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com

Journal of Electrocardiology 44 (2011) 544 554

www.jecgonline.com

A detailed guide for quantification of myocardial scar with the Selvester

QRS score in the presence of electrocardiogram confounders
Zak Loring, BS, a Sreetharan Chelliah, MBChB, b Ronald H. Selvester, MD, c
Galen Wagner, MD, b David G. Strauss, MD, PhD d,
a

Duke University School of Medicine, Durham, NC, USA

b
Duke Clinical Research Institute, Durham, NC, USA
c
Memorial Hospital Research Center, Long Beach, CA, USA
d
Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD, USA
Received 10 May 2011

Abstract

The Selvester QRS score translates subtle changes in ventricular depolarization measured by the
electrocardiogram into information about myocardial scar location and size. This estimated scar has
been shown to have a high degree of correlation with autopsy-measured myocardial infarct size. In
addition, multiple studies have demonstrated the value of the QRS score in postmyocardial infarct
patients to provide prognostic information. Recent studies have demonstrated that increasing QRS
score is predictive of increased implantable defibrillator shocks for ventricular tachycardia and
fibrillation as well as decreased response to cardiac resynchronization therapy. Although QRS
scoring has never achieved widespread clinical use, increased interest in patient selection and riskstratification techniques for implantable defibrillators and cardiac resynchronization therapy has led
to renewed interest in QRS scoring and its potential to identify which patients will benefit from
device therapy. The QRS score criteria were updated in 2009 to expand their use to a broader
population by accounting for the different ventricular depolarization sequences in patients with
bundle-branch/fascicular blocks or ventricular hypertrophy. However, these changes also introduced
additional complexity and nuance to the scoring procedure. This article provides detailed instructions
and examples on how to apply the QRS score criteria in the presence of confounding conduction
types to facilitate understanding and enable development and application of automated QRS scoring.
Published by Elsevier Inc.

Keywords:

Electrocardiology; Electrophysiology; QRS complex; ECG criteria; Myocardial infarction; Fibrosis; Multimodal
cardiac imaging; Risk stratification

Introduction
In an era of multimodal cardiac imaging, understanding
the information contained in the 12-lead electrocardiogram
(ECG) is important yet frequently overlooked. The Selvester
QRS score, which was described in preliminary form 1972,1
translates subtle changes in cardiac electrical activity into
information about myocardial scar location and size.2,3
Although QRS scoring was rigorously validated in comparison with autopsy-measured myocardial infarct size in the
1980s4-7 and was shown to have prognostic value,3,8-14 this
ECG method did not achieve widespread clinical use.
However, the need to improve patient selection for
implantable defibrillators (ICDs) and cardiac resynchroniza Corresponding author. US Food and Drug Administration, 10903
New Hampshire Avenue, WO62-1126, Silver Spring, MD, 20993, USA.
E-mail address: david.strauss@fda.hhs.gov
0022-0736/$ see front matter. Published by Elsevier Inc.
doi:10.1016/j.jelectrocard.2011.06.008

tion therapy (CRT) has led to a renewed interest in QRS

scoring because characterizing myocardial scar may better
predict which patients will benefit from ICDs and CRT.15,16
The older versions of QRS scoring could only be used in the
absence of ECG confounders (ie, bundle-branch/fascicular
blocks and ventricular hypertrophy), which makes QRS
scoring impractical for ICD/CRT patient selection because
greater than 50% of potential ICD patients and nearly all CRT
patients have ECG confounders.2,15,17 In 2009, new QRS
score criteria for use in the presence of ECG confounders were
published and shown to be able to identify and quantify
myocardial scar in comparison with contrast-enhanced
magnetic resonance imaging (MRI) in patients with ischemic
and nonischemic cardiomyopathy,2,8 including patients with
Chaga's heart disease.3 Subsequent studies have shown that
these QRS score criteria for use in the presence of ECG
confounders can enhance prediction of which patients will

Z. Loring et al. / Journal of Electrocardiology 44 (2011) 544554

15,16

experience appropriate ICD shocks and respond to CRT.

The purpose of this report is to provide more detailed
instructions beyond the 2009 publication for classifying the
type of ECG confounder and applying the QRS score criteria to
better facilitate manual and automated application.
Review of modifications to QRS scoring
The QRS score has been updated and amended multiple
times since its original description in 1972.1 The most recent
changes came in 2009 with a publication describing how to
apply the QRS score in the setting of hypertrophy and
conduction defects.8 Before this study, fascicular blocks,
bundle-branch blocks, and hypertrophy were considered
confounding factors that prevented infarction evaluation via
QRS score. The updated criteria in 2009 account for the
different activation sequences and conduction properties
associated with these defects and are able to distinguish the
additional electrical changes associated with infarction. This
was made possible by using adjusted criteria for each of the
following abnormalities: left and right ventricular hypertrophy
(LVH and RVH, respectively), left anterior fascicular block
(LAFB), left bundle-branch block (LBBB), right bundle-branch
block (RBBB), RBBB + LAFB, and no confounders. The
scoring criteria sets differ slightly among all of these
abnormalities, with LBBB having the most dissimilar criteria,
but they still follow the same principle of a score with each point
representing 3% infarct of the left ventricular (LV) myocardium.
For example, in LBBB, the QRS scoring criteria for the
limb leads (I, II, aVL, and aVF) are similar to those in all other
ECGs; however, the precordial lead scoring criteria are
dramatically different. In normal conduction, anteroseptal
scar causes the rest of the LV to activate largely unopposed,
producing net posteriorly directed electrical activity and
creating a Q wave in leads V1 to V3. Conversely, in LBBB, in
the absence of scar, the LV is activated via electrical
depolarization from the right ventricle (RV) through the
septum and finally out to the posterolateral LV wall, creating
a small or absent initial R wave and deep Q or S wave in V1
and V2 (Fig. 1A). Anteroseptal scar in the presence of LBBB
causes depolarization from the RV to the LV through the
septum to be impeded, and the initial electrical forces are
directed anteriorly because of the unopposed activation of the
RV free wall, resulting in large R waves in V1 and V2 (Fig.
1B).8 Thus, anteroseptal scar results in Q wave formation in
normal conduction but causes large R wave formation in
LBBB. Posterolateral scar disrupts the late forces of the QRS
complex as depolarization spreads from the septum out to the
posterolateral wall, causing notching of the terminal portion
of the S wave in V1 and V2 and, if the scar extends toward the
apex, of the R wave in V5 and V6 (Fig. 2C). Inferior scar
behaves similarly in LBBB as other conduction types,
causing a Q wave in aVF because of unopposed superior
activation early in ventricular activation (Fig. 2D).
In RBBB, the RV activates via depolarization from the LV
through the septum with the RV free wall activating last,
producing broad R or R' waves in V1 and V2.18 This conduction
pattern confounds the diagnosis of posterolateral infarcts that
can also produce large R waves because of unopposed anterior

545

forces. To account for this, in QRS scoring, the R wave criteria

in V1 and V2 for posterolateral scar are increased in the setting of
RBBB, and only the initial part of the R wave that peaks within
the first 50 milliseconds is considered (see Appendix Table 1).
Furthermore, there are additional possible anterior points in the
setting of RBBB to increase the sensitivity to large infarcts that
are the most common cause of RBBB.8

Performing QRS scoring

Classification of conduction/hypertrophy type
Figs. 2 and 3 show flow diagrams that graphically
represent the process of determining the QRS conduction/
hypertrophy type bin in which to evaluate the ECG: LBBB,
LAFB, LVH, RBBB + LAFB, or no confounders. Lead V1
QRS morphology is considered to determine if there is a left
vs right conduction/hypertrophy abnormality. If there is a
terminal negative deflection in lead V1 (rS or Q morphology),
then analysis proceeds according to the diagram in Fig. 2, and
if there is a terminal positive deflection in lead V1 (R or R'),
then analysis proceeds according to the diagram in Fig. 3.
As reported previously,2,8 the definitions for classifying
LBBB and LAFB for QRS score purposes differ slightly
from other reported definitions in the literature.19 The
definitions used with QRS scoring correlate with the
observations made from computer simulations of the
different conduction types from which the QRS score
criteria were derived.18,20 The critical difference with
LBBB (recently described in detail21) is that the QRS
scoring definition for LBBB requires the presence of midQRS notching and a minimum duration of 140 milliseconds
for men and 130 milliseconds for women. To satisfy LAFB
classification for QRS scoring, we have used a minimum
QRS duration of 100 milliseconds because a block in the left
anterior fascicle causes a prolongation of the QRS complex
by 20 milliseconds. 22 However, because women have
shorter baseline QRS duration than men,23 we propose a
minimum QRS duration of 90 milliseconds in women and
100 milliseconds in men for defining LAFB. With regard to
the lack of an upper boundary for QRS duration, LAFB may
coexist with other QRS, prolonging conduction defects such
as LVH, a dilated ventricle, or diffuse interstitial fibrosis
leading to delayed intramural conduction. Patients meeting
LAFB criteria with QRS duration greater than 120
milliseconds undoubtedly have multiple pathologies (eg,
LAFB + LVH); however, these patients are most accurately
evaluated by the LAFB QRS score criteria. For the purposes
of QRS scoring, we recommend using these definitions that
were used during the development of QRS scoring,20 the
validation in comparison with cardiac MRI,2,3 and to predict
outcomes from CRT and ICD therapy.15,16
For scoring purposes, it does not matter if LVH
accompanies one of the abnormal conduction types. The
principal difference between QRS scores of LVH and no
confounders is that, in LVH, Q waves in V1 through V3 only
receive QRS score points if 4 QRS score points or more are
also present in leads I, aVL, V4, V5, or V6. This is because in
LVH, Q waves may be present in leads V1, V2, and V3 in the

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Z. Loring et al. / Journal of Electrocardiology 44 (2011) 544554

absence of infarction; however, evidence of infarction in

other leads makes it more likely that the formation of Q
waves was caused by an infarction. In addition, smooth Q
waves can be normal in V1 to V3 in the presence of LVH, but
notches in the initial 40 milliseconds (NtchInit40) are
considered a sign of infarction. An ECG is considered to
demonstrate LVH if either the Sokolow-Lyon or the Cornell
criteria are satisfied (Figs. 2 and 3).
After determining conduction type, all ECGs should be
evaluated for the presence of right atrial overload (RAO) by

analyzing the P waves in both leads V1 and aVF as shown in

Fig. 4. Right atrial overload commonly occurs in parallel with
RVH.18,20 Large R waves in V1 and V2 are considered
evidence of unopposed anterior electrical forces and are
assigned points indicating infarction in the posterolateral wall
of the LV or, in the case of LBBB, in the anteroseptal the wall;
however, these R waves may also be due to increased anterior
electrical force from RVH. If a patient has RAO, then large R
waves in V1 and V2 are likely to be because of RVH rather
than infarction.8

Fig. 1. Left bundle-branch block activation patterns. All panels demonstrate the ventricular activation pattern in LBBB and ECG wave forms as seen from the
frontal plane (top), horizontal plane (middle), and sagittal plane (bottom) in LBBB without infarction (A), LBBB with anteroseptal infarction (B), LBBB with
posterolateral infarction (C), and LBBB with inferior infarction (D). Colored lines represent areas of myocardium activated within the same 10-millisecond
period (isochrones). Numbers represent milliseconds since beginning of activation. Key ECG changes include the development of large R waves in V1 and V2
with anteroseptal infarction (B), increased R/R' amplitude ratios in V5 and V6 with apical infarction (B), increased S/S' amplitude ratios in V1 and V2 with
posterolateral infarction (C), and Q waves and decreased R/Q or R/S in aVF amplitude ratios with inferior infarction (D).

Z. Loring et al. / Journal of Electrocardiology 44 (2011) 544554

547

Fig. 1. (continued).

Leads V1 and V2 have different criteria for measuring

anteroseptal and posterolateral scar. The QRS scoring
sheet (Fig. 5) lists the anteroseptal criteria as V1 anterior
and V2 anterior in LBBB and simply as V1 and V2 in all
other conduction types. Posterolateral criteria are listed as V1
posterior and V2 posterior in all conduction types. All
ECGs should be analyzed for the presence of both
anteroseptal and posterolateral scar by evaluating both
sets of criteria for leads V1 and V2. In the presence of
RAO, we have excluded the V1 and V2 posterolateral QRS
score criteria (anteroseptal criteria in LBBB) to prevent
allocating false-positive points due to RVH; however, they
can be included in situations where sensitivity to detect
scar is more valuable than specificity.

Application of QRS scoring

False-positive points in QRS scoring were common in
younger men who have increased voltage and older women
who have lower voltages.8 Before scoring, all absolute
amplitude criteria (not ratios) are corrected to the age of 55
years in the score sheet (Fig. 5) by increasing them 1% per
year for those aged 54 years and younger and decreasing
them 1% per year for those aged 56 years and older. For
women, both duration and absolute amplitude (not ratio)
criteria are further decreased by 10%.
After ECGs have been placed in conduction/hypertrophy
bins and amplitude and duration are corrected, the QRS score
for that conduction/hypertrophy type is selected and applied.

548

Z. Loring et al. / Journal of Electrocardiology 44 (2011) 544554

Lead V1

Lead V1

V1 terminal positive deflection

(R or R wave)

V1 terminal negative deflection

(rS or Q wave)

Yes

QRS 120 ms

QRS 140 ms ( )
QRS 130 ms ( )
AND
mid-QRS (after 40ms)
notching/slurring/slowing
in 2 of the leads V1, V2,
V5, V6, I or aVL

Left Axis

Yes

45 & >180

RBBB+
LAFB

No
RBBB

No

Yes
LBBB

QRS 100 ms ( )
QRS 90 ms ( )
AND
Left axis
-45 & > -180

No

Yes

LAFB

No

QRS 100 ms ( )
QRS 90 ms ( )
AND
Left axis
-45 & > -180

Yes

Sokolow-Lyon OR Cornell Criteria

LAFB

No

Yes

LVH

R in aVL + S in V3 >2.80mV ( )
R in aVL + S in V3 >2.00mV ( )

Sokolow-Lyon OR Cornell Criteria

Sokolow-Lyon
(S in V1) + (R in V5 or V6) 3.50mV
OR
R in V5 or V6 >2.60mV
Cornell criteria

Sokolow-Lyon
(S in V1) + (R in V5 or V6) 3.50mV
OR
R in V5 or V6 >2.60mV
Cornell criteria

No

Yes

LVH

R in aVL + S in V3 >2.80mV ( )
R in aVL + S in V3 >2.00mV ( )

No
No Confounders

Fig. 2. Flow chart for determining conduction/hypertrophy type

abnormality. This chart describes the sequence in which ECGs are
evaluated for conduction type when the terminal deflection in V1 is
negative (rS or Q wave).

Careful measurements of both amplitudes and durations are

made with up to an 8 magnifier, when necessary.
When scoring, 2 concepts must be considered:
weighting and selecting (Fig. 6). Weighting refers to
the number of points awarded for the criteria satisfied and
is provided to the right of the criteria. If the point value
is not listed directly to the right of the criterion, its point
value is the same as the criterion directly above it.
Selecting is the process of choosing a single criterion
from a group. When criteria with multiple weights are
included within a box, they are ordered by decreasing
weights. Therefore, proceeding from the top down within
a box (delineated by a dotted line), only the first satisfied
criterion should be selected. Only 1 criterion can be
selected for each box, but there may be multiple boxes in
each lead. The total point score for each ECG is the sum
of the points accumulated from the criteria satisfied for
each lead.

No Confounders

Fig. 3. Flow chart for determining conduction/hypertrophy type

abnormality. This chart describes the sequence in which ECGs are
evaluated for conduction type when the terminal deflection in V1 is
positive (R or R' wave).

Glossary and definitions

The glossary section in Appendix Tables 1 and 2 contain
definitions and illustrations of terms and criteria that are
encountered when performing QRS scoring. The glossary is
divided into 2 sections: the first is for no confounders, LVH,
LAFB, RBBB, and RBBB + LAFB conduction/hypertrophy
All Conduction
types

P-wave in,
V1 0.1 mV
OR
aVF 0.175 mV
(only positive deflections of
P waves are measured)

No
No Right Atrial
Overload

Yes

Right Atrial Overload

(RAO)
(suspect accompanying RVH)

In RBBB, LAFB, LAFB +

RBBB, LVH and No
confounders, exclude V1,
V2 posterior criteria.
In LBBB, exclude V1, V2
anterior R criteria points.

Fig. 4. Flow chart for determining RAO. After conduction type is

determined by following Fig. 2 or Fig. 3, all ECGs are evaluated for
presence of RAO, which suggests accompanying RVH.

Z. Loring et al. / Journal of Electrocardiology 44 (2011) 544554

549

QRS Scoring
Patient ID

QRS duration

Age & gender

QRS axis

Amplitude adjust
( 1%/yr age 20-54; 1%/yr >55 yrs; 10% for females)

Duration adjust

RAO(**, ***)Yes/No

( 10% for females)

RBBB
Lead
I

II
aVL
aVF

V1
Ant.

Criteria
Q 30 ms
R/Q 1
R 0.2 mV
Q 40 ms
Q 30 ms
Q 30 ms
R/Q 1
Q 50 ms
Q 40 ms
Q 30 ms
R/Q 1
R/Q 2
Q 50 m s
any Q
Init R 20 ms

V1
Post.** Init R
Init R
Init R
Init R
V2
Ant.

60 ms
1.5 mV
50 ms
1.0 mV

50 m s
any Q
R 10 ms
R 0.1mV
Q

V2
Post.** Init R 70 ms
Init R 2.5 mV
Init R 50 ms
Init R 2.0 mV
V3

V4

V5

V6

Q 30 ms
R 10 ms
Q 20 ms
R 20 ms
Q 20 ms
R/ Q 0.5
R/ S 0.5
R/Q 1
R/ S 1
R 0.5 mV
N t c hInit 40
Q 30 ms
R/Q 1
R/ S 1
R/Q 2
R/S 2
R 0.6 mV
N t c hInit 40
Q 30 ms
R/Q 1
R/ S 1
R/Q 3
R/S 3
R 0.6 mV
NtchInit40
Points

Total

%LV infarct
(3 x # pts )
* (fo r LVH) if

LAFB
Pts
1
1
2
1
1
1
3
2
1
2
1
2
1

2
1

2
1

2
1

2
1
1
2
1

1
2
1

1
2
1

LAFB + RBBB

Criteria
Q 30 ms
R/Q 1
R 0.2 mV
Q 40 ms
Q 30 ms
Q 40 ms
R/Q 1
Q 50 ms
Q 40 ms
Q 30 ms
R/Q 1
R/Q 2

Pts
1
1

any QR

R/S 1
R 50 ms
R 1mV
R 40 ms
R 0.7 mV

1
2

Q 0.2&S 0.2mV

any QR
R 10 ms
R 0.1mV
R/S 1.5
R 60 ms
R 2 mV
R 50 ms
R 1.5 mV
Q 0.3&S 0.3mV
Q 30 ms
R 10 ms
Q 20 ms
R 20 ms
Q 20 ms
R/Q 0.5
R/S 0.5
R/Q 1
R/S 1
R 0.5 mV
N t c hInit 40
Q 30 ms
R/Q 1
R/S 1
R/Q 2
R/S 1.5
R 0.6 mV
N t c hInit 40
Q 30 ms
R/Q 1
R/S 1
R/Q 3
R/S 2
R 0.6 mV
NtchInit40

2
1
1
1
3
2
1
2
1

Criteria
Q 30 ms
R/Q 1
R 0.2 mV
Q 40 ms
Q 30 ms
Q 40 ms
R/Q 1
Q 50 ms
Q 40 ms
Q 30 ms
R/Q 1
R/Q 2
Q 50 ms
any Q

Init R
Init R
Init R
Init R

60 ms
1.5 mV
50 ms
1.0 mV

1
2
1
1
2
1
1
2
1

1
2
1

1
2
1

LVH

Pts
1
1

Criteria
Q 30 ms
R/Q 1
R 0.2 mV
Q 40 ms
Q 30 ms
Q 40 ms
R/Q 1
Q 60 ms
Q 50 ms
Q 40 ms
R/Q 1
R/Q 2

2
1
1
1
3
2
1
2
1
2

(o r any Q if *)
N t c hInit 40
R/S 1
R 50 ms
R 1mV
R 40 ms
R 0.7 mV

1
2
1

2
1

Init R 70 ms
Init R 2.5 mV
Init R 50 ms
Init R 2.0 mV

Q 30 ms
R 10 ms
Q 20 m s
R 20 m s
Q 20 ms
R/Q 0.5
R/S 0.5
R/Q 1
R/S 1
R 0.5 mV
N t c hInit 40
Q 30 ms
R/Q 1
R/S 1
R/Q 2
R/S 1.5
R 0.6 mV
N t c hInit 40
Q 30 ms
R/Q 1
R/S 1
R/Q 3
R/S 2
R 0.6 mV
NtchInit40

Pts
1
1
2
1
1
1
3
2
1
2
1

Criteria
Q 30 ms
R/Q 1
R 0.2 mV
Q 40 ms
Q 30 ms
Q 30 ms
R/Q 1
Q 50 ms
Q 40 ms
Q 30 ms
R/Q 1
R/Q 2

Pts
1
1
2
1
1
1
3
2
1
2
1

LBBB
Lead
I

Criteria
any Q
R/Q 1
R/S 1
R/Q 1.5
R/S 1.5
Q 40 ms
Q 30 ms
R/Q 0.5
R/S 0.5
Q 50 ms
Q 40 ms
R/S 0.5
R/ Q 0.5

II

aVL

any QR

50 m s
any Q
R 10 ms
R 0.1mV

No Confounders

any Q

1
2

R/S 1
R 50 ms
R 1m V
R 40 ms
R 0.7 mV

1
2

1
V1

Q 0.2&S 0.2 mV

Q 0.2&S 0.2mV

any QR
(o r any Q if *)
Ntc hInit40
R / S 1.5
R 60 ms
R 2 mV
R 50 ms
R 1.5 mV
Q 0.3&S 0.3mV

any Q
R 10 ms
R 0.1mV
R/S 1.5
R 60 ms
R 2 mV
R 50 ms
R 1.5 mV
Q 0.3&S 0.3mV
Q 30 ms
R 10 ms
Q 20 ms
R 20 m s
Q 20 ms
R/Q 0.5
R/S 0.5
R/Q 1
R/S 1
R 0.5 mV
N t c hInit 40
Q 30 ms
R/Q 1
R/S 1
R/Q 2
R/S 2
R 0.6 m V
N t c hInit 40
Q 30 ms
R/Q 1
R/S 1
R/Q 3
R/S 3
R 0.6 mV
NtchInit40

1
1
2
1

1
2
1

1
2
1

QR& (Q 30 ms)

Ntc hInit40
any QR
(o r any Q if *)
Q 20 ms
R/Q 0.5
R/S 0.5
R/Q 1
R/S 1
R 0.5 mV
N t c hInit 40
Q 30 ms
R/Q 1
R/S 1
R/Q 2
R/S 2
R 0.6 mV
N t c hInit 40
Q 30 ms
R/Q 1
R/S 1
R/Q 3
R/S 3
R 0.6 mV
NtchInit40

1
2
1
1
2
1

1
2
1

1
2
1

1
2
1

Points

Points

Points

Points

% LV infarct
(3 x # pts )

%LV infarct
(3 x # pts )

% LV infarct
(3 x # pts )

% LV infarct
(3 x # pts)

R/S 1
R/Q 1
Q 50 ms
Q 40 ms
R / Q 0.5
R/S 0.5
NchInit40

aVF

1
2
1

Ant.***

V1
Post
V2
Ant.***

1
2
1
1
2

V2
Post
V5

1
V6
1
2
1

Total

R 0.3 mV
R 30 ms
R 0.2 mV
R 20 ms
S/S' 2.0
S/S' 1.5
S/S' 1.25
NchInit40
R 0.4 mV
R 30 ms
R 0.3 mV
R 20 ms
S/S' 2.5
S/S' 2.0
S/ S' 1.5
any Q
R/R ' 2
R/R' 1
R/S 2
R 0.5 mV
Q 20 ms
R/R' 2
R/R' 1
R/S 2
R 0.6 mV
Points

Pts
1
2
1
2
1
1
2
1
2
1
2
1
1
1
2
1
3
2
1
1
2
1
3
2
1
1
2
1
1
1
2
1
1

%LV infarct
( 3 * # pt s )
1
2
1

4 other points in leads I, aVL, V4, V5 or V6 then count QS in V1-V3

** (RAO) if P positive amp in V1 0.1 mV or aVF P .175 mV, then exclude V1-V2 Post criteria

*** (RAO) if P positive amp in V1

0.1 mV or aVF P .175 mV, then
exclude V1-V2 R-criteria points

Fig. 5. QRS scoring sheet. Sample QRS scoring sheet with all conduction types and criteria is listed. After demographic information is entered in the top portion,
conduction type is selected, and analysis proceeds down the appropriate column.

types (Appendix 1), and the second is only for LBBB

conduction type (Appendix 2). This is because of LBBB
having different criteria definitions compared with the other
conduction/hypertrophy types.
Examples
An example ECG with a completed score sheet is
depicted in Fig. 7. In addition, the online supplement
contains 2 sets of ECGs (1 scanned, 1 digital) with both
blank test sets and completed score sheets. This supplement
is included to provide an opportunity to apply the QRS
scoring criteria in the various conduction abnormalities on
prescored examples.

Limitations of QRS scoring

As with all diagnostic modalities, the QRS score has
limitations. Using P wave amplitude evidence of RAO to
diagnose RVH is not a widely used method; however, it does not
rely on features of the QRS complex that may be affected by
infarction. Previous studies have found that P wave analysis for
diagnosing RVH has a sensitivity of 30% to 40% and a
specificity of 80% to 91%.24,25 Because the presence of RAO is
used to exclude evaluation of posterolateral infarction,
specificity is more important than sensitivity. One consequence
of this method is that patients with both RAO and posterolateral
infarction (or anteroseptal infarction in LBBB) may have
underestimated QRS scores. Another challenge arises when

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Z. Loring et al. / Journal of Electrocardiology 44 (2011) 544554

Fig. 6. Selecting and weighting examples. Criteria for an example lead are
shown. Boxes are delineated by dotted lines, check marks and x's indicate
which criteria are satisfied, and circles indicate criteria that are selected and
contribute to the overall score for the lead. The Q 20 milliseconds criterion is
met, yielding 1 point for the top box in this lead. Proceeding from the top down
to the next box, the next criterion that is met is R/S 0.5, yielding 2 points (no
point value is listed directly to the right of this criterion; therefore, its point
value is equal to that of the criterion directly above it). Although 2 additional
criteria are met (R/S 1 and R 0.5 mV), only the single criterion within each
box that is closest to the top of the box is selected.

individual ECGs straddle the definitions of conduction/

hypertrophy types. Although the QRS score criteria were
tested when adhering to the previously outlined conduction/
hypertrophy type definitions, further research may improve
the classification of borderline ECGs, especially with regard
to defining the presence vs absence of LBBB.21
It is possible that beat-to-beat variation may lead to
different numbers of points to be assigned to a lead
depending on which beat is evaluated. The best way to
limit bias and error in this setting is to score the most
representative QRS complex (ie, isoelectric baseline, no
interceding premature beat, etc) or the computer-generated
median beat, if available. Some of the criteria call for
recognition of notches and/or slurs in the QRS complex. The
presence and/or morphology of slurs and notches can be
greatly affected by low ECG sampling rates or poor-quality
tracings. Sampling rates of at least 500 Hz are ideal for QRS
scoring but not always available. Many of the previously
cited studies used routinely acquired paper 12-lead ECGs,
suggesting that QRS scores derived from lower sample rate
ECGs still provide clinically useful information. These
studies demonstrated good intra- and interobserver agreement, and manually applied QRS score criteria also
demonstrated a strong ability to identify scar in reference
to contrast-enhanced MRI (receiver operating characteristic
area under the curve, 0.91 [95% confidence interval, 0.860.95]) and good correlation with MRI scar size (r = 0.74, P b
.0001).2,15 Limitations of beat-to-beat variability, poorquality paper ECGs, and the increasing complexity of the
QRS score criteria can be improved by implementation of
automated QRS scoring algorithms.
Conclusions
The Selvester QRS score is a useful clinical tool that
provides perspective on the relationship between cardiac
electrical function and structural changes (viz, scar presence
and size). The clinical use of understanding this relationship
continues to be explored. By providing this detailed guide,
we hope to empower others to continue to study QRS
scoring, enable programming of automated QRS scoring,

Fig. 7. QRS score example. The ECG and completed QRS score sheet are
shown for a 45-year-old man with a QRS score of 7.

and help determine how this understanding can best inform

clinical decisions.
Acknowledgments
Supported, in part, by Duke University's Clinical and
Translational Science Award grant TL1RR024126 from
NCRR/NIH (to Z. Loring) and Food and Drug Administration Critical Path and Office of Women's Health grants (to
D. Strauss).

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551

Appendix Table 1: Glossary for no confounders, LVH, LAFB, RBBB, and RBBB + LAFB
Definitions

Illustrations

Q-Wave: When the first deflection of the QRS complex is negative, it is termed a Q-wave. It can be seen as
smooth Q or notched Q.

Smooth Q: Present if there is no reversal in direction 0.05 mV in the first negative deflection (left picture).
Notched Q: Present when there is a reversal in direction 0.05 mV within the initial negative deflection
(right picture).

Q-Wave Duration: Taken from the start of the global QRS complex (ie, if there is an isoelectric segment
preceding a Q-wave, it contributes to the Q-wave duration (left picture) to the point directly above the
peak of the notch in a notched Q (right picture) or where the tracing recrosses the PQ baseline in a
smooth Q.

Q-Wave Amplitude: Measured from the nadir of the negative deflection of the notch in a notched Q (left picture)
or from the most negative deflection (right picture), to the PQ-segment baseline in a smooth Q.

QR: R-wave must be present following a Q-wave.

Any Q: Any type of Q-wave is present.
In leads V1-V3 for LVH:
If QR is present, a point is given.
If any Q-wave is present a point is only given if 4 other QRS points are present in leads I, aVL, V4,
V5, or V6. This is done because LVH can cause a Q-wave in V1-V3 without the presence of infarction;
however, if signs of anterior infarct are present in other leads, then the Q-wave in V1-V3 is more likely
caused by infarct/scar.
R-Wave: The first positive deflection of the QRS complex.

R-Wave Duration:
No Q-wave: Measured from beginning of global QRS complex to the point where it re-crosses PQ-segment
baseline or the end of the QRS complex (whichever comes first).
Q-Wave Present: The R wave begins when the Q-wave returns to the PQ-segment baseline and ends when the
tracing re-crosses the PQ baseline or the end of the QRS complex (whichever comes first).

R-Wave Amplitude: Measured from the PQ-segment baseline to the most positive deflection before it re-crosses
the baseline (regardless of the presence of a notch). Except RBBB, see below.
In LAFB, lead V2: An R wave must be present to receive ANY points.
In RBBB:
When awarding points for large R waves in V1-V2 for posterolateral infarct, a notch (reversal in direction 90
that peaks within the first 50 ms should be considered the peak of the initial R wave (Init R). The nadir of
the notch should be considered the end of the initial R wave.
If the R wave's initial peak occurs after the first 50 ms of the global QRS complex, points are not given.
This is done because the later part of the R wave or R' represents the depolarization of the right
ventricle.
The duration of the initial R wave is measured from where the R wave begins to either the nadir of the
notch following the initial peak or where the tracing re-crosses the PQ baseline. Initial R waves refer to
the initial peak of the R wave; presence of Q waves preceding the R wave does not discount the
InitR criteria.

(continued on next page)

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Z. Loring et al. / Journal of Electrocardiology 44 (2011) 544554

Appendix Table 1 (continued)

Definitions

Illustrations

S-Wave: The first negative deflection after an R wave.

S-Wave Amplitude: Measured from the PQ-segment baseline to the most negative part of the S wave (regardless
of presence of notch).

NchInit40: Any reversal of direction 90 that begins within the first 40 ms of the global QRS complex yields 1
point in V4, V5, and V6 in all conduction types (except LBBB) and also 1 point in V1, V2, and V3 in LVH.
Smooth R or Q-waves do not satisfy NchInit40 criteria.

R/Q or R/S Amplitude Ratios:

Ratio of the R-wave amplitude to the Q- or S-wave amplitude.
If no R wave is present, then this is considered an R/S or R/Q of 0, which receives the maximum points for the
ratio criteria.
For QRS complexes with multiple R and/or R' waves, only the first R wave is considered for scoring.
Similarly, for QRS complexes with multiple S or S' waves, only the first S wave is considered for scoring.

Q 0.2 & S 0.2 mV and Q 0.3 & S 0.3 mV:

Points will be awarded for this criteria only if BOTH the Q and the S amplitudes of the lead are 0.x mV
(where x = 2 for V1 posterior and x = 3 for V2 posterior).
If either the Q or S wave is absent, the wave is regarded as having an amplitude of 0.00 mV.

QR and (Q 30 ms):
Points will be awarded only if BOTH QR morphology is present AND Q-Wave duration is 30 ms.

Appendix Table 2: Glossary for LBBB

Definitions
Q-Wave: When the first deflection of the QRS complex is negative, it is termed a Q-Wave. It can be seen as
smooth Q or notched Q.
In contrast to QRS scoring in other conduction/hypertrophy types, notches are ignored for the purpose of
defining the end of the Q-wave.

Q-Wave Duration: Taken from the start of the global QRS complex (ie, if there is an isoelectric segment
preceding a Q-wave, it contributes to the Q-wave duration) and proceeds until the tracing recrosses the
PQ-segment baseline (regardless of the presence of a notch).

Q-Wave Amplitude: Measured from PQ baseline to the most negative deflection (regardless of the presence
of a notch).

Illustrations

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553

Appendix Table 2 (continued)

Definitions

Illustrations

R-Wave Amplitude and Amplitude Ratios (R/Q and R/S):

When considering absolute R-wave amplitude or R/Q or R/S amplitude ratios, the most positive point
(R or R') should be considered the R wave (regardless of notches).
The most negative point should be considered the Q or S wave amplitude (regardless of notches).

R-Wave Duration: R-wave duration is measured from the start of the global QRS complex to the point where
it recrosses the PQ baseline (regardless of presence of notches) or the end of the QRS complex (whichever
comes first).

NchInIt40: A notch (change in direction 90) that begins its change in direction within the initial 40 ms.
A notch on the R wave or a notch on the S wave within the first 40 ms does count as a NchInIt40.
A smooth R wave does not count as NchInIt40.
In LBBB, qR waves count as NchInIt40.

R/R' and S/S' Amplitude Ratios:

These points can be obtained in V1-V2 (S/S' amplitude ratio) and V5-V6 (R/R' amplitude ratio).
The R or S is defined as the first peak/nadir, notch or beginning of the slur.
If no R wave is present, for this criteria, treat Q-wave as S wave.
The R' or S' is defined as the second peak/nadir, notch, or end of the slur after the initial 40 ms of the
QRS complex.
If there is no identifiable notch/slur, then these criteria should be ignored.
In leads V5 and V6, both peaks/notches/slurs must be above the PQ baseline to receive R/R' points.

Appendix A. Supplementary data

Two sets of ECGs are included that can be used to
practice QRS scoring. ECG set 1 consists of 26 scanned
ECGs along with a key with annotated ECGs and completed
QRS scoring sheets. ECG set 2 contains 12 ECGs of higher
quality along with a key with completed QRS scoring sheets.
Supplementary data to this article can be found online at
doi:10.1016/j.jelectrocard.2011.06.008.
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