qs- qr-pattern in leads absence myocardial infarction...

QS- and QR-Pattern in Leads V3 and V4 in

Absence of Myocardial Infarction:Electrocardiographic and Vector-

cardiographic Study

By BORYS SURAWICZ, M.D., ROBERT G. VAN HORNE, M.D., JOHN R. URBACH, M.D., ANDSAMUEL BELLET, M.D.

A QS or QR pattern in the absence of myocardial infarction is frequently present in lead V3 andoccasionally in lead V4. Exploration by means of multiple chest and abdominal unipolar leads andvectorcardiograms revealed that in almost all such cases, the vector of the initial portions of theQRS complex is directed downwards. Accordingly, in the absence of infarction, patients pre-senting this pattern almost invariably showed an initial R wave in the leads recorded from posi-tions below the standard level of V3 and V4. The vast majority of patients with myocardialinfarction with a similar QRS pattern showed a Q wave in the lower leads. Consideration of ver-tical components of cardiac voltages may be helpful in the interpretation of the precordial leads.

T HE PRESENCE of a QS pattern or ofan abnormally deep and wide Q wave(deeper than 25 per cent of succeeding

R wave and wider than 0.04 second) in pre-cordial leads V3 to V6 is usually, although notinvariably, attributed to myocardial infarction.Occurrence of a QS pattern or of a significantQ wave in leads V3 and V4 and on some occa-sions even in leads V5 and V6, in the absence ofmyocardial infarction, has been demonstratedin cases of left ventricular hypertrophy,1' , 12,14, 15, 28 hypertrophy or dilatation of the rightventricle8 10, 12, 13, 19-22, complete or "incom-plete" left bundle branch block,16' 17, 18, 23-26right bundle branch block,23 and displacementof the heart.15 In his study of electrocardio-grams which may be mistaken for myocardialinfarction, Myers emphasized the occurrenceof these patterns on several occasions. It seems

From the Division of Cardiology of the Phila-delphia General Hospital, Philadelphia, Pa.

This work was aided by grant H-141 (C6), fromthe United States Public Health Service and partlyaided by a grant from the Eli Lilly Co., Indianapo-lis, Ind.

Dr. Surawicz was formerly a Research Fellow ofthe American Heart Association at the PhiladelphiaGeneral Hospital.

Part of the results of this study were presented atthe Meeting of the College of Physicians of Phila-delphia, Section of Medicine, April, 1954.

391

to be justifiable to suspect that in many in-stances myocardial infarction has been diag-nosed incorrectly on the basis of a QS, QR orQRS pattern in the precordial leads. (Seefig. 1.) This suspicion is augmented by thefact that there are very few electrocardio-graphic diagnostic criteria which differentiatea QS or QR deflection of myocardial infarctionfrom an identical deflection caused by otherfactors.The present investigation was initiated in

the hope of finding a method which might helpto differentiate these patterns which are foundwith myocardial infarction from similar pat-terns not associated with infarction. At thesame time we have attempted to obtain infor-mation regarding the factors responsible forthe genesis of the QRS patterns which simulatemyocardial infarction in the precordial leads.Two major principles of electrocardiographic

diagnosis were applied: (1) exploration of theprecordium by means of multiple semidirectunipolar leads; and (2) vectorcardiogramsrepresenting the distant indirect leads andpicturing the over-all or average electrocar-diograms.1"

METHODThe routine, 12-lead electrocardiograms made at

the Heart Station of the Philadelphia General Hos-pital were screened daily during the period from

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QS- AND QR-PATTERN IN ABSENCE OF MYOCARDIAL INFARCTION

August 1953, until arch 1954, for patterns (is-playing a QS coml)lex or a significant Q watve inthe stan(Iar(d precor(lial leads V3 and V4. Cases withtl QS or QRt pattern limited to leads V1 and Vt, were

W.

FIG. 1.Electrocardiogram of a 57 year- 0( Negroman with pulmonary emphysema and a possibleAddison's disease 24 hours before death. ylyocardialinfarction was suspected because of the QS patternin leads V2, V3 and V4. Autopsy revealed no cardiacabnormalities except slight dilatation of the rightventricle. Heart weight 280 Gm. Thickness of theleft ventricle 12 mm.; of the right ventricle, 4 mm.

not included because the occurrence of such patternsin the absence of mv-ocardial infarction is widelvknown. Cases with a significant Q wave wh'lii(clh isdeeper than one-fourth of the 1 wave and wviderthan 0.04 second in leads V5 anlc V6 were not in-cluded because these findings are almost invariablyclue to infarction. As a result, the selected groupincluded only cases of mvocardial infarction in whichthe QRS changes (lue to infarction did not extendfurther to the left than lead V4 and cases of nonin-farction with an absent initial R wave in leads V3and V4 which c(ould have been mistaken for theabove infarction pattern. None of the features ofthe electrocardiogram, other than the QRS com-plex, were considered in the selection of cases.

During the selection of cases for this study, itbecame obvious that various observers differed intheir judgment as to ^-hat is a (liscernible initial Rwave. On several occasions a given electrocardio-graphic QRS complex was designated by some ob-servers as rS while others preferred to call the samecomplex QS. In order to determine the error whichmight be due to this factor of difference in interpre-tation, 15 different (omplexes with an absent or aveir small initial R 'ave and a deep S or QS wavewere presented to 20 experienced cardiologists whowvere asked whether, in their opinions, the 15 com-plexes should be designated QS, rS or undertermi-nable. The results of this inquiryv are presented infigure 2. It has become obvious that an R wavesmaller than 0.5 mm. can hardly be recognizecl assuch even if the te(hlical recording of the tracing

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1 S 5_ 1

1.3 14 1I5.cs-

RS i4 10 1086 4

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20FIG. 2. Fifteen electrocardiographic complexes from one of the right precordial leads Ipreselnted to

20 cardiologists. In the first line beneath each complex is shown the number of personls w-ho desig-nated this complex as. RS; in the second line, the number of persons who designate(l this complexas undeterminable and in the third line, the number of pelrsoI1s who designated it as QS.

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SURAWICZ, VAN HORNE, URBACH AND BELLET

is good. The material selected for this study con-tains only cases in which all authors of this paperfelt that there was no initial R wave in leads V3 or V4.

The patients selected for the study were subjectedto the following examinations: (1) clinical evalua--tion, (2) recording of one or two leads synchronouslywith lead V3 or V4, (3) multiple chest and abdominalunipolar electrocardiographic leads, (4) vectorcar-,diograms and (5) special roentgenologic studies. Allthese studies were performed on the same day.

(1) The clinical evaluation was based on a carefulhistory and physical examination. The majority ofthe examined individuals were ward patients whosehospital and out-patient records could be tracedback for a varying length of time. From the dayon which the patient was selected for study, hiscourse was followed by means of periodic clinicaland electrocardiographic examinations. All availableautopsy findings were secured.

(2) In order to establish whether the initial nega-tive QRS deflection in leads V3 and V4 representedthe earliest part of the ventricular depolarization,leads V3 and/or V4 were recorded synchronouslywith lead I, aVF, and one of the precordial V leadsby means of Sanborn-Polyviso direct-writing elec-trocardiograph.

(3) The electrocardiographic exploration includedstandard limb and augmented unipolar limb leads,standard precordial leads V1 through V6, leads VE,V3R and V7 and 26 additional chest and abdominalleads. The additional leads consisted of two groups:leads recorded from the chest at the levels above,and leads recorded from the chest and abdomenbelow, the standard levels. The high leads weretaken from the second and third intercostal spacesat positions V, through V5, from the fourth inter-costal space at the position V3 through V6 and alsofrom the level of the fifth rib at position V4. Thelow leads were taken from the fifth intercostal spaceat the position V3, from the ensiform (E) level atthe positions V, through V5 and from the epigastriclevel (ep), which was determined by the mid-pointbetween the ensiform process and the umbilicus, atthe positions V3 through V5. In some of the latercases, leads from the mid-line at the levels of umbili-cus ("0") and between umbilicus and ensiform proc-ess ("EO") recommended by Lambert32 were re-corded in addition.

(4) Vectorcardiograms were obtained with San-born Vectorcardiograph consisting of the Poly-VisoRecorder -Model 64-1300 A, Coupling unit MIodel78-100, and the Duinont Cathode Ray OscillographType 304H. The electrode attachment sy stems werethose described by Wilson and his co-workers"1 39referred to in this paper as "tetrahedron" and byGrishman and associates47 referred to in this paperas "cube".

Analysis of the QRS loops was undertaken in thefollowing manner: The initial deflection was takento be the first four points (0.02 second) emergingfrom the central blob. The direction of the initial

QRS deflection was expressed through reference tothe x, y and z axes in both reference systems. Thedirection of progression of the electron beam wasrecorded as clockwise or counterclockwise in thehorizontal and sagittal planes. The total number ofpoints from the beginning to the end of the QRSloop were counted in each plane. Each plane wasthen divided into four quadrants and the numberof points counted in each quadrant. In addition, ineach plane, it was noted in which of the quadrantsthe major part of the QRS loop area was situated.Irregularities and indentations in the loops werenoted and arbitrarily graded from 1 (completelysmooth) to 4 (very irregular).

(5) Six-foot chest roentgenograms with the pa-tient in the supine position were obtained with thesites of the standard precordial electrode positionson the chest and abdomen indicated by lead num-bers.

MATERIALSix groups of individuals were studied: Group 1,

24 patients with mynocardial infarction; group 2, fourpatients with possible myocardial infarction; group3, 25 patients with absent myocardial infarction;and group 4 six patients in whom myocardial infarc-tion was considered unlikely; group 5, 10 patientswith left ventricular hypertrophy; and group 6, 10normal persons without evidence of cardiovasculardisease.

Classification of the material in the first fourgroups was made, without the consideration of theresults of special studies, on the basis of the clinicalevaluation, follow-up records and autopsy findings,which were available in 10 patients. The group withinfarctions included patients with conclusive evi-dence of myocardial infarction gained from autopsyor a combination of a typical clinical course andserial electrocardiograms. Most of the infarctionshad occurred within the preceding 12 months. Thegroup with possible infarctions included patients inwhom infarction was suggested by the serial electro-cardiograms, but the remaining clinical data werenot sufficiently conclusive. The group with absenceof infarctions included five patients in whom thediagnosis was established by autopsy and those pa-tients in whom there was no suspicion of infarctioneither in the history or in the serial electrocardio-grams recorded during a period from one to severalyears prior to the study. The group designated as"infarction unlikely" included similar patients inwhom infarction was at no time suspected clinically,but no previous serial tracings were available.

Fifty-nine patients whose data were subjected tofinal evaluation included 45 males and 14 females.Forty patients were white and 19 were Negroes.The age of the patients ranged from 39 to 84 years,averaging 64.5 years. The distribution of the sex,race and age factors within the two major groups ofproven and absent infarction showed no significantdifferences.

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QS- AND QR-PATTERN- IN ABSENCE OF MYOCARDIAL IN-FARCTION\-

Patients in group 5 were selected at random fromthe Hospital population. They had proved left ven-tricular hypertrophy, as determined by x-ray studyand an electrocardiographic pattern of left ventricu-lar hypertrophy and "strain". None of them hadhistory of myocardial infarction or chest pain atany time. The group included four males and sixfemales who were 52 to 76 years old with an averageage of 62.

Individuals in the group 6 were 25 to 47 yearsold. Five normal persons had hearts in a verticalanatomical and five in a horizontal anatomical po-sition.

RESULTS

Time of Onset of QRSThe results of the synchronous recording of

lead V\3 or VT4 with other leads in all groups ofcases can be summarized by a statement thatin no case was the initial QRS deflection inleads V3 or V4 preceded by an earlier deflectionin some other lead. The beginning of the QRScomplex in leads V3 and V4 coincided usuallywith the beginning of the QRS complex in otherprecordial leads (V1 and V2) but in more thanhalf of the cases occurred 0.01 to 0.02 secondearlier than the QRS onset in the limb leadsaV, or I.

Direction of the Initial QRS DeflectionThe differences between the group with

myocardial infarctions and the group with pos-sible infarctions on the one hand and the differ-ences between the group with absent infarctionand the group in which infarction was unlikelyon the other hand were insignificant. It appearsto be justifiable, therefore, to discuss only thedifferences between the group with myocardialinfarction and the group with absence of in-farction. Following are the more importantresults:

(a) Standard Precordial Leads: In thestandard lead V3, a QS pattern or a significantQ ware was present in 22 out of 24 patientswith infarction and in 21 out of 25 patientswithout infarction. In standard lead V4, theQS pattern or a significant Q wX-ave was presentin three patients without infarction and in ninewith infarction. In standard precordial leadsV5 through V7, the presence of a small Q wavewas encountered in 71 per cent of the infarctioncases and in o0Ily 32 per cent of the noninfarc-

tion cases. In standard precordial leads V3R,V1 and V2 the groups with infarction andwith no infarction showed only insignificantdifferences. In the majority of the patients inboth groups all three right precordial leadsshowed a QS pattern, but all initial R wave waspresent in leads V3R, V1, and inl some casesalso in V2 in eight patients with infarction andsix without infarction.

InI the group of 10 patients with left ven-tricular hypertrophy, without a QS pattern inleads V3 and V4, a QS pattern was present infour cases in lead V3R, and in three cases inleads V1 and V22.

(b) Low Precordial Leads: In lead VE aninitial R wave was present in 17 per cent of thepatients with infarction and in 48 per centwithout infarction. The situation was verysimilar in lead ViE (lead V, made at level ofensiform). In lead VIE the difference betweenthe QRS pattern in patients with infarctionand without infarction was somewhat larger;the initial R wave was present, ill only 8 percent of the patients with infarction and in1 56per cent of the patients without infarction.The greatest difference between the QRS

patterns in the infarction and nioniinfarctiongroups was present ill lead V.,; the initial Rwave was present ill 12 per cent of the groupwith infarction and ill 96 per cent of the groupwithout infarction. The patterii ill the leadbetween standard V3 and V3AE, at, the level ofthe fifth intercostal space, was similar to thatin lead V3E ill the group with infarction, butthe presence of the initial R wave ill the groupwithout infarction was less frequent than inlead V3E. All initial R wave in leads V4E, at5E,N\3e.p (lead \3 made at level of epigastrium) and\4cp ill patients without infarction was foundas frequently as in lead V3E, but a higher num-ber of patients with infarction showed aninitial R wave in leads V4E, 5E, V3ep and V 4CIthan ill lead V3E.

In the group of 10 patients with left veni-tricular hypertrophy without a QS pattern illlead V3 and \ 4 a QS pattern was present illthree patients ill lead VTIE, in two cases illlead VE and in one case in lead VIE.

Ill the group of 10 normal patienlts, the inii-tial QRS deflection was positive ill all low pre-

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cordial leads with the exception of a small Qwave in leads V4E, 0 5E, and leads V2 throughV5 made at the epigastric level in four casesin which a small Q wave was present in aVF.

(c) High Precordial Leads: Leads from alevel one intercostal space higher than the levelof the standard precordial leads showed gen-erally great similarity of the initial QRSdeflection in both the infarction and the non-infarction groups. In leads V2 through V4 madeat the second intercostal space, the differencein pattern in the infarction and the noninfarc-tion groups was slightly greater since theinitial QRS deflection in these leads wasinvariably negative in the noninfarction groupwhile it was positive in 36 to 45 per cent ofthe infarction cases.

In the group of 10 patients with left ven-tricular hypertrophy without a QS pattern inleads V3 and V4, a QS pattern was present insix patients in lead V, made at the third andsecond intercostal spaces, in five cases in leadV2 taken at the third and second intercostalspaces, in four cases in lead V3 taken at thethird intercostal space and in one case in leadV4 taken at the second intercostal space.

In the group of five normal subjects withvertical aniatomic heart position the initialQRS deflection was positive in precordial leadsV1 through V5, all made from points above theconvrenitional level. In the group of five normalsubjects with horizontal anatomic heart posi-tion, a QS or QR deflection was present inl onesubject in lead V1 made from the third andsecond intercostal space and in two subjectsin leads V3 and V4 made from the level of thesecond intercostal space.

VectorcardiograinsVectorcardiograms were taken on 46 pa-

tients of groups 1, 2, 3, and 4. In 43 of thesepatients, the "tetrahedron" coordination ofWilson (1, (64) was used and in 45 patients thecube modification of Grishman65 was used.Since the group with proved and possibleinfarction, on the one hand, and the groupswith absent or unlikely infarctions on the otherhand showed no significant difference, onlydifferences between the two major groups with

proved and absent infarction will be discussedin detail.

(a) Initial Deflection. (First 0.02 second ofthe ventricular depolarization.) The most sig-nificant difference between the group withproved and absent infarctions w-as in the direc-tion of this deflection along the y axis in bothcoordinate systems. The initial deflection wasdirected downwards in 90 to 92 per cent of thegroup without, and in only 36 to 46 per cent

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FIG. 3. Position of the electrode in the lead V3with relation to cardiac silhouette of the tele-roentgenogram is presented in a schematic way.Sectors LV., L.A. and P.A. correspond to the levelsof the left ventricle, left auricle and pulmonaryartery on the left side of the heart. The open circlesrepresent cases without infarction, solid circlesrepresent cases with infarction, triangles representthe cases with normal hearts in vertical anatomicalposition and squares represent cases with normal inhorizontal anatomical position.

of the group with infarction. In the majority oftracings of patients in both groups (64 to 83per cent) the initial deflection was directed tothe left. In the z axis, when the tetrahedroncoordinates were used, 75 per cent of the pa-tients with no infarction showed anterior pro-gression, whereas only 36 per cent of the groupwith infarction showed this progression. Withthe cube coordinate system there was hardlyany difference (57 and 62 per cent).When analysis was carried out by distribu-

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QS- AND QR-PATTERN IN ABSENCE OF -MYOCARDIAL INFARCTION

x H.5. ,H72 lu4.3VL.W0/H 4I CS t VS

3§C~ tit. V741(5SS ttk10JAtb

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EpiFIG. 4. Electrocardiogram of a 72 year old white man three weeks after myocardial infarction.

Typical history of infarction and characteristic serial electrocardiographic changes. Note a QSpattern in leads V, through 4 and V 3E, V4E, 3i,() Iut anl RS )Patterl iln aGF.

tion in plane quadrants the biggest differencebetween the two groups in both coordinate sys-tems was found in the sagittal plane. Only 4to 10 per cent of the group without infarctionshowed progression of the initial deflection intothe posterior superior quadrant of this plane,while 38 to 50 per cent of the patients withinfarction showed such progression. The differ-ences in the frontal plane were smaller and inthe horizontal plane, negligible. In three di-mensional analysis the differences were evensmaller. The largest difference between thegroups with and without infarction was thatthe initial deflection of the group with n0infarction was directed into the posterior leftsuperior octant in only 4 to 10 per cent, whilein the group with infarction the direction intothis octant occurred in 29 to 31 per cent,.

(b) Orientation of the entire QRS ioop. Analy-sis of the characteristics of the loops showedthat in both groups the loops were most fre-

(queitly found in the left posterior and superioroctanits. The differences in distribution betweenthe inifar(tion and noninfarction groups wereinsigniifi(canit in either coordinate system.Posterior orientation of the loop was encoun-tered more frequently in the tracings recordedwith the cube co-ordinate system.

(c) Direction of rotation of the QRS sE. In thetetrahedron system, in the horizontal plane,counterclockwise rotation was encounteredslightly more frequently (80 per cent) in thegroup with no infarction than in the groupwith infarction (64 per cent), but there waspractically no difference between the findingsin the two groups in the cube system. In thesagittal plane clockwise rotation was slightlymore frequently encountered in the noninfarc-tion group than in the infarction group (43 to54 per cent) in both systems. The differencebetween the cube and tetrahedron systemsconsisted of complete absence of counter-

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SURAWICZ, VAN HORINE, 1

clockwise rotation in tracings of the noninfarc-tion group taken in the cube system, while itwas found in 23 per cent of the tracings in thesame group taken with the tetrahedron sys-tem. Another difference was a more frequentfinding of clockwise rotation in the groupwithout infarction (83 per cent) in the cubesystem, as compared with the tetrahedronsystem (65 per cent).

(d) Irregularities and indentations of the QRSloop. In both systems perfectly smooth loopswere observed somewhat more frequently inthe group without myocardial infarction (26to 40 per cent), than in patients with infarction(14 to 15 per cent). Marked irregularities wereno more common in the group with infarction(22 to 23 per cent) than in the group with noinfarction (13 to 30 per cent) in both systems.Nor was there any significant difference in thedistribution of moderate irregularities betweenthe two groups.

Comparison of the Findings in Low PrecordialLeads with Findings in Lead aVm of theElectrocardiogramIn view of the finding pointing to the con-

clusion that precordial leads V3 and V4 re-corded at the ensiform and epigastric levelsshowed very significant differences in the direc-tion of the initial QRS deflection between thegroup with infarction and the group with noinfarction, it appeared necessary to comparethe findings in these leads with those in leadaV,. Lead aVF is the only standard unipolarlead recorded routinely in which the electrodeis placed below the level of the standard pre-cordial leads.In our patients without infarction, the initial

QRS deflection in aVF was positive in 24 outof 25 cases and coincided in 96 per cent withthe initial QRS deflection of lead V3, and in92 per cent with the initial QRS deflection oflead V3E.Out of the 21 cases of infarction with an ini-

tial negative QRS deflection in lead V3E only10 cases showed an initial negative QRS de-flection in aVF. In the remaining 11 cases, inwhich the initial QRS deflection was positivein aVF, two cases showed an initial negativeQRS deflection in all examined low precordial

URBACH AND BELLET 397

TABLE 1 Subdivision of 25 Cases Wfithout InfarctionSex: M. 18; F. 7. Race: W. 16; C. 9.

Age Distribution 39-84, Av. 65

Condition

HHD...................................HHD & severe kyphoscol...............HHD & bullous emphys.................Cor pulmon. emphys....................Cor pulmon. pulm. fibrosis ..............Cor pulmon. pulm. tb....................Cor pulmon. sarcoid....................Aortic sten. & insuff....................Aortic & mitral dis......................IV sept. defect..........................Senile degener. HD.......................Thyrotoxic HD..........................Emphysema, no heart disease...........No heart & lung dis.....................

Total ........

Anatomic Diagnosis

VIH....................................LV ?...................................LVH & RVH ...........................RVH ...................................Diffuse cardiomeg......................Normal heart...........................

Total.................................

No. of Cases

8I

111214111111

25

No. of Cases

1333114

25

ECG Pattern No. of Cases

LBBB ................................. 3"IV strain* ........................... 11LVH without T inversion* ...... ........ 3RVH ................................. 1Normal with deep S2-3 .................. 3Normal ................................. 3RBBB ................................. 1

Total ................................ 25

* These cases had an absent Q wave in V5 through7, but QRS duration was less than 0.10 sec.

Abbreviations: HHD hypertensive heart dis-ease. IVH left ventricular hypertrophy. RVH-right ventricular hypertrophy. LBBB and RBBB-left and right bundle branch block.

leads, five cases showed an initial positive QRSdeflection only in leads V4ep (fig. 4), four casesin leads V4, and V3ep. Leads from the um-bilical and epigastric levels in the midline(leads VO and VEo of Lambert) were recorded



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31

V, VC VA VS V/+ V/6

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FIG. 5. Electrocardiogram of a debilitated 80year-old white man with a staphylococcus septicemia.Death 11 days after admission. Autopsy revealedsevere dilatation of both ventricles. Heart weight520 Gm. Circular interventricular septum with an

area of erosion at the edge and soft friable vegeta-tions extending to the tricuspid valve. No evidenceof past or recent myocardial infarction. Note a QSpattern in V3 and an initial R wave in V3E and V3ep.

only in four patients with myocardial infarc-tion. In one of these cases the initial QRSdeflection was negative in leads V3E, V3ep andV4E, but positive in leads VO and VEO,

Relation of Electrode Position to Anatomic Posi-tion of the Heart as Shown by X-ray Examina-tion.

Chest roentgenograms with electrode posi-tions marked on chest surfaces were availablein 18 patients with no infarction, in five pa-

tients with myocardial infarction, in five nor-

mal subjects with vertical and in five normalsubjects with anatomically horizontal hearts.The positions of the electrodes were evalu-ated with regard to their projection on the car-

diac shadow.Lead V,: The electrode was located over the

great vessels in the majority of cases. It didnot overlay the ventricles in a single case.

Lead V2: The electrode was located over the

ventricle only in one-half of the normal patientsand in one-sixth of the patients without in-farction.

Lead V3: Figure 3 shows in a semischematicway the relation of the electrode to the cardiacsilhouette in all cases.Lead V4: The electrode was located over the

ventricle (presumably the left) or the areaoutside of the heart shadow at the level of theventricles in all examined cases in all groups.In the normal subjects with horizontal heartsthe electrode was close to the apex, in theother three groups the electrode positions var-ied from a site over the apex to a site over theupper border of the ventricle.

Leads V5 and V6: In all cases of all groupsthe electrode was located outside of the heartshadow at the level of the ventricles.

Analysis of Individual CasesTwenty-five patients with no infarction rep-

resented a variety of clinical and anatomicconditions and electrocardiographic patternswhich are summarized in table 1. A represen-tative case is illustrated in figure 5.

In one of the patients without infarction, itwas noted that the QS deflection in V3 gaveway to an rS deflection during deep expiration.In another case without infarction a QS patternin lead V3 changed into rS after removal of500 cc. of right-sided pleural effusion.

DISCUSSIONThe number of tracings with an absent R

wave in lead V3 in patients without infarctionwas surprisingly high. The exact number ofscreened electrocardiograms is unknown, but itcan be estimated at 5000 to 6000 tracings,which would give an incidence of the discussedpattern of about 0.5 per cent of all electrocar-diographic tracings.* Accordingly a QS or QRpattern in lead V3 in the absence of myocardialinfarction is not very uncommon. This is inagreement with the impression gained fromthe review of literature.The incidence of a QS or QR pattern in lead

V4, in the absence of myocardial infarction,* This number of electrocardiograms does not

represent the number of patients since several trac-ings might have been recorded in the same individual.

398

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SUIRAWICZ, VAN HORNE, URBACH AND BEILLET

was much less frequent and did not exceed0.015 per cent. No instances of a QS or QRpattern in lead V5, in the absence of myocar-dial infarction, were encountered in this study,although proven cases are on record.10The most important result of this study ap-

pears to be the finding of a method which en-ables one to determine, in a great majority ofcases, whether or not a QS or Qit pattern inleads V3 and V4 is due to infarction. Themethod consists in the recording of additionalelectrocardiographic leads at the ensiform andepigastric level below the positions on thechest at which V3 and V4 are conventionallyrecorded. For practical purposes recording ofonly one additional unipolar precordial lead,V3E (lead V3 recorded at the level of the ensi-form), is probably sufficient.

In all of the patients without infarction, thetransition between the initial negative and theinitial positive QRS deflection in the leadsplaced along the vertical axis on the anteriorbody surface, occurred below the level at whichthe conventional leads V3 and V4 are recorded.This implies that, in all cases without infarc-tion with an absent R wave in leads V3 and/orV4, the initial QRS vector was directed down-ward, and the anatomical point of the originof this vector was situated below the level ofthe standard leads V3 and V4. This was sup-ported by the vIectorcardiograms which showedan initial downward spread of excitation in 90to 92 per cent of the QRS loops of the caseswithout infarction.Most of our cases with infarction showed a

Q wave in the lead V3E. If one assumes that theQ wave in the precordial leads appears whenthe electrode faces the infarcted area, thisfinding indicates that the infarction in theabove mentioned cases probably affects theinferior portion of the anterior heart wall.Among the 24 cases of infarction there wasonly one unequivocal case with a QS patternin leads V3 and V4 in which an R wave waspresent in the leads recorded from positionsbelow the conventional leads.An electrocardiographic pattern of myocar-

dial infarction in which QRS changes are pres-ent in standard precordial leads V1 through V4,and leads III and aVF has been frequently en-

countered in the present study. This patternhas been described on numerous occasions:'27 731, 40, 33, 29, 36, 37, 42, 8, 1, 41, 32 (these references are

in chronological order) and designated as an-teroseptal,30' 7extensive infarction of septum in-volviing the anterior and posterior wall,29 ante-roposterior," 42,7 and posteroinferior infarction.8

In two of our cases with such an electrocar-diographic pattern, which came to autopsy,there was an occlusion of the descendingbranch of the left coronary artery with involve-ment of the anterior wall, inferior half of theseptum in both and part of the posterior wallin addition in the other case.

Value of High Precordial Leads

Our study indicates that chest leads recordedfrom the levels above the standard precordialpositions were of little value in differentiationbetween infarction and noninfarction patterns.The occurrence in normal subjects of a QS pat-tern in high right precordial leads1' 8, 48 wasconfirmed by us. In normal persons with heartsin a horizontal position, we also found a QSpattern in leads V3 and V4 taken at the level ofthe second intercostal space.High precordial leads have been utilized for

diagnosis of myocardial infarction.30' 43-45, 1, 5

Our study leads to the conclusion that in themajority of instances a Q wave in high precor-dial leads does not necessarily indicate myo-cardial infarction. In contrast to cases withoutinfarction, a significant percentage of our pa-tients with infarction (28 to 40 per cent)showed the presence of an initial R wave inleads V1 and V6 made one to two intercostalspaces above the standard level.

Absence of an Initial R Wave in Some PrecordialLeads in the Presence of an R Wave in Leadsmade from Positions to the Right of these Leads

Such patterns, as well as progressive diminu-tion of R from right to left precordial positions,have been considered to be suggestive of ante-rior or anteroseptal myocardial infarction.2,18,33It has been noted, however, that in cases ofright ventricular dilatation without myocar-dial infarction, an R wave may be present inlead V1 and either diminish in size or disappearin transitional leads toward the left precor

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)QS- AND Q11-1ATTERN IN ABSENCE OF -MYOCARDIAL INFARCTION

dium.'8 In our cases with QS or QR pattern inleads Vr3 and V4, an initial Ri wave was presentin leads NI3R, V, and occasionally in V2 ill one-third of the patients with infarctioni and illalmost one-fourth of the cases without infarc-tion. This indicates clearly that this pattern isnot specific for myocardial infarction. One ortwo of our cases without inifarctioni, with thedescribed pattern, might have had dilatationof the right v~enitric(le but the majority hadclinically and electrocardiographically an unl-complicated left, ventricular hypertrophy.

Directions of the Initial QRS Deflection its .Ab-sence of Infarction

(a) Transverse Axis: In 14 of our cases with-out infarction, the initial deflection of QR1S wascaused by forces directed from right to left.Only three of these cases had a QRS durationexceeding 0.12 second, while in the remainingcases there was a left venitricular "strain" pat-tern with a QR1S duration of 0.08 to 0.10 sec-on1d. * In the remaining 11 cases of absent mnyo-cardial infarctioni, the initial QRS deflectionwas caused by forces directed from left toright, though the transition between the initialpositive deflection on1 the right side and theinitial negative deflection on the left side wasnot found inl the standard precordial leads, butin the leads made from a site below the level ofthe standard precordial leads.

(b) Vertical Axis: In the cases of left venitric-ular hypertrophy selected at random, the initialdeflection of QRS was caused by forces directeddownward in 7 out of 10 cases. In 25) caseswithout infarction with an initial negative de-flection of QRS ill V3 and V4, the initial deflec-tion of QRS was caused by forces directeddownward in all cases as indicated by the re-sults of the exploration and in 92 per cent asindicated by vectorcardiograms. The majorityof these cases consisted of cases of left ventric-ular hypertrophy. Whether the development ofleft ventricular hypertrophy causes the vectorof the initial deflection of QRS to assume amore dowmward direction in all cases remains to

* Whether these cases have to be designated as

incomplete left bundle blranch block or not appearsto be a debatable sbl)ject which is bey-onid the scopeof this paper.

be prov eni. However, such a shift appears to beprobable because of our observ-ation of a pro-gressiv.e diminution of the size of the initial Rwax-e in the right precordial leads in severalcases in which serial tracings over a period ofmany years were observed.

Causes of Negative Initial Deflection of QRS inthe Standard Precordial Leads in the Absenceof M1yocardial Infarction or Other Conditionsin Which a Part of the illyocardiinm is Decdor Electrically Inactive

These may be the following: (1) atypicalspread of excitation, e.g., the precordial elec-trode faces the same portions of the heart as in.normal persons, but the electrical forces havechanged their direction; (2) normal ventricularexcitation but an altered position of the pre-cordial electrode, e.g., the electrode faces suchportion of the heart in which the initial QRSdeflection is normally negative.

(1) Atypical Spread of Excitation. A negativeinitial deflection of QRS in the precordial leadscan be due either to the presence of an initialnegative deflection instead of a positive one orto an absence of the normal positive deflection.The latter concept has been advanced in orderto explain a QRS pattern in the transitionalleads. It has been postulated that, the initialdeflection of QRS is nearly perpendicular to theaxis of the exploring electrode and thus notrecorded at, all.411'01l5 Such a situation has beenattributed to the depolarization of both sidesof the septum at the same time and thus to cams-cellation of opposite vrectors derived from aseptal activatioin.10 If this were true, the initialdeflection of QRS in the precordial leads fromthe transitional leads displaying QS patternwould be isoelectric. The results obtained inthis study show that the beginning of QBScomplex occurred at the same time in the leadswith a QS or QR pattern as in other synchro-nously recorded precordial leads. Accordingly,the concept of an initial isoelectric deflection ofQRS cannot be used to explain an initial nega-tive QRS deflection in our cases.The initial deflection of QRS in the right and

in the transitional precordial leads may beinegativ e if the spread of excitation is directed

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SURIltAWICZ.. VAN HORNIINJ, URBACH AND BIlT,4'0

from right to left which presumably takesplace in high left bundle branch block. Our non-infarctioin cases with an initial negative QRSdeflectioni in leads V3 and V4 included only 14cases in which the initial deflection of QRS wasconsidered to be caused by forces directed fromright to left while in the remaining 11, the ini-tial deflection of QRS was caused by forcesdirected from left to right. Therefore, it appearsto be doubtful whether one can interpret anelectrocardiographic deflection in the unipolarchest leads without taking into considerationthe vertical components of the cardiac voltages.Our findings indicate that in all cases withoutinfarction the initial QIRS vector was directedinferiorly. This explains the negative initialdeflection of QRS in all leads recorded fromsites above the anatomical point of the origin ofthis vector and the positive initial deflection ofQRS in all leads made from sites below thispoint, regardless of whether the downwardspread has a right-to-left direction, a left-to-right direction or is vertical. This explanationholds if the initial QRS vector in all such ill-stances is directed anteriorly.

For the sake of completeness, one has tomention some other concepts concerning thesame problem. An initial Q wave in right pre-cordial leads has been attributed to congenitalvariation in the distribution of conduction fi-bers.6 An absent R wave in precordial leads incertain cases of right and left ventricular hy-pertrophy has been attributed to a decreaseddensity of the junctions between Purkinjefibers and ordinary muscle as a result of dilata-tion of the affected chamber.30 It has been pos-tulated recently that absence of an initial Rwave in right precordial leads in cases of leftventricular hypertrophy is due to a posteriorspread of the initial deflection of QRS as a re-sult of stretching and bowing of the inflowtract of the left ventricle.34

(2) Change in position of the electrode in rela-tion to the heart. The negative initial deflectionof QRS in the standard precordial leads can-not be satisfactorily explained without takinginto consideration this second factor. This cantheoretically occur either because of a changeof heart position with relation to the electrodeor because of a change of the electrode position

with relation to the heart. The last factor mayplay some role ill certain chest deformities inwhich the upper ribs anteriorly are closertogether than normally, thus making the inter-costal spaces narrow-ei and the position of thestandard electrodes higher than normal. Inone of our cases such a situation was believedto be present. The factor of change of the posi-tion of the heart with relation to the electrodesappears to be of more practical importance.Pardee has demonstrated oil x-ray films of sixindividuals that the electrode in leads V2 and\T3 ill the sixth intercostal space lies over theventricles more frequently than in standardleads V2 and V3 Which overlay supraventricularstructures.35 Figure 10 of reference 19 showsthe x-ray film of a patient with right ventricularhypertrophy ill whom the position of the V3electrode is close to the pulmonary artery seg-ment. On the other hand, fairly numerouspostmortem determinations in which the elec-trode position was correlated with the heartposition have demonstrated the position of theV3 electrode to be near the interventricularseptum ill persons with normal hearts, to theright of the septum in patients with left ven-tricular hypertrophy, and to the left of the sep-tum ill subjects with right ventricular hyper-trophy.13 The horizontal level of the electrodeill the last study was not mentioned, but theillustrated variations of position appear to beof considerable magnitude. Six teleroentgeno-grams in normal students were made by Koss-manl and Johnston and in one illustrated caseelectrode V3 overlies the lower part of the leftventricle.46The results of our x-ray study support the

opinion of Pardee35 that in order to have theelectrode closer to the ventricles one has torecord leads V,2 and V3 at lower levels than thepresent standard level used for these leads. It isdifficult to establish with any degree of accu-racy whether the absence of all initial R wavein our cases without infarction was due in anappreciable number of cases to a high electrodeposition with relation to the heart. The com-parison with the small control group of normalpersons, which show a similar electrode posi-tion in relation to the heart, suggests that thisis not a crucial factor. It, appears to us that the

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low position of the anatomic point of the originof the initial QRS vector was of greater impor-tance as a factor producing the QS deflectionsin the precordial leads than the low position ofthe diaphragm or other changes of the anatomicposition of the whole heart.

Correlation Between Vectorcardiographic Loopsand Scalar Electrocardiographic Patterns Ob-tained With the Chest LeadsIn view of the many theoretical and practical

difficulties of vectorcardiography, it is not sur-prising that the vectorcardiogram did not dif-ferentiate between patients with and thosewithout myocardial infarction. The initial de-flection of the QRS complex corresponds to thefirst 0.02 second or more of the QRS st-loop.In many of the photographs, the white spotmade by the P and T waves is sufficiently largeto cover a portion of the QRS loop. This is oftena significant factor as proved by a count of thetime dots in the same loop in different planes.The QRS duration varied at times as much as100 per cent in the three planes. It is, therefore,frequently impossible to be sure that the timedots interpreted to be the recording of the po-tential of depolarization in the first 0.02 secondare actually recorded at that time. In general,the vectorcardiogram correlated poorly withleads V3 and V4, frequently showing an ante-rior direction of the initial QRS vector when noinitial R waves were recorded in these scalarleads. Although this anterior direction of theinitial QRS vector occurred much more fre-quently in the absence of infarction, the corre-lation with the clinical findings was not suffi-ciently good to be of differential diagnosticimportance. On the other hand, correlation ofvector loops with high and low precordial leadswas very much better. Inferior direction of theinitial QRS vector was usually seen in patientswith initial R waves in leads made from sitesbelow the standard positions, and superiordirection of the initial QRS vector in patientswith initial R waves in high chest leads. Thisbetter correlation of the y axis of the vectorand scalar electrocardiogram may be due to thelesser skewing of this axis by cardiac eccen-tricity.38 None of the other frequently mentioned

signs of infarction (irregularity of the loop,change in rotation of the QRS st) significantlydifferentiated between the subjects of the in-farction and noninfarction groups.The differences between the loops inscribed

by the cube and the tetrahedron coordinatesystems were often considerable. Nevertheless,there was no very significant difference be-tween them in the ability to differentiate pa-tients with from patients without infarction.

SUMMARY

(1) A QS pattern or a significant Q wave inthe lead V3 was found in 25 patients in whommyocardial infarction was considered to be ab-sent (in five patients the findings were provedat autopsy) and in six patients in whom myo-cardial infarction was considered to be unlikely.A similar QRS pattern in lead V4 was found inonly three of these patients. The majority ofthe patients in this group had left ventricularhypertrophy.

(2) The initial QRS deflections of the electro-cardiogram and the vectorcardiogram of thegroup of patients with a QS or QR pattern inleads V3 and V4 who had no infarction and of agroup of patients with infarction who had asimilar QRS pattern were compared. The elec-trocardiogram included 26 additional chest andabdominal unipolar leads. The vectorcardio-grams were recorded by means of the tetra-hedron and cube reference systems.

(3) The differences between the groups ofpatients with and without infarction with re-gard to the direction of the initial QRS deflec-tion and the features of the vectorcardiographicQRS st loop are discussed. The most significantdifferences between the group with infarctionand the group without infarction were found inthe low chest leads V3 and V4 recorded at theensiform and the epigastric levels. Lead V3made at level of ensiform (V3E) showed thegreatest difference: an initial R wave was pres-ent in 24 out of 25 cases without infarction andin only 3 out of 24 cases with infarction. Thus,the direction of the initial QRS deflection inlead V3E differentiated in 84 per cent patientswith infarction from those without infarction

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even when the standard lead V3 showed thesame QRS pattern in both groups of patients.

(4) In chest leads made from sites above thestandard level, the QRS pattern was not sig-nificantly different in the group with and thegroup without infarction, although the pres-ence of an initial R wave in the high leadsoccurred more commonly in patients withinfarction.

(5) No vectorcardiographic feature differen-tiated the infarction and noninfarction groupsin a significant number of cases. The greatestdifference between the two groups concernedthe initial 0.02 second of the QRS loop, whichwas directed inferiorly in 90 to 92 per cent ofthe patients without infarction and in only 36to 46 per cent of those with infarction.

(6) Fifty per cent of patients with infarctionwho had a Q wave in the low chest leads madeat the ensiform or epigastric levels showed aninitial R wave in lead aVF.

(7) The teleroentgenograms recorded in thesupine position with electrode positions markedon the chest revealed that the electrode forlead V3 faced the level of the ventricles inonly 5 out of 18 patients without infarctionwho showed a QS pattern in leads V3 and V4.In the remaining 13 cases, the electrode (V3)faced higher levels of the heart. However, theposition of the electrodes with relation to thecardiac silhouette was fairly similar in a con-trol group of five patients with infarction andfive normal persons with a vertical anatomicalheart position. In a group of five normal sub-jects with horizontal anatomical heart position,the electrodes faced generally lower portions ofthe heart shadow than in the other groups.

(8) The causes of an initial negative QRSdeflection in the absence of myocardial infarc-tion are discussed. The inferior direction of theinitial QRS vector and the low location of thepoint of origin of this vector rather than thelow position of the whole heart appeared to beresponsible for the absent initial R wave inleads V3 and V4 in our patients without in-farction.

(9) The consideration of the vertical com-ponents of the cardiac voltages may be useful

in explanation of the electrocardiographic pat-terns in the unipolar chest leads.

SUMMARIO IN INTERLINGUA

Un configuration QS o QR in le absentia deinfarcimento myocardial es frequentementepresente in le derivation V3 e a vices in lederivation V4. Un exploration per medio demultiple derivationes unipolar e vectocardio-grammas del thorace e abdomine revelavaque in quasi omne tal casos le vector del por-tion initial del complexo QRS exhibi un direc-tion in basso. Consequentemente, in le absentiade infarcimento, patientes monstrante isteconfiguration exhibiva quasi invariabilementeun unda R initial in le derivationes obteniteab positiones infra le nivello standard proV3 e V4. Le grande maj oritate del casos deinfarcimento myocardial con simile configura-tiones QRS monstrava un unda Q in le deriva-tiones inferior. Le consideration de componentesvertical de voltages cardiac es possibilementede adjuta in le interpretation del derivationesprecordial.

ACKNOWLEDGMENTThe authors wish to express their gratitude to

Dr. Eugene Lepeschkin of Burlington, Vermont forhis very helpful criticism, valuable suggestions andreview of the paper; to Dr. Harold Braun for hishelpful criticism; to Dr. Herbert W. Copelan forhis assistance in the working up of several cases;and to the staff of the x-ray department of thePhiladelphia General Hospital for their very kindcooperation.

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3SoKoLOW, M. AND FRIEDLANDER, R. D.: Thenormal unipolar precordial and limb lead elec-trocardiogram. Am. Heart J. 38: 674, 1949.

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SAMUEL BELLETBORYS SURAWICZ, ROBERT G. VAN HORNE, JOHN R. URBACH and

Electrocardiographic and Vectorcardiographic Study in Absence of Myocardial Infarction:4 and V3QS- and QR-Pattern in Leads V

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1955 American Heart Association, Inc. All rights reserved.

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