Journal of Pediatric Cardiology and Cardiac Surgery

Online ISSN: 2433-1783 Print ISSN: 2433-2720
Japanese Society of Pediatric Cardiology and Cardiac Surgery
Japanese Society of Pediatric Cardiology and Cardiac Surgery Academy Center, 358-5 Yamabuki-cho, Shinju-ku, Tokyo 162-0801, Japan
Journal of Pediatric Cardiology and Cardiac Surgery 8(1): 39-52 (2024)
doi:10.24509/jpccs.0801G1

GuidelineGuideline

Guidelines for the Secondary Screening of Heart Disease in Schools: Electrocardiographic Findings of the Initial Screening (JSPCCS2019)

Mamoru Ayusawa1，Mari Iwamoto2，Yoshiaki Kato3，Taichi Kato4，Naokata Sumitomo5，Manatomo Toyono6，Kenji Yasuda7，Eiichi Yamamoto8，Masami Nagashima9，Masao Yoshinaga10，Naomi Izumida11，Hiroya Ushinohama12，Nobuo Tauchi9，Hitoshi Horigome13，Takashi Higaki14，Tatsunori Hokosaki15，Katsumi Abe16，Yoshio Arakaki17，Shun-ichi Ogawa18，Takao Katoh19，Naohiko Takahashi20，Masayasu Hiraoka21Mamoru Ayusawa1, Mari Iwamoto2, Yoshiaki Kato3, Taichi Kato4, Naokata Sumitomo5, Manatomo Toyono6, Kenji Yasuda7, Eiichi Yamamoto8, Masami Nagashima9, Masao Yoshinaga10, Naomi Izumida11, Hiroya Ushinohama12, Nobuo Tauchi9, Hitoshi Horigome13, Takashi Higaki14, Tatsunori Hokosaki15, Katsumi Abe16, Yoshio Arakaki17, Shun-ichi Ogawa18, Takao Katoh19, Naohiko Takahashi20, Masayasu Hiraoka21

1 Department of Pediatrics and Child Health, Nihon University School of Medicine ◇ Tokyo, Japan

2 Department of Pediatrics, Saiseikai Yokohamashi Tobu Hospital ◇ Kanagawa, Japan

3 Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center ◇ Osaka, Japan

4 Department of Pediatrics/Developmental Pediatrics, Nagoya University Graduate School of Medicine ◇ Aichi, Japan

5 Department of Pediatric Cardiology, Saitama Medical University International Medical Center ◇ Saitama, Japan

6 Department of Pediatrics, Akita University Graduate School of Medicine ◇ Akita, Japan

7 Department of Pediatrics, Shimane University Hospital ◇ Shimane, Japan

8 Department of Pediatrics, Ehime Prefectural Central Hospital ◇ Ehime, Japan

9 Aichi Saiseikai Rehabilitation Hospital ◇ Aichi, Japan

10 Department of Pediatrics, National Hospital Organization Kagoshima Medical Center ◇ Kagoshima, Japan

11 Akebonocho Clinic ◇ Tokyo, Japan

12 Ohori Children Clinic and Pediatric Cardiology Division, Fukuoka Children’s Hospital ◇ Fukuoka, Japan

13 Department of Child Health, Faculty of Medicine, University of Tsukuba ◇ Ibaraki, Japan

14 Department of Regional Pediatrics and Perinatology, Ehime University Graduate School of Medicine ◇ Ehime, Japan

15 Department of Pediatrics, National Hospital Organization Yokohama Medical Center ◇ Kanagawa, Japan

16 Division of School Health, Tokyo Health Service Association ◇ Tokyo, Japan

17 Department of Pediatrics, Kurashiki Central Hospital ◇ Oakayama, Japan

18 SUBARU Children’s Clinic and Department of Pediatrics, Nippon Medical School ◇ Tokyo, Japan

19 Clinic of Tobu Railway Co. Ltd. and Department of Cardiology, Nippon Medical School ◇ Tokyo, Japan

20 Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University ◇ Oita, Japan

21 Cardiology Clinic Hiraoka and Tokyo Medical & Dental University ◇ Tokyo, Japan

発行日：2024年2月29日Published: February 29, 2024
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© 2024 特定非営利活動法人日本小児循環器学会© 2024 Japanese Society of Pediatric Cardiology and Cardiac Surgery

The previous “Guideline for Secondary Screening of Heart Disease in Schools (2006 revised version)” has been widely used as a screening tool that utilizes the electrocardiogram (ECG) to detect heart disease in school students.1) More than 10 years have passed since its publication. We need to revise it at this stage to reflect the current advancements in automated ECG diagnosing systems and changes in the growth of students’ physiques.

As the first step for revising the guidelines, we collected ECG readings of approximately 50,000 healthy children in Japan to serve as a reference for the updated normal values.2) This was performed by the Pediatric Electrocardiogram Research Committee (formerly the Committee for the Heart Disease Screening in School of the Japanese Society of Pediatric Cardiology and Cardiac Surgery) and other experts in this field. Then, the previous guidelines were revised to reflect the new reference for normal values. A large proportion of the new guidelines remain the same as the preceding comprehensive guidelines of school heart disease screening published by JCS 2016/JSPCCS 20163); however, several parts have been consecutively discussed, modified, and added, in order to focus on new interpretation of ECG findings in school students.

The main points of revision are as follows:

  1. 1) In addition to the numerical value correction described above, the table of criteria which has been used to detect ventricular hypertrophy by a points system was incorporated into the screening criteria according to a code system.
  2. 2) Criteria and descriptive explanations for “Brugada-type ST-T abnormality,” “ectopic atrial rhythm,” and “Short QT interval” were included.
  3. 3) Annotations were added accordingly, labeled as “Note” or “Notes,” to explain items *1 to *20 to ensure accuracy further.
  4. 4) In addition, we have added the terminology of diagnoses and findings in automated ECG diagnosis, as was presented by the Japanese Heart Rhythm Society in the Expert Consensus Statement in 2019.4) We revised some of these terminologies and definitions while making sure that they are consistent with the Expert Consensus Statement.

The research process, the methods, and a proposal for revisions were presented at a joint meeting with the current School Health Screening Committee in 2019. Subsequent approval for publication of these guidelines in the Journal of the Society was provided.

Admitting that recording of ECG findings is desirable without a filtering system, it is usually necessary to filter noises and baseline oscillations out due to the large volume of ECGs recorded at schools. The ECG findings used in this study were based on filtered ECG records. The filtering maneuver may affect the QRS wave height.

In our study, we found that the R and S waves were reduced by approximately 10–15%, compared with the unfiltered example, after filtering electromyogram and hum noise.

The reference normal ECGs were obtained from students in the first grade of elementary school (6 grades, from 6 to 12 years old), junior high school (3 grades, 12 to 15 years old), and senior high school (3 grades, 15 to 18 years old). Therefore, our screening criteria are based on these references. Findings from each student are assessed according to the criteria for lower grades of elementary school students, for junior high school students, and for senior high school students. In the future, we aim to collect and analyze ECGs in fourth grade students of elementary school with the goal of developing and proposing criteria for screening heart disease in the upper grades of elementary school.

Found below are the explanations for screening categories A, B, and C. If there are two or more findings, the findings with higher categorization (in the order of A, B, and C) are prioritized.

  • Category A: Findings requiring secondary screening or further examination.
  • Category B: Findings not requiring secondary screening (if other abnormal findings are absent).
  • Category C: Findings not requiring heart disease screening at schools.

I. Q Wave

1. Broad Q wave
CategoryCode No.Findings
A1-1-1|Q|/R≥1/3 and Q≥0.03 sec (in any one of the leads I, II, V2 to V6)
1-1-2Q≥0.04 sec (in any one of the leads I, II, V1 to V6)
1-1-4QIII≥0.05 sec and |Q aVF| ≥0.1 mV
1-1-5Q aVF≥0.05 sec
B1-1-3Q aVL≥0.04 sec and R aVL≥0.3 mV
1-2-20.03≤Q<0.04 sec (in any one of the leads I, II, V2 to V6)
1-2-40.04≤QIII<0.05 sec and |Q aVF| ≥0.1 mV
1-2-50.04≤Q aVF<0.05 sec
C1-2-1|Q|/R≥1/3 and 0.02≤Q and <0.03 sec (in any one of the leads I, II, V2 to V6)
1-3-11/5≤|Q|/R<1/3 and 0.02≤Q<0.03 sec (in any one of the leads I, II, V2 to V6)
1-3-30.03≤QaVL<0.04 sec and RaVL≥0.3 mV
1-3-40.03≤QIII<0.04 sec and |QaVF| ≥0.1 mV
1-3-50.03≤QaVF<0.04 sec
2. QS pattern
CategoryCode No.Findings
A1-1-6QS pattern when initial R-wave is present in adjacent right precordial leads (in any one of the leads V2 to V6)
1-1-7QS pattern (all leads V1 to V4 or all leads V1 to V5)
1-1-8QS pattern (lead V6)
1-2-3QS pattern (lead I or II)
1-2-7QS pattern (all leads V1 to V3)
1-3-6QS pattern (leads III and aVF)
C1-3-2QS pattern (leads V1 and V2)
3. Deep Q wave
CategoryCode No.Findings
A1-4-1|QV5|<|QV6| and |QV6| ≥0.5 mV
B1-2-6|Q| ≥0.5 mV (lead III or aVF)
4. Other Q wave findings
CategoryCode No.Findings
A1-5-1qR(S) pattern (lead V1)*1
Note 
*1: When there are unusual findings in the Q wave listed as code nos. 1-2 and 1-3, the ST portion and findings in the T wave (code nos. 4 and 5) must be noted. When abnormalities coexist in both, myocardial ischemia and myocardial disease must be meticulously ruled out.

II. QRS Electrical Axis

Abnormal electrical axis
CategoryCode No.Findings
B2-1-0−90°<QRS axis≤−30°
2-4-1−180°<QRS axis≤−90°*2
2-1-1−30°<QRS axis≤0° (only for students in lower grader of elementary school and students in junior and senior high school students are classified into category C.) for)
2-2-1+135°≤QRS axis≤180°
2-2-2+120°≤QRS axis<+135°
C2-3-0+90°≤QRS axis<+120°
2-5-0Indeterminate axis (90° in the frontal plane)*3
Notes 
*2: In case with severe QRS electrical axis deviation, anterior left bundle branch block or posterior left bundle branch block may be suspected. In such a circumstance, attention must be paid to further findings such as the presence of right bundle branch block or PR interval prolongation. 
*3: An indeterminate electrical axis means that the angle of the electrical axis to the reference line cannot be measured because the amplitudes of the R and S waves are equivalent (the electrical axis is perpendicular to the frontal plane).

III. R Wave and S Wave

1. Right ventricular hypertrophy
CategoryLower grade in elementary schoolJunior and senior high schools
MalesFemales
AqRS, qR, or R type in V1+++
High R wave in right precordial leads
RV1≥2.0 mV≥2.0 mV≥1.5 mV
R<R′ in V1 and R′V1 is:≥1.0 mV≥1.0 mV≥1.0 mV
R>|S| in V1 and RV1 is:≥1.5 mV≥1.5 mV≥1.0 mV
BDeep S wave in left precordial leads
|SV6|≥1.0 mV≥1.0 mV≥1.0 mV
R≤|S| and |SV6| in lead V6 is:≥0.5 mV≥0.5 mV≥0.5 mV
Right axis deviation of QRS electrical axis*4≧120°≧120°≧120°
As data collection from students in higher grades of elementary schools has been insufficient, these values in lower grade students are to be referenced for them.
2. Right ventricular overload/right ventricular high voltage (items with R and S wave probable right ventricular hypertrophy and their code nos.)
CategoryCode No.Findings
A3-2-0qR(S) pattern (lead V1) (same as code No. 1-5-1) or R pattern
3-2-2RV1≥2.0 mV
3-2-4RV1≥1.5 mV (in female students from junior and senior high school)
3-2-7R<R′ in V1 and R′V1≥1.0 mV
3-2-3R>|S| in V1 and RV1≥1.5 mV
3-2-5R>|S| in V1 and RV1≥1.0 mV (in female students from junior and senior high schools)
B3-5-1|SV6| ≥1.0 mV
3-5-2R≤|S| and |SV6| ≥0.5 mV in lead V6
3. Left ventricular hypertrophy
CategoryLower grade in elementary schoolJunior and senior high schools
MalesFemales
AStrain pattern of ST-T in left precordial leads*4, *7+++
High R wave in left precordial leads
RV5≥4.0 mV≥4.5 mV≥3.5 mV
RV6≥3.0 mV≥3.5 mV≥2.5 mV
Deep S wave in right precordial leads
|SV1|+RV5≥6.0 mV≥6.5 mV≥5.0 mV
|SV1|+RV6≥5.0 mV≥5.5 mV≥4.5 mV
Deep Q wave in left precordial leads:|QV5|<|QV6| and |QV6|≥0.5 mV≥0.5 mV≥0.5 mV
BHigh R wave in leads II, III, or aVF
R II and R III≥2.5 mV≥2.5 mV≥2.5 mV
RaVF≥2.5 mV≥2.5 mV≥2.5 mV
Left axis deviation of QRS electrical axis*4≤0°≤−30°≤−30°
As data collection from students in higher grades of elementary schools remains insufficient, these values in lower grade students are to be referenced for them.
4. Left ventricular overload/left ventricular high voltage (items with R and S wave probable left ventricular hypertrophy and their code nos.)
CategoryCode No.Findings
A3-1-4RV5≥4.5 mVMales in junior and senior high schools
3-1-1RV6≥3.5 mV
3-3-3|SV1|+RV5≥6.5 mV
3-3-0|SV1|+RV6≥5.5 mV
3-1-6RV5≥3.5 mVFemales in junior and senior high schools
3-1-3RV6≥2.5 mV
3-3-5|SV1|+RV5≥5.0 mV
3-3-2|SV1|+RV6≥4.5 mV
3-1-5RV5≥4.0 mVLower grade in elementary school
3-1-2RV6≥3.0 mV
3-3-4|SV1|+RV5≥6.0 mV
3-3-1|SV1|+RV6≥5.0 mV
B3-1-8R II and R III≥2.5 mV
3-1-9RaVF≥2.5 mV
Notes 
*4: On top of the heading 3 describing hypertrophy on R and S waves, the items marked with *4 in the table far above are those that determine ventricular hypertrophy on other than R or S waves. The QRS electrical axis must be incorporated with other findings for judgement. 
*5: Left ventricular hypertrophy is difficult to confirm in those with WPW syndrome or with left bundle branch block. 
*6: The amplitude may be slightly lower in female students in senior high school than in those in junior high school. This is because diverse body weight (obesity/thinness) and/or breast development. 
*7: Strain pattern of ST-T: High R wave in leads V5 or V6 with negative or biphasic T wave (− to +). ST segment is often down-sloping or flat.

IV. ST Junction and ST Segment

1. ST depression
CategoryCode No.Findings
A4-1-1ST-J depression≥0.2 mV and flat or down-sloping ST segment (in any one of the leads I, II, aVL, aVF, or V1 to V6)
4-1-20.1≤ST-J depression<0.2 mV and flat or down-sloping ST segment (in any one of the leads I, II, aVL, aVF, or V1 to V6)
9-2-4Strain pattern of ST-T in left precordial leads*7
B4-2-10.05≤ST-J depression<0.1 mV and flat or down-sloping ST segment (in any one of the leads I, II, aVL, aVF, or V1 to V6)
4-3-1ST-J depression<0.05 mV, down-sloping ST segment, and depression of ≥0.05 mV from baseline at ST segment or the lowest point of T wave (in any one of the leads I, II, aVL, or V2 to V6)
4-4-1ST-J depression>0.2 mV and up-sloping ST segment (in any one of the leads I, II, aVL, aVF or V1 to V6)
C4-4-2ST-J depression>0.1 mV and up-sloping ST segment (in any one of the leads: I, II, aVL, or V1 to V6)
2. ST elevation
CategoryCode No.Findings
A9-2-2Brugada-type ECG: coved-type*8, 10
9-2-3Brugada-type ECG: saddleback-type ST elevation*9, 10
C9-2-1ST elevation≥0.2 mV (in any one of the leads II, III, aVL, or V5 to V6): ignore this finding when 6-4: WPW syndrome or 7-1: left bundle branch block is present
Notes 
*8: Brugada-type ST-T abnormality (coved-type): ST elevation≥0.2 mV at the J point in right precordial leads (in any of the leads V1, V2 or V3) and coved-type (type 1) ST-T change are recognized. 
*9: Brugada-type ST-T abnormality (saddleback-type): ST elevation≥0.2 mV at the J point in right precordial leads (in any of the leads V1, V2 or V3) and saddleback-type (type 2) ST-T change are recognized. 
*10: When saddleback-type (9-2-3) of Brugada-type ST-T abnormality is found, secondary screening is required; it is possible for the type to change into the coved-type (9-2-2) depending on diurnal variation, daily variance, or other conditions. 
Saddleback-type in Brugada-type ST-T abnormality would better been investigated further by recording an ECG with a right precordial lead placed one or two intercostal space(s) higher, in addition to regular 12-lead ECG. This is recommended to confirm whether or not the saddleback-type changed into the coved-type.

V. T Wave

CategoryCode No.Findings
A5-1-1Negative, or biphasic T wave with negative deflection≥0.5 mV (in any one of the leads I, II, aVL [R≥0.5 mV], aVF [mainly positive QRS], or V3 to V6) (in any one of the leads V4 to V6 in the precordial leads in elementary school students)
5-2-1Negative, or biphasic T wave with negative deflection≥0.1 mV and <0.5 mV (in any one of the leads I, II, aVL [R≥0.5 mV], aVF [mainly positive QRS], or V4 to V6) (T wave with negative deflection≥0.1 mV and <0.4 mV in lead V4 of lower grade in elementary school students are categorized as B)
5-7-1T wave alternance
B5-3-1Flat (0), negative, or biphasic (± type) T wave with negative deflection<0.1 mV (flat or down-sloping ST segment) (in any one of the leads I, II, aVL [R≥0.5 mV], V5, or V6) (female students in junior or senior high schools with this finding are categorized as C)
5-6-1Positive TV1, RV1≥ |SV1| (only in students in the first year of elementary school or younger)
C5-4-1Positive T wave, 1/20>T/R and R≥1.0 mV (in any one of the leads I, II, aVL, V5 or V6)
9-5-1T>1.2 mV (in any one of the leads II, III, aVF or V6) (Ignore this finding when 6-4: WPW syndrome, 7-1: left bundle branch block, or 7-2: complete right bundle branch block is present)
As data collection from students in higher grades of elementary schools remains insufficient, these values in lower grade students are to be referred for them.

VI. Atrioventricular Conduction

1. Complete atrioventricular block
CategoryCode No.Findings
A6-1-0Third degree (complete) atrioventricular block
2. Second degree atrioventricular block
CategoryCode No.Findings
A6-2-0Second degree atrioventricular block (higher degree)*11
6-2-1Second degree atrioventricular block (Mobitz type II)
6-2-2Second degree atrioventricular block (2 : 1 atrioventricular block)
6-2-3Second degree atrioventricular block (Wenckebach type)
3. PR (PQ) interval
CategoryCode No.Findings
A6-3-0PR interval>0.28 sec
6-3-1PR interval>0.24 sec (only in elementary school students; junior/senior high school students with the same finding are classified to category B)
B6-3-3PR interval≥0.20 sec (only in elementary school students)
C6-5-1PR interval<0.08 sec
4. WPW syndrome (ECG showing delta wave)
CategoryCode No.Findings
A6-4-1WPW syndrome
6-4-3Intermittent WPW syndrome
5. Aberrant conduction
CategoryCode No.Findings
C6-6-0Aberrant conduction
6. Artificial pacemaker
CategoryCode No.Findings
A6-8-0Artificial pacemaker
As data collection from students in higher grades of elementary schools remains insufficient, these values in lower grade students are to be referred for them. 
Note 
*11: Second degree atrioventricular block (higher degree) is a circumstance in which atrioventricular (AV) conduction is 1 in 3 or worse, and missing QRS wave for two or more consecutive atrial contractions.

VII. Intraventricular Conduction

1. Left bundle branch block
CategoryCode No.Findings
A7-1-1Left bundle branch block: QRS duration≥0.12 sec, and VAT≥0.06 sec (in any one of leads I, II, aVL, V5, or V6) with no Q wave (only in junior high and senior high school students)
7-1-2Left bundle branch block: QRS duration≥0.10 sec, and VAT≥0.05 sec (in any one of leads I, II, aVL, V5, or V6) with no Q wave (only in the lower grade students of elementary school)
7-1-3Intermittent left bundle branch block
C9-7-2VAT V6≥0.06sec (ignore this finding when 6-4: WPW syndrome or 7-1: Left bundle branch block is present) (only in junior high and senior high school students)
9-7-3VAT V6≥0.05sec (ignore this finding when 6-4: WPW syndrome or 7-1: Left bundle branch block is present) (only in lower grade students of elementary school)
2. Complete right bundle branch block
CategoryCode No.Findings
A7-2-1Complete right bundle branch block: QRS duration≥0.12 sec, and R′>R and VAT≥0.06 sec (lead V1 or V2) (only in junior high and senior high school students)
7-2-2Complete right bundle branch block: QRS duration≥0.10 sec, and R′>R and VAT≥0.05 sec (lead V1 or V2) (only in lower grade students of elementary school)
7-2-3Intermittent complete right bundle branch block
C9-7-5VAT V1≥0.06sec (ignore this finding when 6-4: WPW syndrome, 7-2: complete right bundle branch block, or 7-3: incomplete right bundle branch block is present) (only in junior and senior high school students)
9-7-4VAT V1≥0.05sec (Ignore this finding when 6-4: WPW syndrome, 7-2: complete right bundle branch block, or 7-3: incomplete right bundle branch block is present) (only in lower grade students of elementary school)
3. Incomplete right bundle branch block*12
CategoryCode No.Findings
A7-3-1Incomplete right bundle branch block: The code 7-3-0 is recognized and R′V1≥|SV1| (only in junior and senior high school students)
7-3-3Incomplete right bundle branch block: The code 7-3-2 is recognized and R′V1≥|SV1| (only in lower grade students of elementary school students)
B7-3-0Incomplete right bundle branch block: QRS duration<0.12 sec, and R<R′ (lead V1 or V2), or notch or slurring of the upward slope of the R wave in lead V1R is found (only in junior and senior high school students)
7-3-2Incomplete right bundle branch block: QRS duration<0.10 sec, and R′>R (lead V1 or V2), or notch or slurring of the upward slope of the R wave in lead V1R is found (only in lower grade students of elementary school)
C7-5-0QRS duration<0.12 sec, R-R′ type, and R′≤R (lead V1 or V2) (only in junior and senior high school students)
7-5-1QRS duration<0.10sec, R-R′ type, and R′≤R (lead V1 or V2) (only in lower grade students of elementary school)
7-5-27-5-0 or 7-5-1, and R′V1≥0.5 mV and RV1≥ |SV1|
4. Intraventricular conduction disturbance*13
CategoryCode No.Findings
A7-4-2Intraventricular conduction disturbance: QRS duration≥0.13sec (only in male senior high school students)
7-4-0Intraventricular conduction disturbance: QRS duration≥0.12sec (only in female senior high school students and in both male and female junior high school students)
7-4-1Intraventricular conduction disturbance: QRS duration≥0.11sec (only in lower grade students of elementary school)
5. Left anterior fascicular block
CategoryCode No.Findings
A7-7-0Left anterior fascicular block: QRS duration<0.12 sec, and |Q in lead I|≥0.025 mV, Q in lead I duration<0.03 sec, and left axis deviation of −45° or more leftward
7-7-1Left anterior fascicular block: QRS duration<0.10 sec, and |Q in lead I|≥0.025 mV, Q in lead I duration<0.03 sec, and left axis deviation of −30° or more leftward (only in lower grade of elementary school students)
6. Bifascicular block
CategoryCode No.Findings
A7-8-0Bifascicular block: 7-2-1 and left axis deviation of −45° or more leftward (only in junior and senior high school students)
7-8-1Bifascicular block: 7-2-2 and left axis deviation of −30° or more leftward (only in elementary school students; junior and senior high school students with this finding are classified to category C)
7. Trifascicular block
CategoryCode No.Findings
A7-9-0Trifascicular block: 7-8-0 bifascicular block and PR>0.28 sec (only in junior and senior high school students)
7-9-1Trifascicular block: 7-8-1 bifascicular block and PR>0.24 sec (only in the lower grade of elementary school students)
As data collection from students in higher grades of elementary schools remains insufficient, these values in lower grade students are to be referred for them. 
Notes 
*12: Students with these findings (code nos. 7-3 or 7-5) should be examined carefully for heart sounds (phonocardiogram). 
*13: Intraventricular conduction disturbance is a supraventricular rhythm, including sinus rhythm, with the QRS width increased but its waveform not fulfilling the definition of a left bundle branch block or right bundle branch block.

VIII. Rhythms

1. Premature supraventricular contractions
CategoryCode No.Findings
A8-1-4Multiform premature supraventricular contractions
B8-1-1Monomorphic premature supraventricular contractions (sporadic cases are classified to category C)
2. Premature ventricular contractions
CategoryCode No.Findings
A8-1-2Monomorphic premature ventricular contractions
8-1-3Combination of 8-1-1: Monomorphic premature supraventricular contractions and 8-1-2: Monomorphic premature ventricular contractions
8-1-5Polymorphic Premature ventricular contraction
8-1-6Premature ventricular contraction couplet
8-1-7R on T type premature ventricular contraction
3. Ventricular tachycardia
CategoryCode No.Findings
A8-2-1Ventricular tachycardia
4. Idioventricular rhythm
CategoryCode No.Findings
A8-2-2Idioventricular rhythm*14
5. Atrial fibrillation
CategoryCode No.Findings
A8-3-1Atrial fibrillation
6. Atrial flutter
CategoryCode No.Findings
A8-3-2Atrial flutter
7. Atrial flutter/fibrillation
CategoryCode No.Findings
A8-3-3Atrial flutter/fibrillation
8. Supraventricular tachycardia
CategoryCode No.Findings
A8-4-1Supraventricular tachycardia
9. Sinus arrest or sinoatrial block
CategoryCode No.Findings
A8-5-1Sinus arrest or sinoatrial block
10. Ectopic atrial rhythm
CategoryCode No.Findings
B8-6-4Ectopic atrial rhythm*15
11. Atrioventricular Junctional rhythm
CategoryCode No.Findings
A8-6-0Accelerated Junctional rhythm, heart rate (≥60bpm)*16
B8-6-1Atrioventricular Junctional rhythm*16
12. Atrioventricular dissociation
CategoryCode No.Findings
B8-6-2Atrioventricular dissociation (exclude complete atrioventricular block)*17
13. Escape beats or escape rhythm
CategoryCode No.Findings
B8-6-3Escape beats or escape rhythm
14. Sinus tachycardia*18
CategoryCode No.Findings
A8-7-1Heart rate (≥200 bpm)
8-7-2Heart rate (≥180 bpm)
B8-7-3Heart rate (≥150 bpm)
8-7-4Heart rate (≥140 bpm) (only in junior and senior high school students, elementary school students with the same finding are classified to C)
C8-7-5Heart rate (≥130 bpm)
8-7-6Heart rate (≥100 bpm)
15. Sinus bradycardia*18
CategoryCode No.Findings
B8-8-1Heart rate<40 bpm
8-8-2Heart rate<45 bpm (only in elementary school students; junior and senior high school students with this finding are classified to C)
C8-8-3Heart rate<50 bpm
8-8-4Heart rate<60 bpm
16. Other arrhythmias
CategoryCode No.Findings
A8-9-9Arrhythmias not otherwise specified
C8-9-1Sinus arrhythmia
As data collection from students in higher grades of elementary schools remains insufficient, these values in lower grade students are to be referenced for them. 
Notes 
*14: Idioventricular rhythm is a condition in which the control site of the heart beating (a pacemaker) is moved to a tissue other than the sinus node and considered to be found within the conduction system at the ventricular level. 
*15: Ectopic atrial rhythm is a condition in which the control site of the heart beating (the pacemaker) is moved to a tissue other than the sinus node and considered to be found within the conduction system at the atrial level (the lower part of the right atrium, the coronary sinus, the left atrium, or other regions in the atrium). 
*16: Atrioventricular junctional rhythm is a condition in which the control site of the heart beating (a pacemaker) is moved to a tissue other than the sinus node and considered to be located around the atrioventricular node. The P wave is negative in leads II, III, and aVF, and the pattern is found either immediately before the R wave (PR time less than 0.09 sec. for lower grade students in elementary school, less than 0.1 sec. for junior and senior high school students), simultaneously (P wave is invisible hidden by R), or immediately after the R wave (retrograde P). If the P wave is not seen, it is necessary to check for sinus dysfunction. Junctional excitation is usually less frequent than sinus node firing and typically occurs at a rate of 30–60/min. When junctional excitation is more frequent than 60/min, it is called accelerated atrioventricular junctional rhythm. 
*17: Atrioventricular dissociation is a condition in which atrial excitation fails to activate the ventricles during the refractory period below the AV node; electricity conduction resumes once the refractory period has passed. Complete atrioventricular block, in which atrial excitation does not activate the ventricles regardless of the refractory period, is therefore excluded. 
*18: Tachycardia or bradycardia should be regarded as phenotypes of disorder of the conduction system.

IX. Others

1. Low voltage
CategoryCode No.Findings
B9-1-0Low voltage: QRS<0.5 mV (all leads I, II, and III) or QRS<1.0 mV (all leads V1 to V6)
2. Atrial load
CategoryCode No.Findings
B9-3-1P≥0.30 mV (in any one of the leads II, III, aVF, or V1)
9-3-3P duration≥0.12 sec (in any one of the leads I, II, or aVL) (only in junior and senior high school students)
9-3-4P duration≥0.10 sec (in any one of the leads I, II, or aVL) (only in elementary school students)
9-3-59-3-3 or 9-3-4, and biphasic P wave and duration of positive part<duration of negative part (in lead V1 or V2)
C9-3-2P≥0.25 mV (in any one of the leads II, III, aVF, or V1)
3. Dextrocardia
CategoryCode No.Findings
A9-6-1Dextrocardia
4. QT prolongation*19
CategoryCode No.Findings
A9-7-1Criteria for QT prolongation using automatic ECG analysis in school screening: QT prolongation is defined as a QTc of ≥0.45 sec, obtained using the Fridericia correction. This is in agreement with the committee of this guideline for this time, as there is no data available from automatic measurement. (The reason for “≥0.45” sec is that QTc obtained in automatic ECG analysis is often approximately 20 msec longer than that that obtained using the tangent method.) When QT prolongation is suspected in automatic analysis, ECG should be reviewed manually using the tangent method (see the following table). The morphology of T wave should be considered as well.
5. Short QT
CategoryCode No.Findings
A9-7-6QTc value (obtained using Bazett’s formula) ≤0.32sec (tentative criteria)*20
6. Reexamination is required
CategoryCode No.Findings
A9-8-0Unreadable ECG due to baseline drift, alternate current interference, artifacts from electromyogram, or other technical errors
7. Negative U wave
CategoryCode No.Findings
B9-2-2Negative U wave
Notes 
*19: When QT prolongation (9-7-1) is fulfilled, attention must be paid to the following characteristic T waves: notched T waves, alternating T waves, broad based T waves, late appearing T waves, etc. 
*20: There are a variety of opinions on the criteria of short QT syndrome, and no worldwide consensus has been made. The following standard values were reported by means of the tangential method with correction using the Bazett method. Male students: ≤0.325 sec, ≤0.315 sec, and ≤0.305 sec in the first grade of elementary school, of junior high school, and of senior high school, respectively. As for female students: ≤0.320 sec in the first grade of elementary, junior high, and senior high schools (Hazeki D, et al. Circ J, 2018; 82(10): 2627–2633).

This is a secondary publication of the guidelines originally published in Pediatric Cardiology and Cardiac Surgery, 2019; 35: S3.1–S3.12 [in Japanese].

引用文献References

1) Baba K, Asai T, Kitada J, et al: Guideline for Secondary Screening of Heart Disease in Schools (2006 revised version)—from the electrocardiogram findings of the primary screening. Pediatric Cardiology and Cardiac Surgery 2006; 22: 503–513 (in Japanese)

2) Yoshinaga M, Iwamoto M, Horigome H, et al: Standard values and characteristics of electrocardiographic findings in children and adolescents. Circ J 2018; 82: 831–839

3) Sumitomo N, Baba R, Doi S, et al: Japanese Circulation Society and the Japanese Society of Pediatric Cardiology and Cardiac Surgery of Joint Working: Guidelines for Heart Disease Screening in Schools (JCS 2016/JSPCCS 2016). Circ J 2018; 82: 2385–2444

4) Kato T, Yashima M, Takahashi N, et al: Expert Consensus Statement: Approaches for Evaluating Accuracy and for Improving Usefulness of Automated ECG Diagnostic Systems—The 1st report: A review of terms of diagnosis and findings used in automated ECG diagnosis. Electrocardiogram 2019; 39: 69–84 (in Japanese)

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