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The Fourth Universal Definition of Myocardial Infarction (FUDMI) [published simultaneously in 2018 in numerous journals including Circulation, Journal of the American College of Cardiology and European Heart Journal] focuses mainly on the distinction between non-ischemic myocardial injury and myocardial infarction (MI), along with the role of cardiovascular magnetic resonance, in order to define the etiology of myocardial injury. As a consequence, there is less emphasis on updating the parts of the definition concerning the electrocardiographic (ECG) changes related to MI. Evidence of myocardial ischemia is a prerequisite for the diagnosis of MI and the ECG is the main available tool for i) detecting acute ischemia, ii) triage and iii) risk stratification upon presentation. This review focuses on multiple aspects of ECG interpretation that we firmly believe should be considered for incorporation in any future update to the Universal Definition of MI. Our counterpoint view is that: a) the use of the ECG following coronary artery bypass surgery should be better explored and defined; b) the emphasis in the FUDMI on convex versus concave ST-elevation, which is questionable, should be balanced by the fact that many patients with true ST-elevation MI (STEMI) present with a concave form of ST elevation; c) reciprocal ST-depression in STEMI caused by right coronary artery or left circumflex artery occlusion, should be set against the fact that not all anterior STEMIs present with reciprocal ST-depression which can also be seen in cardiomyopathy and left ventricular hypertrophy; d) the "posterior" leads V7-V9 should be placed on a horizontal line from V4, rather than follow the 5th intercostal space; e) ST-depression in V1-V3 is not a manifestation of ischemia of the basal inferior segment, placed horizontally; f) Interpreting ST-T changes in patients with conduction abnormalities and pacemakers should be further defined. [ABSTRACT FROM AUTHOR]

Digital electrocardiographs are now widely available and a large number of digital electrocardiograms (ECGs) have been recorded and stored. The present study describes the development and clinical applications of a large database of such digital ECGs, namely the CODE (Clinical Outcomes in Digital Electrocardiology) study. ECGs obtained by the Telehealth Network of Minas Gerais, Brazil, from 2010 to 17, were organized in a structured database. A hierarchical free-text machine learning algorithm recognized specific ECG diagnoses from cardiologist reports. The Glasgow ECG Analysis Program provided Minnesota Codes and automatic diagnostic statements. The presence of a specific ECG abnormality was considered when both automatic and medical diagnosis were concordant; cases of discordance were decided using heuristisc rules and manual review. The ECG database was linked to the national mortality information system using probabilistic linkage methods. From 2,470,424 ECGs, 1,773,689 patients were identified. After excluding the ECGs with technical problems and patients <16 years-old, 1,558,415 patients were studied. High performance measures were obtained using an end-to-end deep neural network trained to detect 6 types of ECG abnormalities, with F1 scores >80% and specificity >99% in an independent test dataset. We also evaluated the risk of mortality associated with the presence of atrial fibrillation (AF), which showed that AF was a strong predictor of cardiovascular mortality and mortality for all causes, with increased risk in women. In conclusion, a large database that comprises all ECGs performed by a large telehealth network can be useful for further developments in the field of digital electrocardiography, clinical cardiology and cardiovascular epidemiology. [ABSTRACT FROM AUTHOR]

Six ECG patterns are found more frequently in healthy black adults than in whites. These patterns are presumably benign, but also may resemble those of malignant disease. 1) Healthy black adults show higher QRS voltage, and more often meet ECG criteria for left ventricular hypertrophy (LVH). Associated repolarization abnormalities can produce ST segment elevation (STE) that resembles ST elevation MI (STEMI). 2) The pattern of benign anterior STE, seen often in males, is more common in black subjects. Similar to LVH, this pattern may falsely suggest STEMI. 3) Both early repolarization (ER) and benign inferolateral STE are more common in black patients. Although they may convey a higher risk of fatal arrhythmias or cardiac death in white populations, it does not appear that black subjects with these patterns show a similar risk. 4) The persistent juvenile T wave inversion pattern shows asymmetric T wave inversion (TWI) in V1-V4, without ST segment deviations. It is most common in black females, and is considered benign. However, this pattern can also resemble the anterior TWI of arrhythmogenic right ventricular cardiomyopathy (ARVC). 5) A pattern of anterior TWI with associated J point elevation is a common finding in the black population, especially athletes. It could suggest hypertrophic cardiomyopathy, but can be presumed to be a benign finding in black athletes, when TWI is limited to V1-V4 and preceded by J point elevation. 6) TWI in the lateral precordial leads, usually associated with end-QRS slurring or notches is seen much more often in apparently healthy black subjects than white subjects. Unlike the anterior TWI pattern, however, it cannot be presumed benign. In conclusion, awareness of these ECG patterns may help to avoid unnecessary diagnostic or therapeutic interventions, but also encourage appropriate investigations. [ABSTRACT FROM AUTHOR]

Although automated ECG analysis has been available for many years, there are some aspects which require to be re-assessed with respect to their value while newer techniques which are worthy of review are beginning to find their way into routine use. At the annual International Society of Computerized Electrocardiology conference held in April 2017, four areas in particular were debated. These were a) automated 12 lead resting ECG analysis; b) real time out of hospital ECG monitoring; c) ECG imaging; and d) single channel ECG rhythm interpretation. One speaker presented the positive aspects of each technique and another outlined the more negative aspects. Debate ensued. There were many positives set out for each technique but equally, more negative features were not in short supply, particularly for out of hospital ECG monitoring. [ABSTRACT FROM AUTHOR]

Aims: To objectively characterize and mathematically justify the observation that vectorcardiographic QRS loops in normal individuals are more planar than those from patients with ST elevation myocardial infarction (STEMI).Methods: Vectorcardiograms (VCGs) were constructed from three simultaneously recorded quasi-orthogonal leads, I, aVF and V2 (sampled at 1000 samples/s). The planarity of these QRS loops was determined by fitting a surface to each loop. Goodness of fit was expressed in numerical terms.Results: 15 healthy individuals aged 35-65years (73% male) and 15 patients aged 45-70years (80% male) with diagnosed acute STEMI were recruited. The spatial-QRS loop was found to lie in a plane in normal controls. In STEMI patients, this planarity was lost. Calculation of goodness of fit supported these visual observations.Conclusions: The degree of planarity of the VCG loop can differentiate healthy individuals from patients with STEMI. This observation is compatible with our basic understanding of the electrophysiology of the human heart. [ABSTRACT FROM AUTHOR]

Background: The spatial QRS-T angle is ideally derived from orthogonal leads. We compared the spatial QRS-T angle derived from orthogonal leads reconstructed from digital 12-lead ECGs and from digital Holter ECGs recorded with the Mason-Likar (M-L) electrode positions.Methods and Results: Orthogonal leads were constructed by the inverse Dower method and used to calculate spatial QRS-T angle by (1) a vector method and (2) a net amplitude method, in 100 volunteers. Spatial QRS-T angles from standard and M-L ECGs differed significantly (57°±18° vs 48°±20° respectively using net amplitude method and 53°±28° vs 48°±23° respectively by vector method; p<0.001). Difference in amplitudes in leads V4-V6 was also observed between Holter and standard ECGs, probably due to a difference in electrical potential at the central terminal.Conclusion: Mean spatial QRS-T angles derived from standard and M-L lead systems differed by 5°-9°. Though statistically significant, these differences may not be clinically significant. [ABSTRACT FROM AUTHOR]

At the April, 2015 International Society for Computerized Electrocardiology (ISCE) Annual Conference in San Jose, CA, a special session entitled Remembering Ron & Rory was held to pay tribute to the extraordinary work and lives of two experts in electrocardiology. The session was well attended by conference attendees, Childers' family members and friends, and additional colleagues who traveled to San Jose solely to participate in this session. The purpose of the present paper is to document the spirit of this special session as faithfully as possible using the words of the session speakers. [ABSTRACT FROM AUTHOR]

Aims The objective of the study was to develop normal limits of the ECG in an apparently healthy population of South Asians living in India. Methods Three centres contributed to recording 12 lead ECGs on identical digital electrocardiographs. Apparently healthy volunteers were recruited and ECGs were first transferred to a local database and then to Glasgow where all ECGs were analysed by the same University of Glasgow ECG Interpretation Program. Results A total of 963 individuals were recruited into the study (30.4% female) with an age range of 18–83 years. QRS duration was longer in males than females, QT interval was longer in females than males, and QRS voltages in general were higher in males than females and in younger compared to older individuals. Conclusion Findings in general paralleled those in other populations and suggested that criteria for a white Caucasian population could be applied to a South Asian Indian population. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this study was to define criteria suited to automated detection of end QRS notching and slurring and to evaluate their accuracy. One hundred resting 12 lead ECGs from young adult men, split randomly into equal training and test sets, were examined independently by two reviewers for the presence of such notching or slurring. Consensus was reached by re-examination. Logic was added to the Glasgow resting ECG program to automate the detection of the phenomenon. After training, the automated detection had a sensitivity (SE) of 92.1% and a specificity (SP) of 96.6%. For the test set, SE was 90.5%, SP 96.5%. Two populations of healthy subjects – one Caucasian, one Nigerian – were analysed using the automated method. The prevalence of notching/slurring with peak/onset amplitude respectively≥0.1mV in two contiguous inferolateral leads was 23% and 29% respectively. In conclusion, the detection of end QRS notching or slurring can be automated with a high degree of accuracy. [Copyright &y& Elsevier]

Abstract: The recent resurgence of interest in early repolarization has demonstrated a variation in the definition of the term and a consequent variation in the prevalence of the pattern in different studies. This can vary from 35% in males and 21.5% in females if ST elevation is not considered part of the definition, to 3.3% and 0.5% in females with the inclusion of ST elevation. In contrast, the prevalence of the Brugada Syndrome is in the order of 0.1%–0.2% in Japan for example and has been found to be significantly lower in Denmark. Standardisation of measurement definitions, particularly for early repolarisation, is required. [Copyright &y& Elsevier]

Abstract: Background: There has been no large study of ECG measures derived by automated methods in an apparently healthy indigenous West African population. Methods: ECGs were recorded from apparently healthy Nigerians and analysed using automated methods. Age and sex based normal ranges were then established. Results: A total of 782 males and 479 females aged between 20 and 87years were studied. Mean QRS duration in males was 87.9±9.4ms and 83.4±7.6ms in females (P <.0001). Mean QTc (Hodges) was 393±16ms in males and 406±16ms in females (P <.0001). The Cornell index (SV3+RaVL) was higher in males and decreased with increasing age in males though the reverse was true in females (P <.0001). STj amplitude was lower in older compared to younger males and higher in males. Conclusion: This is the first large study of automated ECG measurements from healthy blacks living in West Africa which allows the determination of ECG normal limits in such a population. [Copyright &y& Elsevier]

Abstract: This study investigates the characteristics of contemporary pacemaker pulses as recorded from the body surface. Twelve-lead paced ECGs from 140 patients (68±12years, 71% males) were collected at 32,000 samples per second. Pacer pulses were manually annotated based on the high-sampling rate data stream. The results show that durations of the various pulses are stable, while amplitudes exhibit large variations. Also, more than 50% of pulses have either durations <0.5ms or amplitudes <2mV, which are the AAMI/IEC thresholds for detection and marking of pacemaker pulses on an ECG report. Therefore the current standards for pacemaker pulse detection are not fit for purpose and require to be updated. Further, this study suggests that a high-sampling rate database should be used as a standard test for pacemaker annotation and detection from body surface ECGs. [Copyright &y& Elsevier]

Abstract: Objective: We examined potential determinants and prognostic value of the corrected QT interval (QTc). Design: A total of 4252 British men aged 60 to 79 years had a resting 12-lead electrocardiogram. Potential determinants of the QTc were assessed using multivariable regression. Men were followed up for 7 years. Results: A 1 standard deviation increase in QTc (26 milliseconds) was associated with increased all-cause mortality (hazard ratio, 1.13; 95% confidence interval, 1.05-1.22). Longer QTc was associated with increasing age, preexisting coronary heart disease, and a range of drugs. Shorter QTc was present in diabetics and smokers. Corrected QT interval was related inversely with serum potassium and calcium and positively with serum urate, sodium, and systolic blood pressure. The relation of QTc to all-cause mortality was independent of adjustment for these factors. Conclusions: Age, preexisting coronary heart disease, certain medications and biochemical factors, and diabetes are independently associated with QTc. Corrected QT interval is an independent predictor of all-cause mortality. [Copyright &y& Elsevier]

Abstract: The Working Group on Electrocardiographic Diagnosis of Left Ventricular Hypertrophy, appointed by the Editor of the Journal of Electrocardiology, presents the alternative conceptual model for the ECG diagnosis of left ventricular hypertrophy (LVH). It is stressed that ECG is a record of electrical events, not of mechanical events and/ or anatomical characteristics. Considering the electrical characteristics of pathologically changed myocardium should lead to better understanding and improved clinical usefulness of the ECH in the clinical diagnosis of LVH. [Copyright &y& Elsevier]

Introduction: Racial differences in the ECG have been known about for many years but there has been no significant comparison of large population groups. This study set out to remedy this shortcoming., Methods: Digital ECG data were available for four population samples gathered in Scotland, Taiwan, Nigeria and India. All ECGs were recorded in the different countries and processed centrally by the University of Glasgow ECG Analysis Program. Measurements were analysed statistically to look for significant differences., Results: There were 4223 individuals in the study (2559 males and 1664 females). In general terms, findings such as QRS duration being longer in males than females applied to all four races. More specifically, QRS voltages were higher in young black males compared to others, while ST amplitudes, as in V2, were higher in Chinese and Nigerian males than in Caucasians., Conclusion: Race requires to be taken into account to enhance automated interpretation of the ECG., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Electrocardiograms (ECGs) were recorded at baseline, annually thereafter, and at run-out in the West of Scotland Coronary Prevention Study to which 6595 men aged from 45 to 65 years on entry were recruited. The baseline ECGs were analyzed with respect to (a) the primary end point of the study, namely, fatal or nonfatal myocardial infarction (MI) and (b) all-cause mortality. In addition, incident MIs were reviewed to determine those detected by ECG only. Heart rate, indexed left ventricular mass, frontal T axis, and T amplitude in lead I were all significantly predictive with respect to the primary end point in a multivariate analysis. With respect to all-cause mortality, minor ST-T changes, 10-second heart rate variability, and frontal T axis were similarly predictive. Of 355 incident MIs, 47.3% were silent or unrecognized and detected by ECG only. A simple ECG-based risk prediction equation for fatal and nonfatal MI is introduced.

The project I4C (Integration and Communication for the Continuity of Cardiac Care) is carried out for the advancement of cardiac care, from prevention to follow-up. The goals of I4C are: (1) integrated access to patient data, wherever they are stored; (2) support of evidence-based care; (3) consistent recording of patient data (eg, patient history, electrocardiograms IECGs] or cine-angios) in a multimedia patient record; and (4) a documented reference data set for research. In several clinics, workstations are being installed to serve the four goals. Integration with other information systems in clinical care is realized by encapsulation. A computer-based patient record (ORCA) has been developed to support the collection, consultation, and sharing of patient data. In I4C, ORCA is intended for use in a research setting as well as routine patient care. The functionality of ORCA covers the collection of patient history data in a highly structured manner, the recording of drug prescriptions, an overview of laboratory test results, and viewers for ECGs and angiographic images. At present, structured data entry and consultation is supported in six European languages.

The techniques that improve the overall repeatability of computer interpretation of electrocardiograms (ECGs) that have been recorded several minutes apart from patients in a clinically stable condition are described. Estimates of the normal amounts of variability present in many ECG parameters that are used in the identification of a variety of cardiac abnormalities have been adopted in conjunction with smoothing techniques to form the basis of the new methodology. When applied to the Glasgow ECG analysis program, these new methods improve overall repeatability by about 31% when tested on a set of 263 pairs of ECGs. Randomly generated noise was added to the test set and an additional technique aimed at removing noise from the ECG tracings was used in conjunction with the smoothing methods. The observed improvement over the original repeatability was 63%.

The Megacare Electrocardiographic (ECG) Management System (Siemens-Elema, Stockholm, Sweden) incorporates methods for serial comparison of the 12-lead ECG based on the Glasgow interpretation program. While a computer is obviously useful for reporting serial changes following myocardial infarction, it was believed helpful to produce a summary serial comparison statement that would take into account the fact that ECG appearances may normally fluctuate from day to day for a variety of reasons. Thus, five additional summary statements were added to the Glasgow program to indicate the extent of change globally compared to the previous ECG recording. In an ECG management system, an important facility that can potentially cause difficulties with serial comparison is overreading. When a statement has been altered by a reviewer, the changes are required to be incorporated into the ECG file so that in any subsequent serial comparison, the modified report is available for comparison with the next ECG. The Megacare system allows for this, and its methodology is described in this article.

The Minnesota code was introduced in 1960, and since then, a number of computer programs have been written for classifying electrocardiograms according to the rules of the code. However, in 1982, extended rules for serial comparison based on the Minnesota code were published. This article presents the details of implementation of automated serial electrocardiographic comparison using the code. Its application in the West of Scotland Coronary Prevention Study, which was a double-blind trial of lipid lowering in 6.595 men, is also discussed.

The effects of age, sex, and race on the electrocardiogram (ECG) were studied using three separate populations: a pediatric group of 1,782 neonates, infants, and children, and adult white group of 1,555 individuals, and an adult Chinese cohort of 503 individuals. All ECGs were processed using the same computer program, and various interval measurements were derived, including QRS duration, heart rate, QT dispersion, and selected Q-wave durations. Also, a small subgroup of 195 white subjects had a signal-averaged ECG recorded. In the pediatric group, there was a clear link between age and QRS duration, which increased linearly from about 1 year of age to adolescence. In the adults, the principal differences were an increased QRS duration in men compared with women both in the standard and signal-averaged ECG. Upper limits of normal heart rate also tended to be higher in women than in men in the two adult populations. Small racial differences could be seen in some measurements, but were not thought to be of clinical significance.

This study describes the implementation of novel techniques that have been designed with the aim of improving the repeatability of the diagnostic section of the Glasgow electrocardiographic (ECG) analysis program. Specific reference is made to the agreement in consecutive computer-assisted diagnoses of inferior myocardial infarction (IMI). Inherent repeat variation was estimated in ECG parameters of interest and used in conjunction with smoothing methods to produce a continuous Q-wave index ranging from 0 (no IMI) to 1 (IMI). A decision as to the presence or absence of IMI was then made on the basis of this smooth index. The sensitivity and specificity of the new approach remain unchanged from the conventional procedure when analyzing single ECGs. However, consistency in interpretation of day-to-day and minute-to-minute ECG interpretations was enhanced. Specific reference is made to the agreement between consecutive pairs of computer-assisted diagnoses of ECGs from the same patient with which one or both interpretations was that of IMI.

An investigation into the use of software-based artificial neural networks for the electrocardiographic (ECG) detection of inferior myocardial infarction was made. A total of 592 clinically validated subjects, including 208 with inferior myocardial infarction, 300 normal subjects, and 84 left ventricular hypertrophy cases, were used in this study. A total of 200 ECGs (100 from patients with inferior myocardial infarction and 100 from normal subjects) were fed to 66 supervised feedforward neural networks for training using a back-propagation algorithm. QRS and ST-T wave measurements were used as the input parameters for the neural networks. The best performing network using QRS measurements only and the best using QRS and ST-T data were selected by assessing a test set of 292 ECGs (108 from patients with inferior myocardial infarction, 84 from patients with left ventricular hypertrophy, and 100 from normal subjects). These two networks were then implanted separately into the deterministic Glasgow program for further study. After the implementation, it was found necessary to include a small inferior Q criterion to improve the specificity of reporting inferior myocardial infarction, thereby producing a small loss of sensitivity as compared with use of the network alone. The use of an artificial neural network within the deterministic logic performed better than either alone in the diagnosis of inferior myocardial infarction, producing a 20% gain in sensitivity with 2% loss in overall specificity compared with the original deterministic logic.

Derived vectorcardiograms from 503 healthy Chinese individuals (248 men and 255 women) were analyzed to determine the normal ranges of scalar and vector measurements in a Chinese population. In both sexes, the magnitude of the maximal spatial QRS and T vectors decreased significantly with age and was significantly smaller in women in all age groups. The results of this study were concordant with the results of previous studies using the Frank lead system in Caucasians, but the derived vectorcardiogram has the advantage of not requiring any leads additional to those used for recording the conventional 12-lead electrocardiogram. In conclusion, it was found that for healthy Chinese individuals there are significant age and sex related influences on the normal ranges of derived vectorcardiograms. Therefore, vectorcardiographic diagnostic criteria for Chinese individuals should be age-related and sex-related.

This study describes a method for improving the day-to-day and minute-to-minute repeatability of the deterministic computer-assisted diagnosis of left ventricular hypertrophy. Conventional upper limits of normal for many age-dependent electrocardiographic parameters have been replaced by continuous equations, thereby, eliminating points of discontinuity that can contribute to lack of repeatability. Estimates of the normal amounts of variability present in many electrocardiographic parameters that are used in the diagnosis of left ventricular hypertrophy are calculated. These estimates are then used together with a smoothed version of a score function to form the basis of the new technique. The implementation of smoothing techniques enhances the repeatability of the Glasgow electrocardiographic analysis program. With respect to the electrocardiographic diagnosis of left ventricular hypertrophy, these methods eliminate 44% of the day-to-day and 50% of the minute-to-minute inconsistencies in computer reports.

An investigation into the use of software-based neural networks for the detection of atrial fibrillation was made. At a specific point in the Glasgow 12-lead electrocardiographic interpretation program, a decision has to be made as to whether atrial fibrillation or sinus rhythm with supraventricular or ventricular extrasystoles is present. The same input parameters used for the deterministic logic at that point were also utilized to train a variety of neural networks. Results from a separate test set showed that the sensitivity of detecting atrial fibrillation could be improved using the best of the neural networks. On the other hand, it was felt that the original deterministic logic could be improved by considering adjustments in order that the presence of certain combinations of findings not previously regarded as representing atrial fibrillation would now do so. When the deterministic logic was upgraded in this way, it was found, again using a separate test set, that the revised logic was improved compared to the original, and also gave a performance similar to that of the neural network. It is concluded that the use of a neural network at a specific diagnostic decision point in a rhythm analysis program can be as effective as deterministic logic, which may take several years to perfect.

The usefulness of neural networks for pattern recognition in electrocardiographic (ECG) ST-T segments was assessed. Two thousand ST-T segments from the 12-lead ECG were visually classified singly into 7 different groups. The material was divided into a training set and a test set. Computer-measured ST-T data for each element in the training set, paired with the corresponding classification, was input to various configurations of software-based neural networks during a learning process. Thereafter, the networks correctly classified 90-95% of the individual ST-T segments in the test set. The importance of the size and composition of the training set in determining the performance of a network was clearly demonstrated. In conclusion, neural networks can be used for classification of ST-T segments. If carefully incorporated into a conventional ECG interpretation program, neural networks may well be of value for automated ECG interpretation in the near future.

The conventional approach to recording the vectorcardiogram is to use a specially designed set of electrodes that derive 3-orthogonal leads, ideally corrected with respect to lead strength and direction. This has disadvantages in that it entails a separate recording as opposed to the use of the 12-lead ECG that is universally used. On the other hand, recently developed equations allow the vectorcardiogram to be derived from the 12-lead ECG, and although there is not a one-to-one correspondence with the vectorcardiogram derived using a corrected orthogonal lead system, it has been shown that there is a high degree of similarity between the two derivations. This article discusses the advantages of utilizing the "derived 12-lead vectorcardiogram," which is claimed to have information that is complementary to that of the scalar 12-lead ECG display. It is suggested that using the combination of the 12-lead ECG and the vectorcardiogram derived therefrom, provides the optimum approach to ECG interpretation as compared to using either method alone.

In an international collaborative project aimed at producing common standards for quantitative electrocardiography, a standard communications protocol (SCP-ECG) was developed for computerized electrocardiography. The protocol consisted of standards for the interchange, encoding, and storage of digital ECG data. The work was performed in three distinct, but closely related, work-packages and in close collaboration with representatives from 13 manufacturers of computerized electrocardiographs from all over the world. The objectives and results of SCP-ECG are briefly described in this paper.

The development of a data base is described which can be used as common reference for ECG computer programs analyzing 12 or 15 simultaneously recorded leads. This data base is an extension of the 3-lead CSE reference library, described previously.

A study of more than 1,780 neonates, infants, and children was carried out, using a digital electrocardiograph with a sampling rate of 500 per second, to revise the normal limits of the pediatric ECG. The 12-lead ECG was used with V4R replacing V3. All leads were recorded simultaneously off-line in digital form on magnetic tape and were subsequently analyzed using well-established computing techniques. The results showed that the upper 98 percentile limit of normal amplitudes could be up to 46% higher than previously published limits. Differences in some mean values were very much higher, though these are of less clinical significance. In addition, QRS durations were found to be wider than previously published data. Sex-related differences could be demonstrated in both amplitude and duration measurements, particularly in the early adolescent years. This study confirms that to record pediatric ECGs with high fidelity, it is necessary to use equipment that converts the ECG from analog to digital form at a rate of 500 samples/sec. Significant errors in amplitude and duration measurements may be expected if a much lower sampling rate is utilized.

In an international project investigators from 21 institutes are trying to establish a common reference library and evaluation methods for testing the diagnostic performance of various ECG computer programs using ECG independent clinical information. Preliminary results indicate that the classification accuracy of different programs varies widely.

A unique method for serial comparison of electrocardiograms is introduced. A Siemens 440 or 740 electrocardiograph can be linked directly to a central minicomputer system, from which serial data for up to three previously recorded ECGs from the same patient can be retrieved and transferred back to the ECG machine. Serial comparison logic has been incorporated into the diagnostic program inside the 440 and 740 so that immediate serial comparison can be undertaken at the bedside or in the clinic.

12-lead electrocardiograms (ECGs) from 503 healthy Chinese individuals were computer-analyzed to derive the normal limits of the ECG in a Chinese population. With respect to ECG amplitudes, there were highly significant differences between men and women. The mean S wave amplitude in V2 decreased with increasing age, but the mean R wave amplitude in V5, for example, remained remarkably constant throughout the age groups. The QRS duration was on average 7.6 msec shorter in women than in men. The mean frontal QRS axis shifted superiorly by 17 degrees with increasing age, resulting in an upward trend in R wave amplitude in leads I and aVL. It was concluded that ECG diagnostic criteria for Chinese individuals should be age- and sex-dependent.