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Criteria for Intraventricular Conduction Disturbances and Pre-Excitation

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Criteria for Intraventricular Conduction Disturbances and Pre-Excitation JACC Vol. 5, No.6 1261 June 1985:1261-75 COOPERATIVE STUDIES Criteria for Intraventricular Conduction Disturbances and Pre-excitation JOS L. WILLEMS, MD,* ETIENNE O. ROBLES DE MEDINA, MD, FACC,t ROLAND BERNARD, MD,t PHILIPPE COUMEL, MD,§ CHARLES FISCH, MD, FACC,II DENNIS KRIKLER, MD, FACC,** NICOLAI A. MAZUR, MD,tt FRITS L. MEHLER, MD, FACC (Chairman),t LARS MOGENSEN, MD,:j::j: PIERRE MORET, MD, FACC,§§ ZBYNEK PISA, MD,IIII PENTTI M. RAUTAHARJU, MD,*** BORYS SURAWICZ, MD, FACcl1 YOSHIO WATANABE, MD, FACC,ttt HEIN J. J. WELLENS, MD, FACCt:j::j: World Health Organization/International Society and Federation for Cardiology Task Force Ad Hoc In an etTortto standardize terminology and criteria for and left posterior fascicular block, nonspecific intra­ clinical electrocardiography, and as a follow-up of its ventricular block, WoltT-Parkinson-White syndrome and work on definitions of terms related to cardiac rhythm, related pre-excitation patterns. Criteria for intraatrial an Ad Hoc Working Group established by the World conduction disturbances are also briefly reviewed. Health Organization and the International Society and The criteria are described in clinical terms. A concise Federation of Cardiology reviewed criteria for the di­ description of the criteria using formal Boolean logic is agnosis of conduction disturbances and pre-excitation. given in the Appendix. For the incorporation into com­ Recommendations resulting from these discussions are puter electrocardiographic analysis programs, the limits summarized for the diagnosis of complete and incom­ of some interval measurements may need to be adjusted. plete right and left bundle branch block, left anterior (J Am Coll CardioI1985,'5:1261-75) In recent years at international meetings and through con­ nication between the interpreter and the user. Since other certed actions, several investigators (1-6) have made an groups specifically have addressed the problems of stand­ appeal for standard rules of measurement, classification and ardization of terminology (1-2) and measurement (5-6), description for electrocardiographic features. Such stan­ the present Task Force was established to examine the pos­ dards are desirable to improve patient care and disseminate sibility of standardization of diagnostic classification criteria. medical knowledge and experience. Patient care can be im­ At the 10th Bethesda Conference on Optimal Electro­ proved by enhancing the consistency and quality of the cardiography (1), it was proposed to categorize diagnostic electrocardiographic report and, thus, facilitating commu- electrocardiographic statements into three categories (Table I): From the *University of Leuven, Leuven, Belgium; tUniversity of I) Type A statements refer to an anatomic lesion or patho­ Utrecht, Utrecht, The Netherlands; :j:Universityof Brussels, Brussels, Bel­ gium; §University of Paris, Paris, France; [Krannert Institute of Cardiol­ physiologic state, such as hypertrophy, infarction, ischemia, ogy, Indiana University, Indianapolis, Indiana; **University of London, pulmonary disease, drug and metabolic effects, and which London, England; ttNational Cardiology Research Centre, Moscow, can be verified by nonelectrocardiographic evidence; U.S.S.R.; :j::j:Karolinska Sjukhuset, Stockholm, Sweden; §§University of Geneva, Geneva, Switzerland; II11Worid Health Organization, Geneva, 2) Type B statements refer to an anatomic or functional Switzerland; ***Dalhousie University, Halifax, Canada; tttFujita Gakuen disturbance, such as arrhythmias and conduction defects, University, Nagoya, Japan; :j::j::j:University of Limburg, Maastricht, The and which are detectable mainly by the electrocardiogram Netherlands. This study was supported by grants from the World Health Organization (Geneva), the European Commission (82/616/EEC 11.2.2) itself; and and the Dutch Heart Foundation, Utrecht, The Netherlands. Manuscript 3) Type C statements refer to electrocardiographic fea­ received October 9, 1984; revised manuscript received December 26, 1984, accepted January 16, 1985. tures that do not fit into type A or B categories and often Address for reprints: Jos L. Willems, MD, University Hospital Gas­ are merely descriptive, such as nonspecific ST-T changes, thuisberg, 49 Herestraat, 3000 Leuven, Belgium. electrical axis deviation and low QRS voltage. © 1985 by the American College of Cardiology 0735-1097/85/$3.30 1262 WHO/ISFC TASK FORCE JACC Vol. 5. No.6 CRITERIA FOR CONDUCTION DISTURBANCES June 1985:1261-75 It is widely recognized that an optimal selection and Table 2. Categories of Intraventricular Block evaluation of criteria for type A statements should be based Bundle branch block on a library of cases in which the condition has been de­ Complete right termined or excluded by independent nonelectrocardi­ Complete left ographic techniques. Both type B and type C statements, Incomplete right however, are primarily detected on the electrocardiogram Incomplete left Fascicular block itself, either from surface or intracardiac leads. Since the Left anterior elaboration of a data base for the evaluation of type A Left posterior statements requires a large collaborative effort, this Task Bi- and trifascicularblocks Force has assigned its objectives toward the standardization Nonspecific intraventricular block of Type B statements. As a follow-up to its work on rhythm Pre-excitation Wolff-Parkinson-White pattern (syndrome) statements (2), the aim of the Task Force was to reach a Other pre-excitation patterns consensus on criteria for conduction disturbances and pre­ Intraatrial block excitation (Table 2). Recommendations for Some Derived of small amplitude. Whenever the QRS complex consists Electrocardiographic Measurements of two or more deflections of comparable amplitude in more The reader is referred to specific reports of the American than one standard limb lead, an axis should be determined Heart Association Committee on Electrocardiography (7) for each of these deflections . and the Working Party on Common Standards for Quanti­ Area method. The net amplitude and direction of the tative Electrocardiography (5-6) for recommendations on QRS complexes in any two of the standard bipolar leads (I, basic nomenclature for the P-QRS-T complex, wave defi­ II, III) or augmented leads (aVR , aVL, aVF) has been used nitions and primary electrocardiographic measurements. Some most often for the determination of the mean electrical axis additional recommendations to these reports are needed with in the frontal plane (8-10). However, to be accurate, one respect to some derived measurements. should utilize the net area rather than the amplitude of the Electrical axis of the QRS complex. An instantaneous various components of the QRS complex (11-13). The areas electrical axis represents the direction of the electrical forces of these deflections are first added algebraically and sub­ at any given instant, whereas the mean electrical axis refers sequently projected on the sides of the Einthoven triaxial to the average direction of the activation or repolarization or hexaxial reference system . The axis is then determined process during the cardiac cycle . Instantaneous and mean at the intersection and expressed in polar coordinates as electrical axes may be determined for any deflection (P, specified in the American Heart Association report (7). All QRS, ST-T) in the three planes (frontal, transverse and computer electrocardiographic analysis programs should uti­ sagittal) as well as spatially. The determination of the elec­ lize the area method. For the calculation of the areas, the trical axis of a QRS complex is useful for the diagnosis of same QRS group onset and offset should be used for each certain intraventricular conduction disturbances. lead, with the QRS onset being defined as the onset of the An average axis is meaningful when the QRS complex earliest deflection and the QRS offset as the latest end in has one dominant deflection and when other deflections are any of the simultaneously recorded three or more leads. Because of Einthoven's law, which stipulates that leads I + III = II, the same mean QRS axis should theoretically be obtained from any pair of simultaneously recorded bi­ Table 1. Three Categories of Electrocardiographic Statements* polar standard leads. However, to increase reproducibility I. Type A, documentable by nonelectrocardiographic means in the presence of noise or low voltage, averaging of axes Infarction/injury determined by different lead combinations may be recom­ Hypertrophy/enlargement/overload Chronic obstructive lung disease/pulmonary emphysema mended for computer processing. Metabolic/digitalis/otherdrug effects Intrinsicoid deflection versus R peak time. The defi­ Ischemia (possibly documentable) nition and interpretation of the term "intrinsicoid deflec­ 2. Type B, detectable primarily by electrocardiography tion" have changed over the years. Initially, only the term Rhythm disturbances including pacemaker rhythms and artifacts "intrinsic deflection " was used to indicate the instant at Conduction disturbances 3. Type C, morphologic descriptive statements which the area of cardiac muscle immediately below a uni­ Axis deviation polar epicardial electrode was completely depolarized (8). Low or increased QRS voltage Later, this concept was extended to the precordial leads, Nonspecific ST-T changes, strain, large T waves for which the term intrinsicoid deflection was introduced. *Adapted from Rautaharju PM, et al. (4) with permission. Some authors (13) have also applied
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