ECG criteria
- Points are awarded using a predefined, lead-specific table of the classical scoring system (Wagner/Selvester QRS score) rather than a uniform rule for all leads.
- Q-wave duration: a threshold of $\ge 30\text{ ms}$ ($0.03\text{ s}$) applies only to specific leads (e.g., I, aVL, V5–V6, II, III, aVF) and only in table-specified combinations with other conditions, rather than as a universal rule.
- Q/R and R/S amplitude ratios: specific thresholds are considered in several leads (e.g., $\text{Q/R} \ge 1/3$ in certain leads), defined individually for each lead rather than an arbitrary Q-wave "increase".
- Amplitude and duration of the initial R wave in leads V1–V2: evaluated using standardized, lead-specific thresholds (e.g., small R-wave magnitude in V2 within a specified time window); this feature is nonspecific and is only scored within the complete algorithm.
- Notching of the initial part of the QRS complex: scored only in leads and QRS phases explicitly provided by the table of the selected score version, rather than as any subjective slowing of R-wave upstroke.
- QRS parameters in V1–V2 (R-wave amplitude and upstroke time) are separate lead-specific table criteria and are not sufficient by themselves for posterobasal localization without the remaining algorithm items.
- The total score across the leads included in the algorithm (typically up to $\sim31–32$ points in the classical full version) is converted into the approximate percentage of affected LV myocardium using the conversion table of a specific score version (an approximation of about $3\text{ LV mass %}$ per 1 point is frequently used, but this applies only to the version where this relationship has been validated).
- The result is interpreted alongside the clinical picture and, when possible, contrast-enhanced cardiac MRI; the calculation requires the complete original criteria table rather than a paraphrase.
What it looks like on ECG
The Selvester score is not a single sign, but a formalized point-scoring algorithm based on a 12-lead ECG (typically excluding aVR in the classical version) with a lead-specific criteria matrix: a specific set of rules is defined for individual leads and lead groups, rather than an identical full set of features for every lead independently. This reduces the risk of double-counting the same abnormality.
Depending on the version, the matrix accounts for the following in different leads:
- presence and duration of a pathological Q wave — the $\ge 30\text{ ms}$ threshold is applied only where specified by the table, often in combination with Q-wave depth;
- lead-specific threshold ratios of Q/R and R/S amplitudes;
- lead-specific thresholds for the amplitude and upstroke time of the initial R wave, especially in V1–V2 (its reduction is nonspecific and is assessed only as part of the overall algorithm);
- notching of the initial part of the QRS complex in leads where it is specifically designated by the table.
Points from individual leads are summed into a total score (typically up to $\sim31–32$ points in the classical full version). The complete table with specific thresholds for each lead is provided in the original source of the score and in specialized guidelines for electrocardiographic infarct size estimation; calculations cannot be reproduced without it.
Approximate distribution of affected zones by lead groups:
| Zone | Leads | Main criterion according to the table |
|---|---|---|
| Anterior/septal | V1–V4 | Q, R reduction and delayed upstroke |
| Inferior | II, III, aVF | pathological Q, notches |
| Lateral | I, aVL, V5–V6 | R reduction, Q |
The score does not diagnose acute myocardial infarction. The diagnosis of acute MI is established based on clinical presentation, high-sensitivity troponin dynamics, and ECG criteria for ischemia/ACS (including occlusion equivalents), with imaging when necessary; the Selvester score merely complements the evaluation with a quantitative characterization of the volume of already electrocardiographically evident damage.
Mechanism
QRS changes in scar tissue reflect alterations in the net ventricular depolarization vectors: over the necrotic/scar zone, the electrode predominantly records vectors from adjacent viable areas directed differently than the original vector of the defunct area. This produces a deep and wide Q wave, reduced R-wave amplitude, and notching as a trace of heterogeneous, delayed activation propagation around the scar. The larger the volume of affected myocardium and the more leads involved, the higher the total score. This mechanism is nonspecific: similar QRS changes occur in hypertrophic cardiomyopathy, bundle branch blocks, WPW syndrome, and several other conditions, so such mimics must be excluded before applying the score.
Causes
- Electrocardiographically evident LV damage/scar following prior myocardial infarction, regardless of the initial category (STEMI or non-ST-segment elevation ACS)
- Post-infarction cardiosclerosis with scar formation
- Multiple infarctions of varying localization (points are summed across zones)
- Historically used in research to assess infarct size and its relationship with reperfusion (thrombolysis, PCI) and clinical outcomes; clinical assessment of reperfusion efficacy relies on a combination of symptoms, ST-segment dynamics, angiography, and other validated methods rather than serial score calculations.
Differential diagnosis
- Hypertrophic cardiomyopathy and bundle branch blocks can produce pseudo-infarction Q waves — differentiated by clinical presentation, imaging, and characteristic QRS changes for these conditions that do not fit the score table criteria.
- A normal septal q wave in I, aVL, V5–V6 (narrow, $< 30\text{ ms}$, amplitude $< 25\text{ %}$ of R) is not counted as pathological.
- WPW syndrome with a delta wave can mimic a pathological Q wave — look for a short PQ interval and a delta wave.
- Poor R-wave progression in precordial leads without clinical signs of MI: variant of normal, cardiac rotation, incorrect V1–V2 electrode placement, blocks, hypertrophy/cardiomyopathies — evaluated comprehensively with history and comparison to prior ECGs.
Clinical significance and management
The Selvester score is used primarily in cardiological research and when correlating the size of electrocardiographically evident damage with imaging data, primarily late gadolinium-enhanced MRI, which quantitatively assesses scar mass. Echocardiography plays a different role in this context: it does not measure scar mass directly, but indirectly reflects the functional consequences of infarction — regional contractility and overall LV function. The Selvester score is not a routine bedside tool; its value lies in the standardized, reproducible quantitative assessment of myocardial injury volume from the ECG without radiation or contrast burden, although the result remains an empirical estimate with limited accuracy depending on the score version, infarct localization, and chosen validation method, rather than a direct measurement of the scar.
In clinical practice, physicians rely primarily on the presence and localization of pathological Q waves, ST-T dynamics, and imaging data; calculation using the full Selvester score requires a special criteria table for each lead and is more frequently performed in research studies or specialized expert ECG evaluations. When acute myocardial infarction is suspected, the score is not used for diagnosis: symptoms, serial high-sensitivity troponin, ECG criteria for ischemia/ACS, and indicated imaging are assessed.
Common interpretation errors
- Attempting to estimate infarct size "by eye" without a criteria table for the specific lead — points in different leads are calculated using distinct, predefined rules.
- Applying the $\text{Q} \ge 30\text{ ms}$ threshold as a universal rule for any lead, without accounting for the fact that it only applies in specific table combinations.
- Ignoring a normal septal q wave and counting it as pathological.
- Applying the score in the presence of bundle branch block or WPW without corrections — these conditions distort QRS complexes and require separate algorithms.
- Substituting the clinical diagnosis of acute MI with the score result or equating its result to direct measurement of scar mass by MRI.
1. What does the Selvester score primarily evaluate?
The score uses a lead-specific table to convert points for pathological Q waves, reduced R waves, and QRS notching into an estimate of myocardial injury volume.
2. Which QRS feature is not included in the Selvester score criteria?
The scale evaluates only the parameters of the QRS complex (Q, R, notching) according to a given table; the P wave is not taken into account.
3. In what context is the Selvester score predominantly used?
It is a research/expert tool for the quantitative assessment of myocardial damage, rather than a routine method for acute diagnosis.
Frequently asked questions
What does the Selvester score show?
It translates the point total for pathological Q waves, reduced R-wave amplitude, and QRS notching, assigned according to a lead-specific table, into an approximate percentage of left ventricular mass corresponding to the infarct size in the validation cohort. This is an empirical estimate with limited accuracy rather than a direct measurement of scar mass, and it requires clinical interpretation.
Is the Selvester score used in daily practice?
Rarely as a standalone tool. It is more commonly used in research studies and for correlation with contrast-enhanced CMR data; echocardiography in this context provides only an indirect assessment of functional consequences rather than scar mass. In routine interpretation, the physician focuses on the presence of pathological Q waves and the clinical presentation.
Can the acuity of an infarction be determined using the Selvester score?
No, the scale itself does not determine the acuity of the process: it assesses the extent of electrocardiographically evident damage based on QRS changes. The acuity of the infarction is determined by the clinical picture, serial changes in high-sensitivity troponin, and ECG signs of ischemia/ACS, and when necessary, by imaging and coronary angiography data.
Are special leads required to calculate the score?
A standard 12-lead ECG is used, but the criteria of the classic version apply to the leads specified in the scale's table, usually excluding aVR; the specific set of leads and rules depends on the version of the scale. Additional leads (V7–V9, V3R–V4R) are not included in the classic scale.
How does the Selvester score differ from a simple description of a pathological Q wave?
A simple description notes the presence of Q in a specific lead, whereas the scale sums up points across a table-defined set of leads—accounting for Q-wave duration, Q/R and R/S threshold ratios, R-wave amplitude, and notching—providing a quantitative assessment of lesion size rather than merely recording the fact of an alteration.
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Related terms
More in the section "Criteria, Formulas, Algorithms"
Sources
- Surawicz B., Knilans T. Chou's Electrocardiography in Clinical Practice
- Orlov V.N. Guide to Electrocardiography
- AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram, 2009
Educational material for medical students and physicians. Does not replace clinical guidelines and physical examination; the ECG must always be interpreted in conjunction with the clinical picture.