Basic scoring, grading and

classifications in cardiology
1. TIMI Score Calculation for UA/NSTEMI (1 point for each):

- Age 65

- Aspirin use in the last 7 days (patient experiences chest pain despite ASA use in past 7days)

- At least 2 angina episodes within the last 24 hrs

- ST changes of at least 0.5mm on admission EKG

- Elevated serum cardiac biomarkers

- Known Coronary Artery Disease (CAD) (coronary stenosis 50%)

- At least 3 risk factors for CAD, such as: Hypertension 140/90 or on antihypertensives, current
cigarette smoker, low HDL cholesterol (< 40 mg/dL), diabetes mellitus, Family history of
premature CAD (CAD in male first-degree relative or father less than 55, or female first-degree
relative or mother less than 65).

Score Interpretation:

% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia
requiring urgent revascularization.

Score of 0-1 = 4.7% risk

Score of 2 = 8.3% risk

Score of 3 = 13.2% risk

Score of 4 = 19.9% risk

Score of 5 = 26.2% risk

Score of 6-7 = at least 40.9% risk

'TIMI risk estimates mortality following acute coronary syndromes.

2. TIMI Score Calculation for STEMI.

3. Killip class

Killip class I includes individuals with no clinical signs of heart failure.

Killip class II includes individuals with rales or crackles in the lungs, an S 3, and elevated
jugular venous pressure.

Killip class III describes individuals with frank acute pulmonary edema.

Killip class IV describes individuals in cardiogenic shock or hypotension (measured as

systolic blood pressure lower than 90 mmHg), and evidence of peripheral
vasoconstriction (oliguria, cyanosis or sweating).

4. TIMI Grade Flow

TIMI 0 flow (no perfusion) refers to the absence of any antegrade flow beyond a coronary
occlusion.
 TIMI 1 flow (penetration without perfusion) is faint antegrade coronary flow beyond the
occlusion, with incomplete filling of the distal coronary bed.

TIMI 2 flow (partial reperfusion) is delayed or sluggish antegrade flow with complete filling of
the distal territory.

TIMI 3 is normal flow which fills the distal coronary bed completely.

5. Braunwald Classification of Unstable Angina (UA)

Clinical Circumstances

A B C
Severity

Develops in presence Develops in the Develops within

of extracardiac absence of 2 weeks after
condition that extracardiac acute myocardial
intensifies myocardial condition infarction
ischemia (secondary (primary UA) (postinfarction
UA) UA)

I New onset of severe IA IB IC

angina or accelerated
angina; no rest pain

II Angina at rest within IIA IIB IIC

past month but not
within preceding 48
hr (angina at rest,
subacute)

III Angina at rest within IIIA IIIB Troponin IIIC

48 hr (angina at rest, negative
acute)
IIIB Troponin
positive

6. NYHA Functional Classification for Congestive Heart Failure

Class I: patients with no limitation of activities; they suffer no symptoms from ordinary
activities.

Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with
mild exertion.

Class III: patients with marked limitation of activity; they are comfortable only at rest.

Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity
brings on discomfort and symptoms occur at rest.

7. Framingham Criteria for Congestive Heart Failure

Diagnosis of CHF requires the simultaneous presence of at least 2 major criteria or 1 major
criterion in conjunction with 2 minor criteria.

Major criteria:
Paroxysmal nocturnal dyspnea
Neck vein distention
Rales
Radiographic cardiomegaly (increasing heart size on chest radiography)
Acute pulmonary edema
S3 gallop
Increased central venous pressure (>16 cm H2O at right atrium)
Hepatojugular reflux
Weight loss >4.5 kg in 5 days in response to treatment

Minor criteria:
Bilateral ankle edema
Nocturnal cough
Dyspnea on ordinary exertion
Hepatomegaly
Pleural effusion
Decrease in vital capacity by one third from maximum recorded
Tachycardia (heart rate>120 beats/min.)
Minor criteria are acceptable only if they cannot be attributed to another medical condition (such
as pulmonary hypertension, chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome).

The Framingham Heart Study criteria are 100% sensitive and 78% specific for identifying
persons with definite congestive heart failure.

8. Duke Criteria for Infective Endocarditis (IE)

Major criteria:
A. Positive blood culture for Infective Endocarditis
1- Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
viridans streptococci, Streptococcus bovis, or HACEK* group, or
community-acquired Staphylococcus aureus or enterococci, in the absence of a primary
focus
or
2- Microorganisms consistent with IE from persistently positive blood cultures defined as:
2 positive cultures of blood samples drawn >12 hours apart, or
all of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1
hour apart)
B. Evidence of endocardial involvement
1- Positive echocardiogram for IE defined as :
oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant
jets, or on implanted material in the absence of an alternative anatomic explanation, or
abscess, or
new partial dehiscence of prosthetic valve
or
2- New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)

Minor criteria:

Predisposition: predisposing heart condition or intravenous drug use

 Fever: temperature > 38.0 C (100.4 F)

Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic

aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions

Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots, and rheumatoid

factor

Microbiological evidence: positive blood culture but does not meet a major criterion as
noted above or serological evidence of active infection with organism consistent with IE

Echocardiographic findings: consistent with IE but do not meet a major criterion as noted
above

Clinical criteria for infective endocarditis requires:

Two major criteria, or
One major and three minor criteria, or
Five minor criteria

*HACEK group: Haemophilus sp, Actinobacilius actinomycetemcomitans, Cardiobacterium

hominis, Eikenella rodens y Kingella sp

9. Revised Jones Criteria for Acute Rheumatic Fever (ARF)

A firm diagnosis requires that two major or one major and two minor criteria are satisfied, in
addition to evidence of recent streptococcal infection.

Major Criteria

1. Carditis: All layers of cardiac tissue are affected (pericardium, epicardium, myocardium,
endocardium) The patient may have a new or changing murmur, with mitral regurgitation
being the most common followed by aortic insufficiency.

2. Polyarthritis: Migrating arthritis that typically affects the knees, ankles, elbows and
wrists. The joints are very painful and symptoms are very responsive to anti-
inflammatory medicines.

3. Chorea: Also known as Syndenhams chorea, or "St. Vitus dance". There are abrupt,
purposeless movements. This may be the only manifestation of ARF and is its presence is
diagnostic. May also include emotional disturbances and inappropriate behavior.
 4. Erythema marginatum: A non-pruritic rash that commonly affects the trunk and proximal
extremities, but spares the face. The rash typically migrates from central areas to
periphery, and has well-defined borders.

5. Subcutaneous nodules: Usually located over bones or tendons, these nodules are painless
and firm.

Minor Criteria:

1. Fever

2. Arthralgia

3. Previous rheumatic fever or rheumatic heart disease

4. Acute phase reactants: Leukocytosis, elevated eritrosedimentation rate (ESR) and C-

reactive protein (CRP)

5. Prolonged P-R interval on electrocardiogram (ECG)

Evidence of preceding streptococcal infection: Any one of the following is considered

adequate evidence of infection:

Increased antistreptolysin O or other streptococcal antibodies

Positive throat culture for Group A beta-hemolytic streptococci

Positive rapid direct Group A strep carbohydrate antigen test

Recent scarlet fever.

10. Wells Clinical Prediction Rule for Pulmonary Embolism (PE)

Clinical feature Points

Clinical symptoms of DVT 3

Other diagnosis less likely than PE 3

Heart rate greater than 100 beats per minute 1.5

Immobilization or surgery within past 4 weeks 1.5

Previous DVT or PE 1.5

Hemoptysis 1

Malignancy 1

Total points

PE = pulmonary embolism; DVT = deep venous thrombosis.

Risk score interpretation (probability of PE):

>6 points: high risk (78.4%);

2 to 6 points: moderate risk (27.8%);

<2 points: low risk (3.4%)

11. NYHA functional classification

NYHA
Symptoms
Class
Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g.
I
shortness of breath when walking, climbing stairs etc.
Mild symptoms (mild shortness of breath and/or angina) and slight limitation during
II
ordinary activity.
III Marked limitation in activity due to symptoms, even during less-than-ordinary
activity, e.g. walking short distances (20100 m).
 Comfortable only at rest.
Severe limitations. Experiences symptoms even while at rest. Mostly bedbound
IV
patients.

12. The CCS Angina Grading Scale or the CCS Functional Classification of Angina)

Class I Angina only during strenuous or prolonged physical activity

Class II Slight limitation, with angina only during vigorous physical activity

Class III Symptoms with everyday living activities, i.e., moderate limitation

Class IV Inability to perform any activity without angina or angina at rest, i.e., severe
limitation

Class 0: asymptomatic category.

13. Grading of aortic stenosis

Aortic Mild Moderate Severe

sclerosis
Aortic jet velocity (m/s) 2.5 m/s 2.6-2.9 3.0-4.0 >4.0
Mean gradient - <20 (<30a) 20-40b (30-50a) >40b (>50a)
(mmHg)
AVA (cm2) - >1.5 1.0-1.5 <1
Indexed AVA (cm2/m2) >0.85 0.60-0.85 <0.6
Velocity ratio >0.50 0.25-0.50 <0.25

a
ESC Guidelines.

b
AHA/ACC Guidelines.
14. Grading of aortic regurgitation

Mild Moderate Severe

Specific
signs for AR Central Jet, Signs of AR>mild Central Jet, width
severity width < 25% of present but no 65% of LVOT
LVOT criteria for severe
AR Vena contracta >
Vena contracta 0.6cm
< 0.3 cm

No or brief
early diastolic
flow reversal in
descending
aorta
Supportive
signs Pressure half- Intermediate Pressure half-time
time > 500 ms values < 200 ms

Normal LV Holodiastolic aortic

size flow reversal in
descending aorta
 Moderate or greater
LV enlargement
Quantitative parameters
R Vol, < 30 30-44 45-59 60
ml/beat
RF % < 30 30-39 40-49 50
2
EROA, cm < 0.10 0.10-0.19 0.20-0.29 0.30

AR, Aortic regurgitation; EROA, effective regurgitant orifice area; LV, left ventricle;
LVOT, left ventricular outflow tract; R Vol, regurgitant volume; RF, regurgitant fraction.

LV size applied only to chronic lesions. Normal 2D measurements: LV minor-axis 2.8
cm/m2, LV end-diastolic volume 82 ml/m2 (2).

At a Nyquist limit of 5060 cm/s.

In the absence of other etiologies of LV dilatation.

Quantitative parameters can help sub-classify the moderate regurgitation group into
mild-to-moderate and moderate-to-severe regurgitation as shown.

15. Grading of mitral regurgitation

Mild Moderate Severe

Specific
signs of Small central jet Signs of MR>mild Vena contracta width
severity <4 cm2 or <20% present, but no 0.7cm with large central MR
of LA area criteria for severe MR jet (area < 40% of LA) or
with a wall-impinging jet of
Vena contracta any size, swirling in LA
width <0.3 cm
Large flow convergence
No or minimal
flow Systolic reversal in
convergence pulmonary veins
 Prominent flail MV leaflet
or ruptured papillary muscle
Supportiv
e signs Systolic Intermediate Dense, triangular CW
dominant flow signs/findings Doppler MR jet
in pulmonary
veins E-wave dominant mitral
inflow (E >1.2 m/s)
A-wave Enlarged LV and LA size,
dominant mitral (particularly when normal
inflow LV function is present).

Soft density,
parabolic CW
Doppler MR
signal

Normal LV size
Quantitative parameters
R Vol < 30 30-44 45-59 60
(ml/beat
)
RF (%) < 30 30-39 40-49 50
EROA < 0.20 0.20-0.29 0.30-0.39 0.40
(cm2)

CW, Continuous wave; EROA, effective regurgitant orifice area; LA, left atrium; LV, left ventricle;
MV, mitral valve; MR, mitral regurgitation; R Vol, regurgitant volume; RF, regurgitant fraction.

LV size applied only to chronic lesions. Normal 2D measurements: LV minor axis 2.8 cm/m2, LV
end-diastolic volume 82 ml/m2, maximal LA antero-posterior diameter 2.8 cm/m2, maximal LA
volume 36 ml/m2 (2;33;35).

In the absence of other etiologies of LV and LA dilatation and acute MR.

At a Nyquist limit of 50-60 cm/s.

Usually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral
stenosis or other causes of elevated LA pressure.

Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and 0.9 cm for
central jets, respectively, with a baseline shift at a Nyquist of 40 cm/s; Cut-offs for eccentric jets are
higher, and should be angle corrected (see text).

Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-
moderate and moderate-to-severe as shown.
16. Grading of mitral stenosis

Mild Modera Severe

te
Specific findings
Valve area (cm2) >1.5 1.0-1.5 <1.0
Supportive findings
Mean gradient (mmHg)a <5 5-10 >10
Pulmonary artery pressure <30 30-50 >50
(mmHg)

a
At heart rates between 60 and 80 bpm and in sinus
rhythm.

17. Mitral stenosis: Wilkins score

Gra Mobility Thickening Calcification Subvalvular

de Thickening
1 Highly mobile Leaflets near A single area of Minimal thickening
valve with only normal in increased echo just below the mitral
leaflet tips thickness (4-5 brightness leaflets
restricted mm)
2 Leaflet mid and Midleaflets Scattered areas Thickening of chordal
base portions normal, of brightness structures extending
have normal considerable confined to to one-third of the
mobility thickening of leaflet margins chordal length
margins (5-8
mm)
3 Valve continues Thickening Brightness Thickening extended
to move extending extending into to distal third of the
forward in through the the mid- chords
diastole, mainly entire leaflet (5- portions of the
from the base 8mm) leaflets
4 No or minimal Considerable Extensive Extensive thickening
forward thickening of all brightness and shortening of all
movement of leaflet tissue throughout chordal structures
the leaflets in (>8-10mm) much of the extending down to
diastole leaflet tissue the papillary muscles

The total score is the sum of the four items and ranges between 4 and 16.
18. Grading of tricuspid regurgitation

Parameter Mild Moderate Severe

Tricuspid valve Usually normal Normal or Abnormal/Flail
abnormal leaflet/Poor coaptation
RV/RA/IVC size Normal Normal or dilated Usually dilated
Jet area-central <5 5-10 > 10
jets (cm2)
VC width (cm) Not defined Not defined, but > 0.7
< 0.7
PISA radius (cm) 0.5 0.6-0.9 > 0.9
Jet density and Soft and parabolic Dense, variable Dense, triangular with
contourCW contour early peaking
Hepatic vein flow Systolic Systolic blunting Systolic reversal
dominance

CW, Continuous wave Doppler; IVC, inferior vena cava; RA, right atrium; RV,
right ventricle; VC, vena contracta width.

Unless there are other reasons for RA or RV dilation. Normal 2D
measurements from the apical 4-chamber view: RV medio-lateral end-
diastolic dimension 4.3 cm, RV end-diastolic area 35.5 cm 2, maximal RA
medio-lateral and supero-inferior dimensions 4.6 cm and 4.9 cm
respectively, maximal RA volume 33 ml/m 2(35;89).

Exception: acute TR.

At a Nyquist limit of 50-60 cm/s. Not valid in eccentric jets. Jet area is not
recommended as the sole parameter of TR severity due to its dependence on
hemodynamic and technical factors.

At a Nyquist limit of 50-60 cm/s.

Baseline shift with Nyquist limit of 28 cm/s.

Other conditions may cause systolic blunting (eg. atrial fibrillation, elevated
RA pressure).

19. Grading of pulmonary regurgitation

Specific findings
Mean pressure gradient 5 mmHg
Inflow time-velocity integral >60 cm
T1/2 190 ms
Valve area by continuity equationa 1 cm2
Supportive findings
Enlarged right atrium moderate
DHated inferior vena cava

a
Stroke volume derived from left or right ventricular outflow. In the presence
of more than mild TR, the derived valve area will be underestimated.
Nevertheless, a value 1 cm2 implies a significant haemodynamic burden
imposed by the combined lesion.

20. Grading of tricuspid stenosis

Parameter Mild Moderate Severe

Pulmonic valve Normal Normal or Abnormal
abnormal
RV size Normal Normal or dilated Dilated
Jet size by color Doppler Thin (usually < 10 mm in Intermediate Usually large, with a wide
length) with a narrow origin; May be brief in
origin duration
Jet density and Soft; Slow deceleration Dense; variable Dense; steep deceleration,
deceleration rate CW deceleration early termination of
diastolic flow
Pulmonic systolic flow Slightly increased Intermediate Greatly increased
compared to systemic
flow PW

CW, Continuous wave Doppler; PR, pulmonic regurgitation; PW, pulsed wave Doppler; RA, right
atrium; RF, regurgitant fraction; RV, right ventricle.

Unless there are other reasons for RV enlargement. Normal 2D measurements from the apical 4-
chamber view; RV medio-lateral end-diastolic dimension 4.3 cm, RV end-diastolic area 35.5
cm2(89).

Exception: acute PR

At a Nyquist limit of 50-60 cm/s.

Cut-off values for regurgitant volume and fraction are not well validated.
 Steep deceleration is not specific for severe PR.

21. Grading of pulmonary stenosis

Mild Modera Severe

te
Peak velocity <3 3-4 >4
(m/s)
Peak gradient <36 36-64 >64
(mmHg)

22. Levine grading scale

1. The murmur is only audible on listening carefully for some time.

2. The murmur is faint but immediately audible on placing the stethoscope on

the chest.

3. A loud murmur readily audible but with no palpable thrill.

4. A loud murmur with a palpable thrill.

5. A loud murmur with a palpable thrill. The murmur is so loud that it is audible
with only the rim of the stethoscope touching the chest.

6. A loud murmur with a palpable thrill. The murmur is audible with the
stethoscope not touching the chest but lifted just off it.

23. Vaughan Williams classification

Cla Basic
Comments
ss Mechanism
 sodium-channel
I Reduce phase 0 slope and peak of action potential.
blockade

Moderate reduction in phase 0 slope; increase APD; increase

IA - moderate
ERP.

IB - weak Small reduction in phase 0 slope; reduce APD; decrease ERP.

Pronounced reduction in phase 0 slope; no effect on APD or

IC - strong
ERP.

II beta-blockade Block sympathetic activity; reduce rate and conduction.

potassium- Delay repolarization (phase 3) and thereby increase action

III
channel blockade potential duration and effective refractory period.

calcium-channel Block L-type calcium-channels; most effective at SA and AV

IV
blockade nodes; reduce rate and conduction.

APD, action potential duration; ERP, effective refractory period; SA, sinoatrial node; AV,
atrioventricular node.

26. Staging of PVD: Fontaine Classification

1. Stage I Asymptomatic. Of note: Fontaine stage I does in fact describe patients who are
for the most part asymptomatic. Careful history may actually reveal subtle and non-
specific symptoms such as paresthesias. Physical examination may reveal cold
extremities and other signs of subclinical peripheral artery disease. More examples
include bruits over blood vessels and lack of normal pulses.

2. Stage II Intermittent claudication. This stage takes into account the fact that patients
usually have a very constant distance at which they have pain:

o Stage IIa Intermittent claudication after more than 200 meters of pain free
walking.

o Stage IIb Intermittent claudication after less than 200 meters of walking

3. Stage III Rest pain. Rest pain is especially troubling for patients during the night. The
reason for this is twofold: First, the legs are usually raised up on to a bed at night, thus
diminishing the positive effect gravity may have had during the day when the legs were
dependent. Second, during the night the lack of sensory stimuli allow patients to focus on
their legs.
 4. Stave IV Ischemic ulcers or gangrene (which may be dry or humid).

27. Rutherford classification

1. Stage 0 Asymptomatic

2. Stage 1 Mild claudication

3. Stage 2 Moderate claudication The distance that delineates mild, moderate and severe
claudication is not specified in the Rutherford classification, but is mentioned in the
Fontaine classification as 200 meters.

4. Stage 3 Severe claudication

5. Stage 4 Rest pain

6. Stage 5 Ischemic ulceration not exceeding ulcer of the digits of the foot

7. Stage 6 Severe ischemic ulcers or frank gangrene

Poin
28. Romhilt Estes Criteria
ts

Voltage Criteria (any of):

1. R or S in limb leads 20 mm
3
2. S in V1 or V2 30 mm

3. R in V5 or V6 30 mm

ST-T Abnormalities:

ST-T vector opposite to QRS without digitalis 3

1
ST-T vector opposite to QRS with digitalis

Negative terminal P mode in V1 1 mm in depth and 0.04 sec in duration

3
(indicates left atrial enlargement)

Left axis deviation (QRS of -30 or more) 2

QRS duration 0.09 sec 1

Delayed intrinsicoid deflection in V5 or V6 (>0.05 sec) 1

29. Sokolow-Lyon index

 S in V1 + R in V5 or V6 (whichever is larger) 35 mm ( 7 large squares)

R in aVL 11 mm

30. Cornell voltage criteria The Cornell criteria for LVH are:

S in V3 + R in aVL > 28 mm (men)

S in V3 + R in aVL > 20 mm (women)

 The Brugada criteria/algorithm:

1. Is there concordance present in the precordial leads (leads V1-V6)?

Also sometime explained as the absence of an RS complex, concordance is diagnostic of VT. A

simple way to think of this would be to ask the question, are all of the QRS complexes
completely upright or completely downward in the precordial leads? If the answer is yes, then
VT is the diagnosis.

2. Is the R to S interval > 100 ms in any one precordial lead?

If present, then VT is the diagnosis. Simply use calipers to measure the distance between the R
wave to S wave in each precordial lead and see if it exceeds 100 ms.

3. AV dissociation present?

If present, the diagnosis is ventricular tachycardia.AV dissociation occurs when P wave

(represents atrial depolarization) are seen at different rates than the QRS complex. This is
present in only a small percentage of ventricular tachycardia ECG tracings, however is
diagnostic of VT. Frequently, this is difficult to see due to the fast rate of the QRS complex.

4. Examine the morphology of the QRS complex to see if it meets the below specific criteria
for VT as below.

VT is frequently either in a right bundle branch block pattern (upright in V1) or a left bundle
branch block pattern (downward in V1).

If upward in lead V1 (RBBB pattern), then VT is present in the following situations:

A monophasic R or biphasic qR complex in V1.

If an RSR pattern (bunny-ear) is present in V1 with the R peak being higher in amplitude than the R peak,
the VT is present.

A rS complex in lead V6 favors VT

If downward in lead V1 (LBBB pattern), then VT is present in the following situations:

The presence of any Q or QS wave in lead V6 favors VT

A wide R wave in lead V1 or V2 of 40 ms or more favors VT

Slurred or notched downstroke of the S wave in V1 or V2 favors VT

 Duration of onset of the QRS complex to peak of QS or S wave > 60 ms favors VT
The rules for left bundle branch block are:

Superventricular rhythm

QRS duration 120 ms (but < 200 ms)

rS or QS complex in lead V1

Monomorphic R-wave in lead I

SGARBOSSA
In 1996 the GUSTO-I investigators including Elena Sgarbossa, M.D. published a very well
known study in the New England Journal of Medicine that attempted to elucidate the ECG
features of acute, evolving MI in the presence of left bundle branch block.

These features included:

Concordant ST-elevation (ST-elevation in the same direction as the majority of the QRS
complex)

Concordant ST-depression (ST-depression in the same direction as the majority of the QRS
complex in leads V1, V2, or V3)

Discordant ST-segment elevation 5 mm

 Trifascicular block
can be incomplete or complete, depending on whether all three fascicles have
completely failed or not.

Incomplete trifascicular block

Incomplete (impending) trifascicular block can be inferred from one of two
electrocardiographic patterns:

Fixed block of two fascicles (i.e. bifascicular block) with evidence of delayed
conduction in the remaining fascicle (i.e. 1st or 2nd degree AV block).

Fixed block of one fascicle (i.e. RBBB) with intermittent failure of the other two
fascicles (i.e. alternating LAFB / LPFB).

Complete trifascicular block

Complete trifascicular block produces 3rd degree AV block with features

of bifascicular block.

This is because the escape rhythm usually arises from the region of either the left
anterior or left posterior fascicle (distal to the site of block), producing QRS
complexes with the appearance of RBBB plus either LPFB or LAFB respectively.

The most common pattern referred to as trifascicular block is the combination of

bifascicular block with 1st degree AV block.

Incomplete trifascicular block

Bifascicular block + 1st degree AV block (most common)

Bifascicular block + 2nd degree AV block

RBBB + alternating LAFB / LPFB

Complete trifascicular block

Bifascicular block + 3rd degree AV block

Reasonable (WHO) criteria for the WPW pattern on ECG

are:
1.PR interval under 0.12s
2.A delta wave
3.QRS duration of 0.12s (or more)
 4.A normal P-wave axis

ECG changes in RBBB

Diagnostic Criteria

Broad QRS > 120 ms

RSR pattern in V1-3 (M-shaped QRS complex) An RSR pattern

in V1-3 may also be caused by Brugada syndrome an ECG

pattern associated with malignant ventricular arrhythmias.

Wide, slurred S wave in the lateral leads (I, aVL, V5-6)

Associated Features

ST depression and T wave inversion in the right precordial

leads (V1-3)