ECG Measurments and Interpretation Programs

Art. no.: 714251 rev.: a

Physician’s Guide
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Article No: 714251 rev.: a

SAG 2.510809
Issue date: 23.06.09
 User Guide CP300

Table of content
1 Importend notices ................................................ 5
1.1 Disclaimer ........................................................................................................... 5
1.2 Physicians Responsibility .................................................................................... 5

2 Definition of Terms............................................... 7
2.1 Heart Rates (HR) ................................................................................................ 7
2.2 Intervals ............................................................................................................... 7
2.3 Electrical Axis ...................................................................................................... 8
2.4 Examples ............................................................................................................ 9

3 Measurements .................................................... 11

4 Interpretation statements .................................. 13

4.1 Statement of Confidence ................................................................................... 13
4.2 Procedure for Evaluation ................................................................................... 13
4.3 Statements Indicating Level of Confidence ....................................................... 14
4.4 Paediatric ECG Interpretation ........................................................................... 14

5 Rhythm Statements............................................ 15
5.1 Atrial premature complex(es) ............................................................................ 15
5.2 Ventricular premature complex(es) ................................................................... 15
5.3 Atrial escape complex(es) ................................................................................. 15
5.4 Ventricular escape complex(es) ........................................................................ 15
5.5 Interpolated atrial premature complexe) ........................................................... 15
5.6 Interpolated ventricular premature complexes .................................................. 16
5.7 Complexes with aberrant intraventricular conduction ....................................... 16
5.8 Sinus rhythm ..................................................................................................... 16
5.9 Sinus arrhytmia ................................................................................................. 16
5.10 Sinus bradycardia ............................................................................................. 16
5.11 Sinus tachykardia .............................................................................................. 16
5.12 Supraventricular rhythm .................................................................................... 16
5.13 Supraventricular arrhytmia ................................................................................ 17
5.14 Supraventricular tachycardia ............................................................................. 17
5.15 Junctional rhythm .............................................................................................. 17
5.16 Accelerated junctional rhythm ........................................................................... 17
5.17 Regular rhythm, no P wave found ..................................................................... 17
5.18 Idioventricular rhythm ........................................................................................ 17
5.19 Ventricular tachycardia ...................................................................................... 17
5.20 Atrial fibrillation .................................................................................................. 17
5.21 Atrial flutter ........................................................................................................ 18
Art. no.: 714251 rev.: a

5.22 Atrial fibrillation / flutter with rapid ventricular response .................................... 18

5.23 Second / third degree AV-Block ........................................................................ 18
5.24 Pacemaker spikes noted ................................................................................... 18

6 Electrical Axes.................................................... 19
6.1 Abnormal left axis deviation .............................................................................. 19
6.2 Leftward Axis ..................................................................................................... 19
6.3 Rightwards Axis ................................................................................................ 19
6.4 Abnormal right axis deviation ............................................................................ 19
6.5 Abnormal right superior axis deviation .............................................................. 19
6.6 Indeterminate axis ............................................................................................. 19

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 7 Atrial Activity Statements ................................. 21
7.1 Definition of P terminal force ............................................................................. 21
7.2 Possible left atrial abnormality .......................................................................... 21
7.3 Left atrial abnormality ........................................................................................ 21
7.4 Right atrial enlargement .................................................................................... 21
7.5 Biatrial enlargement .......................................................................................... 21
7.6 Prolonged P-R interval ...................................................................................... 22

8 ECG Voltage Statements................................... 23

8.1 Low limb lead voltage ....................................................................................... 23
8.2 Low voltage ....................................................................................................... 23

9 Blocks ................................................................. 25
9.1 Right bundle branch block ................................................................................ 25
9.2 Incomplete right bundle branch block ............................................................... 25
9.3 Left bundle branch block ................................................................................... 25
9.4 Incomplete left bundle branch block ................................................................. 25
9.5 Nonspecific intraventricular block ..................................................................... 25
9.6 Nonspecific intraventricular delay ..................................................................... 25
9.7 Left anterior fascicular block ............................................................................. 25
9.8 Left posteriot fascicular block ............................................................................ 26
9.9 Bifascicular block .............................................................................................. 26

10 QRS Abnormality Statements........................... 27

10.1 QRS (T) contour abnormality, cannot rule out anteroseptal myocardial damage 27
10.2 QRS (T) contour abnormality, cannot rule out anterolateral myocardial damage 27
10.3 QRS (T) contour abnormality, cannot rule out lateral myocardial damage ....... 27
10.4 QRS (T) contour abnormality, cannot rule out inferior myocardial damage ...... 27

11 Myocardial Infarction Statements .................... 29

11.1 QRS (T) contour abnormality, consider ...infarct ............................................... 29
11.2 QRS (T) contour abnormality, consistent with....infarct ..................................... 29

12 ST-T Morphology Statements........................... 31

12.1 ST-T Elevation, consider acute anterior infarct ................................................. 31
12.2 ST-T Elevation, consider acute interior infarct .................................................. 31
12.3 ST abnormality, possible anteroseptal subendocardial injury ........................... 31
12.4 ST abnormality, possible anterior subendocardial injury .................................. 31
12.5 ST abnormality, possible anterolateral subendocardial injury ........................... 31
12.6 ST abnormality, possible lateral subendocardial injury ..................................... 31
12.7 ST abnormality, possible high lateral subendocardial injury ............................. 31
12.8 ST abnormality, possible inferior subendocardial injury .................................... 32
12.9 ST abnormality, possible inferolateral injury ..................................................... 32
12.10 Nonspecific ST depression ............................................................................... 32
Art. no.: 714251 rev.: a

12.11 ST & T abnormality, consider anteroseptal ischemia or right ventricular strain 32

12.12 ST & T abnormality, consider anterior ischemia or left ventricular strain .......... 32
12.13 ST & T abnormality, consider anterolateral ischemia or left ventricular strain .. 32
12.14 ST & T abnormality, consider lateral ischemia or left ventricular strain ............ 33
12.15 ST & T abnormality, consider high lateral ischemia or left ventricular strain .... 33
12.16 ST & T abnormality, consider inferior ischemia or left ventricular strain ........... 33
12.17 ST & T abnormality, consider inferiorlateral ischemia or left ventricular srain . 33
12.18 ST & T abnormality, consider recent .... myocardial or pericardial damage ..... 33
12.19 Nonspecific ST-T abnormality (elevation) ......................................................... 33
12.20 T abnormality in anteroseptal leads .................................................................. 34
12.21 T abnormality in anterior leads .......................................................................... 34
12.22 T abnormality in anterolateral leads .................................................................. 34

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 User Guide CP300

12.23 T abnormality in lateral leads ............................................................................ 34

12.24 T abnormality in high lateral leads .................................................................... 34
12.25 T abnormality in inferior leads ........................................................................... 34
12.26 T abnormality in inferiorlateral leads ................................................................. 34
12.27 Nonspecific T abnormality ................................................................................. 34
12.28 T-wave table (amplitudes in mV) ....................................................................... 35

13 QT Interval........................................................... 37
13.1 Prolonged QT .................................................................................................... 37

14 Hypertrophy Statements.................................... 39
14.1 Left ventricular hypertrohy ................................................................................. 39
14.2 Moderate amplitude criteria for left ventricular hypertrophy .............................. 39
14.3 Amplitude criteria for left ventricualr hypertrophy .............................................. 39
14.4 Consider left ventricular hypertophy .................................................................. 39
14.5 Left ventricular hypertophy ................................................................................ 40
14.6 Right ventricular hypertophy ............................................................................. 40
14.7 Consider right ventricular hypertophy ............................................................... 40
14.8 Right ventricular hypertophy ............................................................................. 40

15 Miscellaneous Statements ................................ 41

15.1 S1, S2, S3 pattern ............................................................................................. 41
15.2 WPW pattern, type A ......................................................................................... 41
15.3 Consider WPW, type B ..................................................................................... 41
15.4 R-S transition zone in V leads displaced to the right ......................................... 41
15.5 R-S transition zone in V leads displaced to the left ........................................... 41
15.6 *Possible reversal of the arm leads ................................................................... 41

16 Low Sensitivity Statements............................... 43

17 Pediatric Interpretation ...................................... 45

17.1 Rhythm analysis ................................................................................................ 45
17.2 WPW syndrom .................................................................................................. 45
17.3 Analysis of ST segment and T wave ................................................................. 45
17.4 Dextrocardia ...................................................................................................... 45
17.5 Interpretation of P wave .................................................................................... 46
17.6 Determination of electrical axis ......................................................................... 46
17.7 ECG Voltages ................................................................................................... 46
17.8 Intraventricular conduction delay ...................................................................... 46
17.9 Prolonged QT .................................................................................................... 47
17.10 Ventricular hypertrophy ..................................................................................... 47

18 Thrombolysis Interpretation.............................. 49
Art. no.: 714251 rev.: a

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Page 4
Art. no.: 714251 rev.: a
 User Guide Importend notices 1

1 Importend notices
1.1 Disclaimer
The Information in this guide has been carefully checked for reliability; however no guarantee
is given as to the correctness of the contents and SCHILLER makes no representations or war-
ranties regarding the contents of this Guide. We reserve the right to revise this document and
make changes in the specification of the product described within at any time without obligation
to notify any person of such revision or change.

1.2 Physicians Responsibility

The Schiller Interpretation and Measurement program is provided for the exclusive use of qual-
ified physicians or personal under their direct supervision. The numerical and graphical results,
and the interpretation of a recording must be examined with respect to the patients overall clin-
ical condition. The recording preparation quality and the general recorded data quality, which
could effect the report data accuracy, must also be taken into account. It is the physicians re-
sponsibility to make the diagnosis or to obtain expert opinion on the results, and to institute cor-
rect treatment if indicated

The information contained in this guide provides an explanation of the measurements and in-
terpretation statements that can be obtained with a resting ECG recorded with the CP300. The
measurement and the interpretation programs, developed over many years, provide one of the
most accurate ECG analysis packages available on the market today.
Art. no.: 714251 rev.: a

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1 Importend notices

Art. no.: 714251 rev.: a

Page 6
 User Guide Definition of Terms 2

2 Definition of Terms
When an auto mode ECG is taken by a Schiller unit with the ECG Interpretation or Measure-
ments option installed, the program documents various measurements derived from the ECG.
This data forms the basis for the interpretation. The following pages define what the measure-
ments are, and how they are derived.

Pat- Name: HR 75 /min

Pat-No:
Born: 25.09.34 Intervals:
RR 800 ms
P 105 ms
Age: 63 PR 160 ms
Sex: M QRS 105 ms
Height: 162cm QT 362 ms
Weight: 74 kg QTC 404 ms
BP: 140 / 90 mmHg
Med: Axis:
Rem.: P 28 o
QRS 39 o
T 38 o
Tu 24 Sep 99 08:44:04

2.1 Heart Rates (HR)

Heart rates (HR) from 30 - 250 beats per minute are measured.

Average heart rate (HR) calculated on the basis of the entire 10 second recording and shown
as number of beats per minute.

2.2 Intervals

RR Average time interval between two consecutive QRS complexes.

P P Wave Duration: the time between the beginning of the first detected P-wave from all 12 aver-
aged leads, to the end of the last detected P-wave from all 12 averaged leads.
Art. no.: 714251 rev.: a

PR PR interval: the period of time between the beginning of the first P-wave taken from all 12 av-
eraged leads, and the beginning of the first detected Q-wave taken from all 12 averaged leads.

QRS The duration of the QRS complex taken from the beginning of the first detected Q-wave from
all 12 averaged QRS complexes, to the end of the last S-wave from all 12 averaged QRS com-
plexes.

QT Interval between the beginning of the first QRS (beginning of ventricular depolarisation) taken
from all 12 averaged leads, and the end of the last T-wave (end of repolarisation phase) taken
from all 12 averaged leads.

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2 Definition of Terms

QTC Normalised QT interval.As the QT interval is dependent on the heart rate it is often converted
to the normalised QTC interval i.e. the QT interval that the patient would show at a heart rate of
60 / min. Usually, the QTC value is 390 + 40 ms.

The conversion is according to Bazetts` formula:

1000
QTC = QT x
RR

All measurements are in milliseconds.

2.3 Electrical Axis

The SCHILLER measurement program calculates the axes on the basis of the maximum de-
flection of the relevant waves in leads I and aVF.

The electrical axes of the heart are determined separately for the P, QRS and T waves. They
indicate the main spreading direction of the electrical vector in the frontal plane.

aVF

The following formula is used for the calculation:

Art. no.: 714251 rev.: a

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 User Guide Definition of Terms 2

2.4 Examples

Taking the example above we get:

aVF
Art. no.: 714251 rev.: a

-90 o

1.82 (lead I Q+R+S+R`+S`)

-180o I
40o
1.51 (lead aVF Q+R+S+R`+S`)

aVF

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2 Definition of Terms

Normal Range 0° to 90°

Abnormal left axis deviation -90° to -30°
Leftward axis -30° to 0°
Rightward axis +90° to + 110°
Abnormal right axis deviation +110° to +180°
Abnormal right superior axis deviation -90° to -180°

Large discrepancies may be found between two measurements with faint P and T
waves. Also breathing and the position of the patient (recumbent / standing) can re-
sult in changes in the electrical axes.

Art. no.: 714251 rev.: a

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 User Guide Measurements 3

3 Measurements
The Schiller measurement program provides a table with lead specific measurement results. In
12 columns i.e. one for each lead, the amplitude values of P, Q, R ,S, T and R', S', T' waves,
the J point and the ST integral are listed in millivolts. The amplitude measurements relate to a
reference value that corresponds to the signal value immediately before the beginning of the
QRS. For P measurment the zero value at Pon is determined as a mean value in an interval
from Pon -20 ms to Pon inclusive. The duration of the Q, R, S, R' and S' waves are given in
milliseconds (rounded to 2 ms) The amplitudes are given in mV (rounded to 0.01 mV).

Parameter Description Unit

P amplitude of P wave mV
Q amplitude of Q wave mV
Qd duration of Q wave ms
R amplitude of R wave mV
Rd duration of R wave ms
S amplitude of S wave mV
Sd duration of S wave ms
R' amplitude of R' wave mV
R'd duration of R' wave ms
S' amplitude of S' wave mV
S'd duration of S' wave ms
J amplitude of J point mV
ST ST integral : averaged amplitude of the ST segment mV
( from the J point to half the distance between the J-point and max.
T wave)
T amplitude of the T wave mV
T' amplitude of the T' wave (in case of biphasic T wave) mV

intrinsicoid deflection point

J- POINT

R
ST

R` T
P
Art. no.: 714251 rev.: a

Q S`

S`d S
R`d

Sd

Rd

Qd

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 3

Page 12
Measurements

Art. no.: 714251 rev.: a

 User Guide Interpretation statements 4

4 Interpretation statements
4.1 Statement of Confidence
The Schiller ECG Interpretation program is designed to assist the physician in reading and eval-
uating an ECG printout. It was developed in cooperation with leading cardiologists and evolved
over many years; extensive checking has been carried out using, among others, the CSE1 di-
agnostic data base. However, no program is completely infallible and interpretative standards
and criteria can and do vary between cardiologists and programs. Never rely solely on the state-
ments given with any computerised interpretation program; a machine cannot deliver a com-
plete diagnosis on the basis of the ECG alone without a considerable amount of additional in-
formation. Always obtain physician’s confirmation.

 The statements given with this or any interpretation program do not replace a detailed re-
port by the physician. The comprehensive clinical diagnosis of a patient is the physician’s
responsibility and privilege.
 The ECG evaluation should always be systematic and conducted in a predetermined or-
der.
 Before each ECG evaluation, verification that the recording was carried out correctly must
be made.
 It should also be determined whether the patient received any heart-active medication
(digitalis, beta-blockers, anti-arrhythmics, diuretics etc.) before the recording that could af-
fect the recording.
 Examine the ECG first in accordance with the procedure given in chapter 4.2, then read
the interpretation statements.

4.2 Procedure for Evaluation

The following procedure is recommended for evaluation:

1. Determine rhythm or rhythm disturbances.

2. Determine heart rate.
3. Check duration of P, PR, QRS and QT.
4. Determine electrical axis in extremity leads and evaluate pericardial leads (R/S ratio, transi-
tional zone etc.).
5. Systematic examination of P, Q, R, S, T waves and ECG segments (ST segment etc.).
6. Brief description of exceptional and abnormal signs within each single section of the wave-
form.
7. Overall evaluation.

In this procedure, you are supported by the SCHILLER ECG interpretation program. It supplies
the necessary measurement data and suggestions for interpretation.
Art. no.: 714251 rev.: a

For an efficient evaluation of interpretation statements it is important that the patient data has
been entered, especially patient’s age and sex as well as any medication.

Each explanation is accompanied by one of the following statements:

• Normal ECG
• Otherwise normal ECG
• Borderline ECG
• Possibly abnormal ECG
• Abnormal ECG

1.Common Standards for Quantitative Electrocardiology (concerted action Project II.1.1.2.)

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4 Interpretation statements

The ECG statement that is given for each interpretive diagnostic statement is given with the di-
agnostic statements in the following pages.

If more than one interpretation statement is applicable, only the general classification statement
with the highest importance level is given on the printout.

4.3 Statements Indicating Level of Confidence

In some interpretation statements, information is provided to indicate the degree of confidence
in the diagnosis. The statements and the level of confidence associated with the statement, are
as follows:

Statement Level of Confidence

Cannot Rule Out.. c. 15%
Possible ... c. 35%
Consider.. c. 50%
Consistent with ... c. 80%

4.4 Paediatric ECG Interpretation

A special section at the end of this book details the interpretation of paediatric ECGs. The
SCHILLER interpretation program automatically distinguishes between adults and pediatric by
using the date of birth as a basis for computing the ECG interpretation.

Art. no.: 714251 rev.: a

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 User Guide Rhythm Statements 5

5 Rhythm Statements
5.1 Atrial premature complex(es)
One or several premature beats of the same shape as the predominant beats were detected in
the absence of atrial fibrillation and the preceding RR interval is < 80% of the RR mean and the
sum of the following RR interval is > 120% of RR mean.

(OTHERWISE NORMAL ECG)

Bigeminy will appear in addition to this statement if at least three supraventricular extrasystoles are de-
tected, each separated from the preceding one by a single predominant beat.

Trigeminy will appear in addition to this statement if at least three supraventricular extrasystoles are de-
tected, each separated from the preceding one by two predominant beats.

(ABNORMAL ECG)

5.2 Ventricular premature complex(es)

One or several premature beats, differing in shape and size from the predominant beats were
detected and the preceding RR interval is < 80% of the RR mean and the sum of the following
RR interval is > 120% of RR mean.

(ABNORMAL ECG)

Bigeminy will appear in addition to this statement if at least three ventricular extrasystoles are detected,
each separated from the preceding one by a single predominant beat

Trigeminy will appear in addition to this statement if at least three ventricular extrasystoles are detected,
each separated from the preceding one by two predominant beats.

(ABNORMAL ECG)

5.3 Atrial escape complex(es)

A beat of the same shape as the predominant beats is detected after a pause longer than 1.8
times of the predominant RR interval preceded by one or several beats of the same shape as
the predominant beats in the absence of atrial fibrillation.

(OTHERWISE NORMAL ECG)

5.4 Ventricular escape complex(es)

A beat differing in shape and size from the predominant beats is detected after a pause longer
than 1.8 times of the predominant RR interval preceded by one or several beats differing in
Art. no.: 714251 rev.: a

shape and size from the predominant beats in the absence of atrial fibrillation.

(ABNORMAL ECG)

5.5 Interpolated atrial premature complexe)

Preceding RR interval <90% of mean RR and the sum of the preceding and following RR inter-
val  120 % of RR mean. Beat of the same shape and size as the predominant beats.

(OTHERWISE NORMAL ECG)

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5 Rhythm Statements

5.6 Interpolated ventricular premature complexes

Preceding RR interval <90% of mean RR and the sum of the preceding and following RR inter-
val  120 % of RR mean. Beat of differing shape than the predominant beats.

(ABNORMAL ECG)

5.7 Complexes with aberrant intraventricular conduction

One or several beats were detected differing in shape and size from the predominant beats but
occurring in time, i.e. separated from the preceding and following beats by the predominant RR
interval. Preceding RR interval > 90% of the RR mean or the sum of the preceding RR interval
and following RR interval 180% of RR mean.

(ABNORMAL ECG)

5.8 Sinus rhythm

A P wave was detected in the averaged ECG cycle, the heart rate ranged from 50 to 100 beats
per minute, and the difference in the duration of the RR intervals between the predominant
beats was no greater than 15%.

(NORMAL ECG)

5.9 Sinus arrhytmia

A P wave was detected in the averaged ECG cycle, the heart rate ranged from 50 to 100 beats
per minute, and the difference in the duration of the RR intervals between the predominant
beats was greater than 15% in at least 3 intervals and no interpolated premature atrial complex-
es, premature atrial complexes, atrial escape complexes or bigemy or trigemy were detected.

(OTHERWISE NORMAL ECG)

5.10 Sinus bradycardia

A P wave was detected in the averaged ECG cycle, and the heart rate was less than 50 beats
per minute.

(OTHERWISE NORMAL ECG)

As above but heart rate 40 beats (ABNORMAL ECG)

5.11 Sinus tachykardia

A P wave was detected in the averaged ECG cycle, and the heart rate was greater than 100
beats per minute.

(OTHERWISE NORMAL ECG)

Art. no.: 714251 rev.: a

5.12 Supraventricular rhythm

A P wave was detected in the averaged ECG cycle, the heart rate ranged from 50 to 100 beats
per minute, and the difference in the duration of the RR intervals between the predominant
beats was no greater than 15% but frontal P axis <-20o or > 100o

(POSSIBLY ABNORMAL ECG)

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 User Guide Rhythm Statements 5

5.13 Supraventricular arrhytmia

A P wave was detected in the averaged ECG cycle, the heart rate ranged from 50 to 100 beats
per minute, and the difference in the duration of the RR intervals between the predominant
beats was greater than 15% but frontal P axis <-20o or > 100o

(OTHERWISE NORMAL ECG)

5.14 Supraventricular tachycardia

The heart rate was greater than 130 beats per minute and the QRS duration < 140 ms.

(OTHERWISE NORMAL ECG)

5.15 Junctional rhythm

No P wave detected in the averaged ECG cycle, QRS duration 140 ms, heart rate  60 / min.
The difference in the duration of the RR intervals between the predominant beats was < 15%.

(ABNORMAL ECG)

5.16 Accelerated junctional rhythm

No P wave detected in the averaged ECG cycle, QRS duration  140 ms, heart rate  130 / min.
(child up to 200). The difference in the duration of the RR intervals between the predominant
beats was < 15%.

(ABNORMAL ECG)

5.17 Regular rhythm, no P wave found

No P wave was detected in the averaged ECG cycle and the QRS duration of the predominant
beats was < 140 ms. The heart rate was between 40 and 140 beats per minute. There was less
than 15% difference in the duration of the RR intervals between the predominant beats.

(POSSIBLY ABNORMAL ECG)

5.18 Idioventricular rhythm

No P wave was detected in the averaged ECG cycle and the QRS duration of the predominant
beats was greater than 140 ms. The heart rate was less than or equal to 40 beats per minute,
and there was less than 15% difference in the duration of the RR intervals between the predom-
inant beats.

(ABNORMAL ECG)

5.19 Ventricular tachycardia

No P wave was detected in the averaged ECG cycle and the QRS duration of the predominant
Art. no.: 714251 rev.: a

beats was greater than 140 ms. The heart rate was greater than or equal to 140 beats per
minute, and there was less than 15% difference in the duration of the RR intervals between the
predominant beats.

(ABNORMAL ECG)

5.20 Atrial fibrillation

No P wave was detected in the averaged ECG cycle, the heart rate was less than 100 beats
per minute, and there was at least 15% difference in the duration of at least one RR interval
between the predominant beats.

(ABNORMAL ECG)

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5 Rhythm Statements

5.21 Atrial flutter

Rate of P wave 160 min., amplitude > 175V in one of the leads II, V1, or V2. Rate of P wave
is different from the QRS rate.

(ABNORMAL ECG)

5.22 Atrial fibrillation / flutter with rapid ventricular response

No P wave was detected in the averaged ECG cycle, the heart rate was equal to or greater than
100 beats per minute, and there was at least 15% difference in the duration of at least one RR
interval between the predominant beats.

(ABNORMAL ECG)

5.23 Second / third degree AV-Block

P wave with a higher rate than the QRS rate in beats / min. have been detected. Most PP inter-
vals lie within 15% of normal median or double median. Minimum mean PP > 500 ms; minimum
PP > 375 ms

(ABNORMAL ECG)

5.24 Pacemaker spikes noted

More than two typical pacemaker spikes were detected in at least two leads of the original ECG
data recorded over 10 seconds.

(ABNORMAL ECG)

Art. no.: 714251 rev.: a

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 User Guide Electrical Axes 6

6 Electrical Axes
The electrical axis is computed on the basis of the algebraic sum of the amplitudes and deflec-
tions of the QRS complex in leads I and aVF. The possible findings with their corresponding
ranges are as follows:

6.1 Abnormal left axis deviation

 -90O to  -30O

ABNORMAL ECG

6.2 Leftward Axis

< -30O to  0O

OTHERWISE NORMAL ECG

6.3 Rightwards Axis

< +90O to  +110O

OTHERWISE NORMAL ECG

6.4 Abnormal right axis deviation

< +110O to  +180O

ABNORMAL ECG

6.5 Abnormal right superior axis deviation

< -90O to  -180O

ABNORMAL ECG

6.6 Indeterminate axis

The algebraic sum of the deflections of the QRS complex in leads I and aVF ranged between -
0.15 mV and +0.15 mV.

(BORDERLINE ECG)
Art. no.: 714251 rev.: a

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 6

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Electrical Axes

Art. no.: 714251 rev.: a

 User Guide Atrial Activity Statements 7

7 Atrial Activity Statements

7.1 Definition of P terminal force

P terminal negative duration (ms)

P amplitude (mV)

P Terminal Force = (P negative amplitude) * (P terminal negative duration) mVms

7.2 Possible left atrial abnormality

P terminal negative force (maximal negative amplitude of P times terminal negative phase of P)
in V1 is -6 mVms > P terminal force -8 mVms. Terminal negative phase > 60 ms, max. nega-
tive P amplitude in V1 -0.1 mv.

(POSSIBLY ABNORMAL ECG)

7.3 Left atrial abnormality

P terminal negative force (maximal negative amplitude < -0.1 mV times terminal negative phase
of P) in V1 is -8 mVms > P terminal force. Terminal negative phase > 60 ms, maximum negative
P amplitude in V1 is  -0.1 mv.

(ABNORMAL ECG)

7.4 Right atrial enlargement

For the detection of a right atrial enlargement (P duration  140 ms), points are allocated to dif-
ferent ECG characteristics possibly caused by this condition according to the following criteria:

P-amplitude in II: 1 point if 0.25 mV  P amplitude < 0.3 mV.

2 points if the P amplitude  0.3 mV.
P-amplitude in III: 1 point if 0.25 mV  P amplitude < 0.3 mV.
2 points if the P amplitude  0.3 mV.
P-amplitude in aVF: 1 point if 0.25 mV  P amplitude < 0.3 mV.
2 points if the P amplitude  0.3 mV.
Art. no.: 714251 rev.: a

The test for right atrial enlargement yielded at least three points.

(POSSIBLY ABNORMAL ECG)

7.5 Biatrial enlargement

The conditions for (possible) left atrial abnormality and right atrial enlargement (at least two
points in the test) have been satisfied.

(ABNORMAL ECG)

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7 Atrial Activity Statements

7.6 Prolonged P-R interval

The duration of the P-R interval was longer than:

 21    4 10  RRinterval     20   ms 

or 220 ms, whichever is less with a lower limit of 205 ms.

(ABNORMAL ECG)

Art. no.: 714251 rev.: a

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 User Guide ECG Voltage Statements 8

8 ECG Voltage Statements

8.1 Low limb lead voltage
The sum of the peak-to-peak QRS amplitudes in leads I, II and III was 1.5 mV or less, and the
difference between the maximal QRS amplitudes in V4-V6 and the minimal QRS amplitudes in
V1-V3 was > 0.7 mV.

(POSSIBLY ABNORMAL ECG)

8.2 Low voltage

The sum of the peak-to-peak QRS amplitudes in leads I, II and III is 1.5 mV or less, and the
difference between the maximal QRS amplitudes (= max R, R') in V4-V6 and the minimal
QRS amplitudes (= min Q, S, S') in V1-V3 is 0.7 mV or less.

( (ppI; ppII, ppIII)  1.5 mV) and

pp
((the maximal amplitude (R, R') from one of the leads V4, V5, V6) -
the minimal amplitiude (Q, S, S') from one of the leads V1, V2, V3)  0.7 mV)

(ABNORMAL ECG)
Art. no.: 714251 rev.: a

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8 ECG Voltage Statements

Art. no.: 714251 rev.: a

Page 24
 User Guide Blocks 9

9 Blocks
9.1 Right bundle branch block
The total duration of QRS was at least 130 ms. The R/S ratio in lead V2 was greater than 1, or
an S wave deeper than 0.20 mV was detected in leads I and V6. In lead V1 or lead V2 a QRS
complex of the (Q)RSR’ type was found. Time of occurrence of the intrinsicoid deflection in V1
and V2 > 60 ms after QRS onset.

(ABNORMAL ECG)

9.2 Incomplete right bundle branch block

The total duration of QRS was shorter than 130 ms. In lead V1 or lead V2 a notched QRS com-
plex or a QRS complex of the RSR’ type was detected. Time of occurrence of the intrinsicoid
deflection in V1 and V2 > 60 ms after QRS onset.

(OTHERWISE NORMAL ECG)

9.3 Left bundle branch block

The total duration of QRS was at least 130 ms. The R/S ratio in lead V2 was less than 1. If an
S wave was found in leads I and V6, it was not deeper than -0.2 mV and the R/S ratio was  1.
The Q wave amplitude in either lead I or lead V6 was  -0.09 mV and mean absolute spatial
velocity in the second third of the QRS < 58.5 mV/s

(ABNORMAL ECG)

9.4 Incomplete left bundle branch block

Same as left bundle branch block, except that the total duration of QRS was shorter than 130
ms and longer than or equal to 120 ms.

(POSSIBLY ABNORMAL ECG)

9.5 Nonspecific intraventricular block

The total duration of QRS was at least 130 ms. The criteria for left bundle branch block, right
bundle branch block, left anterior or left posterior fascicular block were not fulfilled.

(ABNORMAL ECG)

9.6 Nonspecific intraventricular delay

The total duration of QRS was shorter than 130 ms but longer than or equal to 120 ms. The
criteria for incomplete left bundle branch block, incomplete right bundle branch block, left ante-
rior or left posterior fascicular block were not fulfilled.
Art. no.: 714251 rev.: a

(BORDERLINE ECG)

9.7 Left anterior fascicular block

No Q wave was present in lead aVF, i.e. the ventricular depolarisation started in a downward
direction. The R/S ratio in lead aVF was 0.6 or less, and the electrical axis ranged between -30
and -120 degrees. An S wave with an amplitude of-0.25 mV must be present in lead V6. QRS
duration 120 ms but may be longer in the presence of RBBB.

(ABNORMAL ECG)

Page 25
9 Blocks

9.8 Left posteriot fascicular block

The electrical axis ranged between +115° and +180°. The Q wave amplitudes in II, III and aVF
were 0.02 mV, and the Q durations in III, aVF were  40 ms. The R or R’ amplitude in II was
0.8 mV, and in III 1.0 mV. QRS duration 120 ms but may be longer in the presence of RBBB.

(ABNORMAL ECG)

9.9 Bifascicular block

A left anterior fascicular block or a left posterior fascicular block occurred together with a right
bundle branch block.

(ABNORMAL ECG)

Art. no.: 714251 rev.: a

Page 26
 User Guide QRS Abnormality Statements 10

10 QRS Abnormality Statements

The program looks for signs of myocardial damage/infarction in a three steps approach:

• first the vectorcardiogram, constructed out of the 12 lead electrocardiogram (X=17/

16*V6,Y=9/16(II+III), Z=(2*V6-25*V2)/54), is searched for irregularities indicative of myocar-
dial damage;
• second the repolarisation is examined for concomitant abnormalities
• third the ECG is searched for corresponding diagnostic Q/QS waves.
If only the first step yields a positive result, the modifier ‘cannot rule out’ is put out; if the first
two steps result in a positive finding, the modifier ‘consider’ is used. If all three steps yield a pos-
itive result, the modifier ‘consistent with’ is attached to the finding of myocardial damage/infarct.

CANNOT RULE OUT is substituted by CONSIDER in the following statements if in addition to

the QRS contour abnormality pathognomonic inverted T waves were detected in appropriate
leads, i.e.
• I and aVF for inferior localisation
• V1, V2 and V3 for anteroseptal localisation
• V4, V5 and V6 for anterolateral localisation
• and aVL for lateral localisation

10.1 QRS (T) contour abnormality, cannot rule out anteroseptal myocardial damage
There was a pathological start of the ventricular depolarisation. The initial momentary QRS vec-
tors were directed backward and mostly to the left, and remained in this direction during the
greater part of the ventricular depolarisation, instead of remaining directed forward for the first
30 ms then turning backwards and to the left.

(BORDERLINE ECG)

10.2 QRS (T) contour abnormality, cannot rule out anterolateral myocardial damage
The ventricular depolarisation started normally, the initial momentary QRS vectors being direct-
ed forward and to the right. However, instead of then turning to the left and backwards, the mo-
mentary QRS vectors turned further to the right and backwards.

(BORDERLINE ECG)

10.3 QRS (T) contour abnormality, cannot rule out lateral myocardial damage
The ventricular depolarisation started normally, the initial momentary QRS vectors being direct-
ed forwards and to the right. However, instead of then turning to the left and backwards, the
momentary QRS vectors remained directed forwards and more to the right than normal, i.e. the
turn to the left was postponed.
Art. no.: 714251 rev.: a

(BORDERLINE ECG)

10.4 QRS (T) contour abnormality, cannot rule out inferior myocardial damage
The initial 10 to 20 ms momentary QRS vectors were directed upward, which is still normal, but
instead of turning immediately downwards, the momentary QRS vectors remained directed up-
ward for at least the first 40 ms of the ventricular depolarisation and often remained directed
upwards during the greater part of the ventricular depolarisation.

(BORDERLINE ECG)

Page 27
10 QRS Abnormality Statements

Art. no.: 714251 rev.: a

Page 28
 User Guide Myocardial Infarction Statements 11

11 Myocardial Infarction Statements

A diagnosis of myocardial infarction requires the detection of at least one pathognomonic Q or
QS wave (Q/QS), i.e. a Q-wave which measures at least 25% of the amplitude of the following
R wave, and at least 30µV, in leads I, II, aVL, aVF, or V1 to V6, and Q duration  30 ms.

The ECG interpretation program enables the detection of myocardial infarctions within the fol-
lowing areas:

septal Q/QS in V2
anteroseptal Q/QS in at least two of the leads V1 to V3.
anterior Q/QS in V4 only, or Q/QS in V4 in combination with Q/QS in any
other lead V1 to V3 regardless of Q in V5, V6.
anterolateral Q/QS in either V5 or V6, or Q/QS in at least two of the leads V4 to
V6.
lateral Anterolateral and Q/QS in I and/or aVL
high lateral Q/QS in I and aVL
inferolateral Q/QS in II and/or aVF and Q/QS in V6
inferior Q/QS in II and/or aVF
A diagnosis of myocardial damage will be replaced by a diagnosis of myocardial infarction if a
Q/QS was detected. The patient however must be at least 30 years old otherwise INFARCT will
be substituted by MYOCARDIAL DAMAGE.

If only one Q/QS was detected in a certain area, the following diagnosis will appear:

11.1 QRS (T) contour abnormality, consider ...infarct

If more than one Q/QS was detected in a certain area, the following diagnosis will appear:

11.2 QRS (T) contour abnormality, consistent with....infarct

Exception: The septal location is always associated with „cannot rule out“’.

When a diagnosis of myocardial infarction is proposed, the program endeavours to determine

its age:

„Probably old“ will appear when one ST elevation in resp. leads is detected
„Possibly recent“ will appear if at least two ST elevations in resp. leads were detected
„Age undetermined“ will appear in all other cases when no specific ST and T changes were
detected in the leads defining the infarct localisation. No ST elevations in
resp. leads.

A diagnosis of myocardial infarction will always have the classification

ABNORMAL ECG
Art. no.: 714251 rev.: a

Page 29
11 Myocardial Infarction Statements

Art. no.: 714251 rev.: a

Page 30
 User Guide ST-T Morphology Statements 12

12 ST-T Morphology Statements

ST-T Morphology is not diagnosed when RVH and repolarisation abnormality, LVH and repo-
larisation abnormality is detected or in the case of RBBB; LBBB or NSIB.

12.1 ST-T Elevation, consider acute anterior infarct

Sum of the ST elevation in leads V1 to V6 is  1 mV and ST elevation  0.3 mV in at least 2 of
leads V1 to V6. Not diagnosed when WPW, LBBB or NSIB is detected.

(ABNORMAL ECG)

12.2 ST-T Elevation, consider acute interior infarct

Sum of the ST elevation in leads I to III, aVF, V5, V6 and the sum of the ST depression in V1
to V4 is  1 mV and ST elevation  0.2 mV in at least 2 of leads II, III and aVF. Not diagnosed
when WPW, LBBB, RBBB or NSIB is detected.

(ABNORMAL ECG)

12.3 ST abnormality, possible anteroseptal subendocardial injury

ST depressed by at least 0.25 mV in at least one of leads V2 or V3, and no QRS signs of an
anteroseptal myocardial injury or infarct were detected.

(ABNORMAL ECG)

12.4 ST abnormality, possible anterior subendocardial injury

ST depressed by at least 0.25 mV in other precordial lead combinations than those typical for
anteroseptal and anterolateral injuries, and no QRS signs of an anterior myocardial injury or in-
farct were detected.

(ABNORMAL ECG)

12.5 ST abnormality, possible anterolateral subendocardial injury

ST depressed by at least 0.25 mV in at least one of leads V4, V5 and V6, and no QRS signs of
myocardial injury or infarct were detected.

(ABNORMAL ECG)

12.6 ST abnormality, possible lateral subendocardial injury

ST depressed by at least 0.25 mV in leads V5 or V6, and at least 0.15 mV in leads I and aVL,
and no QRS signs of a lateral myocardial injury or infarct were detected.
Art. no.: 714251 rev.: a

(ABNORMAL ECG)

12.7 ST abnormality, possible high lateral subendocardial injury

ST depressed by at least 0.15 mV in leads I or aVL, and no QRS signs of a high lateral myo-
cardial injury or infarct were detected.

(ABNORMAL ECG)

Page 31
12 ST-T Morphology Statements

12.8 ST abnormality, possible inferior subendocardial injury

ST depressed by at least 0.15 mV in leads II and aVF, and no QRS signs of an inferior myocar-
dial injury or infarct were detected.

(ABNORMAL ECG)

12.9 ST abnormality, possible inferolateral injury

ST depressed by at least 0.15 mV in leads II and aVF, and at least 0.25 mV in V6, and no QRS
signs of an inferior myocardial injury or infarct were detected.

(ABNORMAL ECG)

12.10 Nonspecific ST depression

ST < -0.05 mV and > -0.1 mV and no other abnormality or ST depressions mentioned above
were detected.

(BORDERLINE ECG)

12.11 ST & T abnormality, consider anteroseptal ischemia or right ventricular strain

ST depressed by 0.05 to 0.09 mV with T biphasic or negative, or ST depressed by 0.10 to
0.24 mV with T flat, biphasic or negative in at least one of leads V1, V2 and V3, and no QRS
signs of an anteroseptal myocardial injury or infarct were detected. Also:

• ST -0.1 mV and -0.05 mV  T < Tmin (=T flat) or

• ST -0.1 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead or
• ST -0.05 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead
(ABNORMAL ECG)

12.12 ST & T abnormality, consider anterior ischemia or left ventricular strain

ST depressed by 0.05 to 0.09 mV with T biphasic or negative, or ST depressed by 0.10 to 0.24
mV with T flat, biphasic or negative in other precordial lead combinations than those typical for
anteroseptal and anterolateral ischemia or left ventricular strain. Also:

• ST -0.1 mV and -0.05 mV  T < Tmin (=T flat) or

• ST -0.1 mV and T' or T < -0.05 (T inverted, that is QRS mainly positive in same lead or
• ST -0.05 mV and T' or T < -0.05 (T inverted, that is QRS mainly positive in same lead)
(ABNORMAL ECG)

12.13 ST & T abnormality, consider anterolateral ischemia or left ventricular strain

ST depressed by  0.05 mV ith T biphasic or negative, or ST depressed by 0.10 to 0.24 mV with
T flat, biphasic or negative in at least two of leads V4, V5 and V6, and no QRS signs of an an-
Art. no.: 714251 rev.: a

terolateral myocardial injury or infarct were detected. Also:

• ST -0.1 mV and -0.05 mV  T < Tmin (=T flat) or

• ST -0.1 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead or
• ST -0.05 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead
(ABNORMAL ECG)

Page 32
 User Guide ST-T Morphology Statements 12

12.14 ST & T abnormality, consider lateral ischemia or left ventricular strain

ST depressed by  0.05 mV with T flat, biphasic or negative in at least one of leads I, aVL, V4
and V5 and no QRS signs of a lateral myocardial injury or infarct were detected. Also:

• ST -0.1 mV and -0.05 mV  T < Tmin (=T flat) or

• ST -0.1 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead or
• ST -0.05 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead
(ABNORMAL ECG)

12.15 ST & T abnormality, consider high lateral ischemia or left ventricular strain
ST depressed by  0.05 mV with T flat, biphasic or negative in at least one of leads I or aVL and
no QRS signs of a high lateral myocardial injury or infarct were detected. Also:

• ST -0.1 mV and -0.05 mV  T < Tmin (=T flat) or

• ST -0.1 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead or
• ST -0.05 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead
(ABNORMAL ECG)

12.16 ST & T abnormality, consider inferior ischemia or left ventricular strain

ST depressed by  0.05 mV with T flat, biphasic or negative in leads II or aVF, and no QRS
signs of an inferior myocardial injury or infarct were detected. Also:

• ST -0.1 mV and -0.05 mV  T < Tmin (=T flat) or

• ST -0.1 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead or
• ST -0.05 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead
(ABNORMAL ECG)

12.17 ST & T abnormality, consider inferiorlateral ischemia or left ventricular srain

ST depressed by  0.05 mV with T flat, biphasic or negative in leads II or aVF and in V6, and
no QRS signs of an inferior myocardial injury or infarct were detected. Also:

• ST -0.1 mV and -0.05 mV  T < Tmin (=T flat) or

• ST -0.1 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead or
• ST -0.05 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead
(ABNORMAL ECG)

12.18 ST & T abnormality, consider recent .... myocardial or pericardial damage

ST elevated at least 0.20 mV in at least two V leads or 0.1 mV in two inferior leads (II, aVF, III)
and followed by a flat or negative T wave, and no QRS signs of a myocardial damage or infarct
were detected within the same localisation. ST > 0.5T. Also:
Art. no.: 714251 rev.: a

• ST -0.1 mV and -0.05 mV  T < Tmin (=T flat) or

• ST -0.1 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead or
• ST -0.05 mV and T' or T < -0.05 with T inverted, that is QRS mainly positive in same lead
(ABNORMAL ECG)

12.19 Nonspecific ST-T abnormality (elevation)

At least two of the following criteria are met: an ST elevation of at least 0.2 mV is detected in
one of the leads or depending on the main electrical direction of a T wave, an amplitude is high-
er than the upper limit as given on page 35, or an amplitude is smaller than the lower limit as
given on page 35 .

(OTHERWISE NORMAL ECG)

Page 33
12 ST-T Morphology Statements

12.20 T abnormality in anteroseptal leads

T or T' <0.05 mV with T biphasic or negative in at least one of leads V2 and V3, and no QRS
signs of an anteroseptal myocardial injury or infarct were detected.

(ABNORMAL ECG)

12.21 T abnormality in anterior leads

T biphasic or negative in other precordial lead combinations than those typical for anteroseptal
and anterolateral myocardial injuries was detected.

(ABNORMAL ECG)

12.22 T abnormality in anterolateral leads

T biphasic or negative in at least two of leads V4, V5 and V6, and no QRS signs of an antero-
lateral myocardial injury or infarct were detected.

(ABNORMAL ECG)

12.23 T abnormality in lateral leads

T biphasic or negative in at least one of leads I, aVL and V6, and no QRS signs of a lateral my-
ocardial injury or infarct were detected.

(ABNORMAL ECG)

12.24 T abnormality in high lateral leads

T biphasic or negative in leads I and aVL, and no QRS signs of a lateral myocardial injury or
infarct were detected.

(ABNORMAL ECG)

12.25 T abnormality in inferior leads

T biphasic or negative in lead II or aVF, and no QRS signs of an inferior myocardial injury or
infarct were detected.

(ABNORMAL ECG)

12.26 T abnormality in inferiorlateral leads

T biphasic or negative in lead II or aVF and V6, and no QRS signs of a myocardial injury or in-
farct were detected.

(ABNORMAL ECG)
Art. no.: 714251 rev.: a

12.27 Nonspecific T abnormality

T flat. -0.05 mV < T < T minimum and T changes other than those mentioned above were not
detected.

(BORDERLINE ECG)

Page 34
 User Guide ST-T Morphology Statements 12

12.28 T-wave table (amplitudes in mV)

aVL I -aVR II aVF III

Upper limit 0.22 0.35 0.34 0.43 0.31 0.22

NORMAL
Lower limit -0.05 0.07 0.09 0.08 0.00 -0.12

FLAT Lower limit -- -0.04 -0.04 -0.04 -0.04 --

NEGATIVE Upper limit -0-06 -0.05 -0.05 -0.05 -0.05 -0.13

V1 V2 V3 V4 V5 V6

Upper limit 0.39 1.01 1.07 1.04 0.78 0.49

NORMAL
Lower limit -0.13 0.17 0.20 0.16 0.13 0.08

FLAT Lower limit -- -0.04 -0.04 -0.04 -0.04 -0.04

NEGATIVE Upper limit -0.14 -0.05 -0.05 -0.05 -0.05 -0.05

Art. no.: 714251 rev.: a

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12 ST-T Morphology Statements

Art. no.: 714251 rev.: a

Page 36
 User Guide QT Interval 13

13 QT Interval
13.1 Prolonged QT
A QTc duration longer than or equal to 470 ms was detected and no infarction or ischemia or
left ventricular strain detected.

(POSSIBLE ABNORMAL ECG)

Art. no.: 714251 rev.: a

Page 37
 13

Page 38
QT Interval

Art. no.: 714251 rev.: a

 User Guide Hypertrophy Statements 14

14 Hypertrophy Statements
14.1 Left ventricular hypertrohy
Note that no LVH interpretation in the case of LBBB, RBBB, nonspecific block and pre-excita-
tion.

For the detection of a left ventricular hypertrophy, points are allocated to different ECG
characteristics possibly caused by this condition according to the following criteria
(modified Romhilt-Estes point score):

QRS amplitudes: • the sum of the R-amplitude in lead V5 and the absolute value of the S-amplitude in lead V1
3 points if exceeds an age and sex-dependent limit (Sokolow-Lyon). For every 0.5 mV above the limit,
a further point is attributed.
• the greatest R or S deflection in the extremity leads was equal to or greater than an age and
sex-dependent limit (for every 0.3 mV above the limit, a further point is attributed.)
• the greatest S deflection in leads V1 to V2 was equal to or greater than an age and sex-de-
pendent limit (for every 0.5 mV above the limit, a further point is attributed).
• the greatest R deflection in leads V5 to V6 was equal to or greater than an age and sex-de-
pendent limit (for every 0.5 mV above the limit, a further point is attributed).
From the first two criteria, the one with the most points is chosen, then from this one and the
last two criteria the one with the most points is chosen.

ST & T: 3 points if an ST depression or a negative or biphasic wave were detected in leads I, aVL, aVF, V5 or V6.
Only 1 point is attributed when the patient is under digitalis medication.

LAA: 3 points if left atrial abnormality is present and the amplitude criteria scored at least 3 points.

Electrical axis: 2 points if QRS axis ranged from -15 to -120 degrees.

Other QRS criteria: • the interval between the onset of QRS and the maximum QRS vector was longer than 55 ms.
1 point each if • the total duration of QRS was longer than 100 ms and no pathological Q wave detected.
• atrial fibrillation with rapid ventricular response.

14.2 Moderate amplitude criteria for left ventricular hypertrophy

The patient is at least 18 years old, and of all criteria for left ventricular hypertrophy, only the
amplitude criteria were satisfied, but only with 3 to 5 points.

(BORDERLINE ECG)

14.3 Amplitude criteria for left ventricualr hypertrophy

The patient is at least 18 years old and of all criteria for left ventricular hypertrophy, only the
amplitude criteria were satisfied, and with at least 6 points.
Art. no.: 714251 rev.: a

(POSSIBLY ABNORMAL ECG)

14.4 Consider left ventricular hypertophy

The patient is at least 18 years old and the ECG scored at least 5 points according to the criteria
above (3 of these points must stem from the amplitude criteria). If more that 3 points are calcu-
lated from the amplitude criteria, only three are considered i.e. only three amplitude criteria
points go towards the total points score.

(POSSIBLY ABNORMAL ECG)

Page 39
14 Hypertrophy Statements

14.5 Left ventricular hypertophy

The patient is at least 18 years old and the ECG scored 6 points according to the criteria above
(3 of these points must stem from the amplitude criteria) and scored 0 points for ST. If more that
3 points are calculated from the amplitude criteria, only three are considered i.e. only three am-
plitude criteria points go towards the total points score.

`with repolarisation abnormality` is added to the above statement if points have been ob-
tained from STT.

(ABNORMAL ECG)

14.6 Right ventricular hypertophy

Note that no RVH interpretation is given in the case of RBBB, LBBB, nonspecific block
and pre-excitation.

For the detection of a right ventricular hypertrophy, points are allocated to different ECG char-
acteristics possibly caused by this condition according to the following criteria:

Amplitudes: 3 points if • the R deflection in lead V1 was greater than an age- and sex-dependent limit
• the S deflection in the same lead was not deeper than an age and sex-dependent limit (these
limits are different in the case of an incomplete RBBB)
• an S wave deeper than an age and sex-dependent limit was detected in lead V5 or V6, and
the R/S ratio was less than an age and sex-dependent limit in these leads.

ST & T: 3 points if • an ST depression and a negative or biphasic T wave were detected in leads V1 or V2. Only
1 point is attributed when the patient is under digitalis medication.
• ST slope < -0.45 mV/s
• T negative, ST < -0.05 mV, T biphasic, preterminal negative (see illustration

Electrical axis: 2 points if • The QRS axis ranged from +110 to +180 degrees, or from -120 to -180 degrees.
1 point if
• The QRS axis ranged from +90 to +110 degrees

QRS duration: 1 point if • the total duration of QRS ranged between 100 ms and 120 ms (100 ms < QRS duration120
ms)
• occurrence of intrisicoid deflection V1 > 0.04s after QRS onset

14.7 Consider right ventricular hypertophy

The ECG scored 4 points according to the above criteria or 3 points in the presence of a right
atrial hypertrophy or of a sagittal electrical axis (i.e. S1, S2, S3 pattern).

(POSSIBLY ABNORMAL ECG)

Art. no.: 714251 rev.: a

14.8 Right ventricular hypertophy

The ECG scored at least 5 points according to the above criteria.

(ABNORMAL ECG)

Page 40
 User Guide Miscellaneous Statements 15

15 Miscellaneous Statements
15.1 S1, S2, S3 pattern
An S-wave of at least 0.2 mV was detected in at least two of leads I, II and III, and the R/S quo-
tient did not exceed 0.25 in the same leads.

(OTHERWISE NORMAL ECG)

15.2 WPW pattern, type A

Delta waves are detected in at least 3 leads. The QRS sum was positive in lead V1. QRS du-
ration must be <160 ms. If P axis <0o or > 90o then delta waves must be detected in 5 leads; if
PR time > lower limit then delta waves must be detected in 5 leads.

(ABNORMAL ECG)

15.3 Consider WPW, type B

Delta waves are detected in at least 3 leads. The QRS area was negative in lead V1. QRS du-
ration must be <150 ms. If P axis <0o or > 90o then delta waves must be detected in 5 leads; if
PR time > lower limit then delta waves must be detected in 5 leads.

(ABNORMAL ECG)

15.4 R-S transition zone in V leads displaced to the right

No pathological Q wave in V1 - V6. An R/S quotient of at least 3 was detected in lead V2, and
the duration of QRS was not longer than 120 ms.

(OTHERWISE NORMAL ECG)

15.5 R-S transition zone in V leads displaced to the left

No pathological Q wave in V1 - V6. An R/S quotient less than 0.75 was detected in lead V5, and
the duration of QRS was not longer than 120 ms.

(OTHERWISE NORMAL ECG)

15.6 *Possible reversal of the arm leads

The QRS complexes in leads I and V6 were more discordant than concordant, and the P-wave
in lead I was < 0.04 mV. (P(I) < 0.04 mV; QRS axis < -100o or > 120o
Art. no.: 714251 rev.: a

Page 41
15 Miscellaneous Statements

Art. no.: 714251 rev.: a

Page 42
 User Guide Low Sensitivity Statements 16

16 Low Sensitivity Statements

When ‘LOW’ sensitivity is selected, the following statements regarding nonspecific ECG find-
ings are suppressed:

• Indeterminate axis
• Nonspecific intraventricular delay
• Nonspecific ST depression
• Nonspecific T abnormality
• Nonspecific ST-T abnormality (elevation)
• Cannot rule out myocardial damage
• Moderate amplitude criteria for LVH
If one of the above statements has been suppressed, and no other abnormalities are found, the
normal/abnormal classification will be replaced by ”No specific ECG abnormalities”.

The statement ”Atrial fibrillation/flutter” is replaced with ”Irregular rhythm, no P-wave found”.
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16 Low Sensitivity Statements

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 User Guide Pediatric Interpretation 17

17 Pediatric Interpretation
As ECG characteristics of a human being change during childhood and adolescence, age-
based parameters have to be applied for the interpretation of a paediatric ECG in order to better
assess its variations.

The SCHILLER ECG interpretation program for pediatric was developed in cooperation with
leading cardiologists of university hospitals and is intended for use on ECGs of pediatric from
birth up to the age of 18.

The SCHILLER ECG interpretation program for pediatric differentiates between the following
age categories:

• the first 24 hours in life of a newborn child

• 1-2 days
• 3-6 days
• 7-30 days
• 1-2 months
• 3-5 months
• 6-11 months
• 1-2 years
• 3-4 years
• 5-7 years
• 8-11 years
• 12-17 years
Following is a description of the main differences between the interpretive statements given in
the SCHILLER paediatric ECG program, and the adult interpretation program.

17.1 Rhythm analysis

For rhythm analysis no distinction other than applying age-dependent limits is made between
pediatric and adults.

17.2 WPW syndrom

Age-dependent limits are applied. The 12 standard leads are searched for delta waves. The
presence of delta waves in at least 3 leads and a duration of PR interval of less than 150 ms
(WPW pattern type A) or of less than 140 ms (WPW pattern type B) will satisfy the criteria for
Wolff-Parkinson-White syndrome. When the frontal P axis is below 0° or above 90°, delta waves
must be present in at least 5 leads and the duration of the PR interval must be less than the
average, age-dependent duration. When the R/S ratio in lead V1 is less than 1, the statement
WPW pattern type B is produced, otherwise the statement WPW pattern type A will be given.

17.3 Analysis of ST segment and T wave

Art. no.: 714251 rev.: a

For pediatric up to the age of 12, the leads V1 to V4 are not used for ST &T analysis and no
attempt will be made to interpret signs of myocardial infarction. Contour abnormalities are inter-
preted as in the adult ECG.

17.4 Dextrocardia
For the diagnosis of dextrocardia, the sum of the R and |S| amplitudes in lead V1 must exceed
the sum of the R and |S| amplitudes in leads V5 and V6 by at least 90% each, no criteria for
intraventricular block should be satisfied and at least two of the leads I, aVL, V5 and V6 should
either have a Q amplitude > 1/4 the sum of the R and |S| amplitudes and an R amplitude >
100µV OR should show an RSR’ pattern with an R amplitude < 50µV , an R’ amplitude > 100µV
and a S amplitude > 1/4 the sum of the R and |S| amplitudes.)

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17 Pediatric Interpretation

17.5 Interpretation of P wave

Interpretive statements for atrial activity, such as prolonged P-R interval, biatrial enlargement,
right atrial enlargement, left atrial abnormality, possible left or right atrial abnormality, are made.

The statement prolonged P-R interval is produced for a PR duration longer than the P limit for
the patient’s age (The P limit is defined as the 98 % percentile (for the patient’s age) + 20 ms ).

The criteria for possible left atrial abnormality is satisfied, when PTF (= P terminal force, re-
sulting from the largest amplitude of the terminal negative portion of the P wave in lead V1 and
its duration) is < -6 mVms .

An interpretative statement is made for left atrial abnormality when the amplitude of the neg-
ative portion of P in lead V1 is < -200µV or when the duration of the P wave is longer than 140
ms and the amplitude of the negative portion of P in lead V1 is <-100µV.

An interpretative statement is made for right atrial enlargement when a P maximum > 250µV
is present in at least one lead.

The criteria for biatrial enlargement is satisfied in the presence of both left and right atrial en-
largement.

17.6 Determination of electrical axis

The determination of the electrical axis is carried out the same way as for an adult , however,
the statement ‘axis normal considering age’ or ‘axis abnormal considering age’ depends
upon the limit values for age.

17.7 ECG Voltages

An interpretative statement is made for low voltage when the peak-to-peak QRS amplitudes
do not exceed 500 µV in any frontal leads. When the peak-to-peak QRS amplitudes in the fron-
tal leads range between 500µV and 1000µV (exclusive) and the peak-to-peak QRS amplitudes
in the chest leads being below 1500µV, then the criteria for low voltage are satisfied, too.

17.8 Intraventricular conduction delay

In general, no search is made for intraventricular conduction delay in the presence of ‘WPW’.

Left bundle branch block 1. The QRS duration is longer than the limit for age. The R/S ratio in leads V1 and V2 is less
than or equal to 1. If S (in lead V6) is smaller than the average value for age , then S (in lead
I) should be  -0.2 mV.
2. The R/S ratio in lead V6 must correspond to the limit value for age, the same applies to the
R/S ratio in lead I. Q in lead I must be  -0.05 mV, and in lead V6  -0.03 mV. The mean
spatial velocity of the ECG within the mid-third section of QRS must be less than the limit
value (58,5 mVs).

When any of the conditions mentioned under item 2 is not fulfilled, either the interpretative state-
Art. no.: 714251 rev.: a

ment ‘nonspecific intraventricular block’ (when exceeding the limit values for blocks) or
‘nonspecific intraventricular delay ’ (when exceeding the limit values for conduction delay) is
made. Otherwise the statement ‘left bundle branch block’ or ‘incomplete left bundle branch
block’ is given, wherever appropriate. QRS duration must be fullfilled in any case.

Right bundle branch block The criteria for RBBB is satisfied in the absence of LBBB or in the presence of a QRS complex
with M or W-shaped curves in leads V1 or V2.

When these conditions are fulfilled, either the interpretative statement ‘right bundle branch
block ’ (when exceeding the limit values for blocks) or ‘incomplete right bundle branch block
’ (when exceeding the limit values for conduction delay ) is made.

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 User Guide Pediatric Interpretation 17

Left fascicular blocks Criteria for the presence of left anterior fascicular block : QRS duration < limit value for age
(QRS duration  limit value only in the presence of RBBB); -30°  QRS axis > -120°; no Q in
lead aVF; R/S ratio in lead aVF  0.6; S in lead V6  limit value for large S amplitude in lead V6.

Criteria for the presence of left posterior fascicular block: QRS duration < limit value for blocks
for the patient’s age (QRS duration  limit value only in the presence of RBBB); 115°  QRS
axis  180°; R or R’ in lead II  0.8 mV; R or R’ in lead III  1.0 mV; Q -0.02 mV in leads
II,III,aVF; Q duration in leads III,aVF  40 ms.

17.9 Prolonged QT
When the limit value for age is exceeded, an interpretative statement is made for prolonged
QT under the condition that there are no signs of intraventricular delay (including block),
ischemia or left ventricular strain.

17.10 Ventricular hypertrophy

Left ventricular hypertro- No LVH interpretation in the presence of blocks or WPW syndrome.
phy
The statement ‘Consider left ventricular hypertrophy’ is made when either |S V1| > limit , |S
V1| > 0.25* peak-to-valley value of QRS or R in lead V6 > limit value -0.2 mV.

‘Left ventricular hypertrophy’ is considered when the conditions for ‘consider left ventricular
hypertrophy ’ are fulfilled and, |S V1| > limit value of +0.5 mV and R in V6 > limit value +0.5 mV
or when (R V6 +|S V1| ) > limit.

‘Left ventricular hypertrophy with repolarisation abnormality’ is considered when the con-
ditions for left ventricular hypertrophy are fulfilled and when in any of the leads I,aVL,V4,V5,V6
following criteria are met: ST amplitude < J amplitude, ST amplitude < -0.05 mV, and R ampli-
tude  1.1 mV.

The statement ‘Left ventricular hypertrophy with strain’ is produced when the conditions for
left ventricular hypertrophy with repolarisation abnormality are fulfilled and when in any of the
leads I,aVL,V4,V5,V6 at least two show the following characteristics: max (R,R’) > |min
(Q,S,S’)| and T amplitude < ST amplitude and < -0.2 mV .

Right ventricular hypertro- No RVH interpretation in the presence of LBBB, RBBB, nonspecific block or WPW syndrome.
phy
In the presence of an incomplete right bundle branch block no detection is made for right ven-
tricular hypertrophy when max (R,R’) is  1.5 mV (1 mV for pediatric younger than 1 year).

The statement ‘Consider right ventricular hypertrophy’ is produced when any of the follow-
ing conditions is fulfilled:

• min (S,S’) < S limit value of -0.2 mV and |min (S,S’)| > 0.25* (max (R,R’) - min (Q,S,S’) in lead
V6, or
• S or S’ in V6 is not equal to 0 and R/S ratio in V6 < limit, or
• S or S’ in V1 is not equal to 0 and R/S ratio in V1 > limit, or
Art. no.: 714251 rev.: a

• Q in V1 < -0.02 mV and R in V1 > 0.5 mV, or

• he child is older than 1 year and younger than 8 years and T in V1 > 0.1 mV and T’ in V1 = 0,
and a negative or biphasic T wave has been detected in leads V5 and V6.
‘Right ventricular hypertrophy’ is suggested when max (R V1, R’ V1) > limit value, or when
Q in V1 < -0.02 mV and max (R V1, R’ V1) > 0.75 mV .

The statement ‘right ventricular hypertrophy with repolarisation abnormality’ is produced

when the criteria for right ventricular hypertrophy have been met and when ST amplitude < J
amplitude in the leads V1,V2,V3 or when ST or T amplitude in the same leads  -0.1 mV and
when ST or T amplitude in the leads V4,V5,V6 exceeds or equals to -0.1 mV not more than
once.

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17 Pediatric Interpretation

The statement ‘Right ventricular hypertrophy with strain’ is produced when in at least two
of leads V1,V2 and V3 an ST depression with inverted T wave of less than -0.2 mV in amplitude
has been detected.

The limit values and criteria for the paediatric ECG interpretation statements are based upon
following publications:

• Davignon A et al. , Normal ECG standards for infants and children, Pediatr. Cardiol. 1979/80;
1:133-152.
• Liebman J, Plonsey R, Gilette PC, eds. Paediatric Cardiology. Williams and Wilkins, Baltimore
1982.
• Macfarlane PW, Veitch Lawrie TD,Comprehensive Electrocardiology, Pergamon Press, New
York 1989
• Liebman J, Plonsey R, Rudy Y, Paediatric and Fundamental Electrocardiography, Martinus
Nijhoff Publishing, Boston 1987
• Gutheil H, Kinder-EKG, Thieme, Stuttgart 1989

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 User Guide Thrombolysis Interpretation 18

18 Thrombolysis Interpretation
The SCHILLER Thrombolysis Software (SCHILLER STP) is a software program designed to aid
the physician’s decision-making process in the pre-hospital and emergency department setting
by using medication, patient age, gender and ECG features to provide the predicted probability
of acute cardiac ischemia or acute coronary syndrome (ACS). The SCHILLER STP software
package enhances the computer-assisted ECG analysis capabilities as a software option in the
CARDIOVIT AT-101 and CARDIOVIT AT-102 ECG recording devices.

The information used to calculate the predicted probability of acute cardiac ischemia is availa-
ble for real-time in the emergency department and as retrospective review to aid quality assur-
ance.

Clinical studies at the Thorax Center of the Erasmus University in Rotterdam (Prof. Simoons),
have proven the benefits of this tool.

It is possible to manually select or configure the CARDIOVIT AT-101 and CARDIOVIT AT-102
to automatically report the probability of acute cardiac ischemia on the printed ECGs. To prompt
the report generation, one must only enter three variables in the patient ID field: age, gender
and medication. The reports can be stored in SCHILLER’s SEMA Data Management System.

The SCHILLER STP provides an additional tool to assist with the diagnosis of acute cardiac
ischemia, also including unstable angina pectoris and acute myocardial infarction.

In order to calculate the predicted probability of acute cardiac ischemia, it is necessary to ex-
amine three ECG features from the computerized ECG analysis:

• presence or absence of abnormal Q waves

• presence and degree of ST segment elevation or depression
• presence and degree of T-wave elevation or inversion

In order to allow conclusive results, it is necessary that the ECG features appear in minimum
two related leads and causes that might interfere with the ECG interpretation such as secondary
LVH, RBBB and LBBB repolarization abnormalities, artificial pacemaker or early repolarization
can be excluded. Although the appearance of any single ECG feature is not conclusive for a
diagnosis, the accumulation of the most important ECG features are excellent indications for
the detection of acute coronary syndrome.

The SCHILLER STP report is used instead of the standard automatic ECG report in clinical set-
tings where acute cardiac ischemia is a major diagnostic concern.

The SCHILLER STP report is based on the standard ECG report, showing a standard ECG
trace with ten seconds of ECG waveforms and standard waveform measurements. It also in-
cludes any number of the following interpretive statements indicating the prediction of throm-
bolysis:

• ST-T elevation, acute anterior infarct

Art. no.: 714251 rev.: a

• ST-T elevation, acute inferior infarct

• possible infarct or other abnormality
• no significant abnormalities
• ECG consistent with large infarction
• ECG consistent with medium-sized infarction
• consider thrombolytic therapy if symptoms are suspect for infarct and patient is 70 years or
less
• consider thrombolytic therapy if symptoms are suspect for infarct and patient is 80 years or
less

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