < 4 years of age).
  • rsr', rsR', or rSR' in leads V1 or V2.
  • S wave of greater duration than R wave or ≥ 40 ms in leads I and V6.
  • R peak time ≥ 50 ms in lead V1 but normal in leads V5 and V6.[6]

Nonspecific or Unspecified Intraventricular Conduction Disturbance

Criteria

  • QRS duration ≥ 110 ms (≥ 90 ms in children 8 to 16 years of age; ≥ 80 ms in children < 8 years of age).
  • Absence of criteria for LBBB or BBBB.[7]

Ventricular Preexcitation of Wolff-Parkinson-White Type

Criteria

  • PR interval < 120 ms during sinus rhythm assuming no intra-atrial or interatrial conduction block (or < 90 ms in children).
  • Delta wave: slurring of initial portion of the QRS complex, which either interrupts the P wave or arises immediately after its termination.
  • QRS duration > 120 ms (or > 90 ms in children).
  • Secondary ST and T wave changes.[8]

Left Atrial Enlargement

Criteria

  • P wave duration ≥ 110 ms (sensitivity 62%; specificity 86%)[9]
  • Negative phase of P wave in V1 ≥ 40 ms (sensitivity 20%; specificity 98%)
  • P terminal force in V1 ≥ 40 msec-mm (sensitivity 56%; specificity 95%)
  • Negative phase of P wave in V1 > 1 mm
  • Notched P wave with interpeak interval > 40 ms
  • P wave/PR duration > 1.6

Right Atrial Enlargement

Criteria

  • A tall upright P wave in lead II (> 2.5 mm), often with a peaked or pointed appearance.
  • Prominent initial positivity of the P wave in V1 or V2 (≥ 1.5 mm).

Left Ventricular Hypertrophy

Criteria

  • Romhilt-Estes criteria (4 points = probable, 5 points = definite):
  • Largest R or S in limb leads ≥ 20 mm or S in V1 or V2 ≥ 30 mm or R in V5 or V6 ≥ 30 mm (3 points)
  • ST displacement opposite to QRS deflection: without digoxin (3 points); with digoxin (1 point)
  • LAA (3 points)
  • LAD (2 points)
  • QRS duration ≥ 90 ms (1 point)
  • Intrinsicoid deflection (QRS onset to peak of R) in V5 or V6 ≥ 50 ms (1 point)
  • Sokolow-Lyon criteria:
  • S in V1 + R in V5 or V6 ≥35 mm
  • R in aVL ≥11 mm
  • Cornell criteria:
  • R in aVL + S in V3 >28 mm in men or >20 mm in women
  • If LAD or LAFB, S in lead III + max (R+S) in precordial leads ≥ 30 mm

Right Ventricular Hypertrophy

Criteria

  • Increased R/S ratio in V1 (> 1)
  • Tall R wave in V1 (> 6 mm)
  • Deep S wave in V5 (> 10 mm) or V6 (> 3 mm)
  • Drop in R/S ratio across precordium (R/S ratio in V1 > R/S ratio in V3 or V4)

Biventricular Hypertrophy

Criteria

  • ECG criteria for LVH plus the presence of:
  • Prominent S waves in V5 or V6
  • Right axis deviation
  • Tall biphasic R/S complexes
  • Right atrial enlargement

Pathologic Q Wave

QT Prolongation

Criteria

  • QTc > 450 ms in males or > 460 ms in females.[10][11]

Causes

  • Congenital
  • Medications
  • Autonomic dysfunction
  • Electrolyte imbalances
  • Miscellaneous

Poor R Wave Progression

Criteria

  • Loss of anterior forces without frank Q waves in precordial leads (decrease in R wave amplitude from V1 to V2, or V2 to V3, or V3 to V4)
  • R wave in V3 ≤ 3 mm

Causes

ST Elevation

ST Depression

T Wave Inversion

Low Voltage

References

  1. ↑ Surawicz, Borys, Rory Childers, Barbara J. Deal, Leonard S. Gettes, James J. Bailey, Anton Gorgels, E. William Hancock, et al. “AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances: 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.” Journal of the American College of Cardiology 53, no. 11 (March 17, 2009): 976–81. doi:10.1016/j.jacc.2008.12.013.
  2. ↑ Surawicz, Borys, Rory Childers, Barbara J. Deal, Leonard S. Gettes, James J. Bailey, Anton Gorgels, E. William Hancock, et al. “AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances: 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.” Journal of the American College of Cardiology 53, no. 11 (March 17, 2009): 976–81. doi:10.1016/j.jacc.2008.12.013.
  3. ↑ Surawicz, Borys, Rory Childers, Barbara J. Deal, Leonard S. Gettes, James J. Bailey, Anton Gorgels, E. William Hancock, et al. “AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances: 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.” Journal of the American College of Cardiology 53, no. 11 (March 17, 2009): 976–81. doi:10.1016/j.jacc.2008.12.013.
  4. ↑ Surawicz, Borys, Rory Childers, Barbara J. Deal, Leonard S. Gettes, James J. Bailey, Anton Gorgels, E. William Hancock, et al. “AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances: 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.” Journal of the American College of Cardiology 53, no. 11 (March 17, 2009): 976–81. doi:10.1016/j.jacc.2008.12.013.
  5. ↑ Surawicz, Borys, Rory Childers, Barbara J. Deal, Leonard S. Gettes, James J. Bailey, Anton Gorgels, E. William Hancock, et al. “AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances: 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.” Journal of the American College of Cardiology 53, no. 11 (March 17, 2009): 976–81. doi:10.1016/j.jacc.2008.12.013.
  6. ↑ Surawicz, Borys, Rory Childers, Barbara J. Deal, Leonard S. Gettes, James J. Bailey, Anton Gorgels, E. William Hancock, et al. “AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances: 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.” Journal of the American College of Cardiology 53, no. 11 (March 17, 2009): 976–81. doi:10.1016/j.jacc.2008.12.013.
  7. ↑ Surawicz, Borys, Rory Childers, Barbara J. Deal, Leonard S. Gettes, James J. Bailey, Anton Gorgels, E. William Hancock, et al. “AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances: 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.” Journal of the American College of Cardiology 53, no. 11 (March 17, 2009): 976–81. doi:10.1016/j.jacc.2008.12.013.
  8. ↑ Surawicz, Borys, Rory Childers, Barbara J. Deal, Leonard S. Gettes, James J. Bailey, Anton Gorgels, E. William Hancock, et al. “AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram: Part III: Intraventricular Conduction Disturbances: 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.” Journal of the American College of Cardiology 53, no. 11 (March 17, 2009): 976–81. doi:10.1016/j.jacc.2008.12.013.
  9. ↑ Hazen MS, Marwick TH, Underwood DA (1991). "Diagnostic accuracy of the resting electrocardiogram in detection and estimation of left atrial enlargement: an echocardiographic correlation in 551 patients". Am Heart J. 122 (3 Pt 1): 823–8. PMID 1831587.
  10. ↑ Rautaharju PM, Surawicz B, Gettes LS, Bailey JJ, Childers R, Deal BJ; et al. (2009). "AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part IV: the ST segment, T and U waves, and the QT interval: 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". J Am Coll Cardiol. 53 (11): 982–91. doi:10.1016/j.jacc.2008.12.014. PMID 19281931.
  11. ↑ Drug and Therapeutics Bulletin (2016). "QT interval and drug therapy". BMJ. 353: i2732. doi:10.1136/bmj.i2732. PMID 27334640.
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