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Shahbudin H.

Rahimtoola, MD, Section Coordinator

Abnormal ECG in Clinically Normal Individuals


Charles Fisch, MD

THE ECG is a record of the changing absence of cardiac disorder. +120°, first-degree atrioventricular
potential of an electrical field gener- This discussion deals largely with block, right bundle-branch block, non¬
ated by the heart and may not always the abnormal ECG in the absence of specific intraventricular conduction
reflect accurately the electrical activ- cardiac disease or extracardiac dis¬ defect, left ventricular hypertrophy,
ity of the heart per se. The clinical turbance known to affect the heart atrial premature complexes and ven¬
diagnosis extracted from the ECG is and the ECG. tricular premature complexes greater
based on studies correlating clinical, than six complexes per minute, and
anatomical, pathological, and experi- The Normal ECG Wolff-Parkinson-White syndrome
mental findings coupled with careful, Ranges of normalcy for ECG com¬ was noted in 1.4%, 2.1%, 0.3%, 0.3%,
frequently purely deductive, analysis ponents should be based on an analy¬ 0.1%, 0.1%, 0.7%, 0.8%, and 0.3%,
of numerous records. In reality, sis of randomly selected, preferably respectively.' These findings are in
therefore, the ECG reflects largely an consecutive, routine ECGs recorded in agreement with observations made in
empirical body of information that young persons without cardiovascular a group of 5,000 male members of the
can be used, within limits, to identify disease. It is reasonable that only Canadian Air Force.2 In neither series
anatomical, metabolic, ionic, and he- unequivocal ECG changes should be were abnormalities of the ST seg¬
modynamic changes. considered. Consideration of minor ment, left bundle-branch block, or
Despite this basic limitation, the changes such as, for example, QRS or atrial fibrillation encountered.
ECG is an extremely useful clinical T-wave amplitude is often nonproduc¬ An abnormal ECG in the absence of
tool. It is the only practical method of tive. Admittedly, a statistical differ¬ heart disease may be the result of
recording the electrical behavior of ence may exist between groups, but faulty technique of recording, extra-
the heart. It is often an independent for any one individual, the impor¬ cardiac artifacts, or an abnormality
marker of myocardial disease and, tance of an absolute amplitude or of a of the ECG per se.
occasionally, the only indication of a minor change from tracing to tracing
pathological process. Since the ECG may be difficult to assess. This is true
Errors of Technique and Artifacts
reflects an electrical phenomenon, it because such variability often reflects Errors of Technique.—These include
is not surprising that it may be a normal curve of distribution and application of electrode paste over the
normal in the presence of cardiac because there is a lack of agreement precordium without ensuring discrete,
abnormality and abnormal in the as to when a given value becomes isolated contact for each of the pre¬
abnormal. cordial electrodes, errors of lead
The prevalence of abnormal ECGs placement, failure to shift the switch
This article is one of a series sponsored by the was extremely low in a study of 776 for aV„ to precordial V position,
American Heart Association. consecutive patients 18 to 25 years of improper standardization, excessive
From the Krannert Institute of Cardiology, Depart-
ment of Medicine, Indiana University School of age without cardiovascular disease. paper speed, and incorrect mounting.
Medicine, and the Veterans Administration Medical The patients were admitted because Poorly applied electrode paste
Center, Indianapolis. of acute psychiatric disorders. Left-
Reprint requests to Department of Medicine,
"joins" the precordial electrode sites
Indiana University School of Medicine, Indianapolis, axis deviation in excess of —30 °C, and may result in an abnormal record
IN 46202 (Dr Fisch). right-axis deviation greater than reflecting the net or "average" of a

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number of otherwise normal precor¬ The Abnormal ECG The most common cause of an
dial complexes. Two common errors Central to any discussion of an abnormal Q wave is an unusual posi¬
of electrode placement include rever¬ abnormal ECG in a normal heart is tion of the heart in the thorax. An
sal of the left- and right-arm connec¬ acceptance of the fact that anatomi¬ "abnormal" Q wave in leads III and
tions and placement of the precordial cal and functional disorders are aV, is frequently observed in obese
electrodes at the level of the second or excluded on the basis of clinical and individuals with high diaphragms.
third rather than the appropriate laboratory evaluation. It is probable, Similarly, a Q wave can be observed
fourth interspace. The reversal of however, that occasionally the ECG is in leads II, III, and aV, in association
limb leads simulates mirror-image a more sensitive marker of myocar- with tall R waves, both the result of a
dextrocardia. This error can be easily dial abnormality than either the clin¬ vertical position seen in asthénie indi¬
recognized because the precordial ical or laboratory evaluation. For viduals with a low diaphragm. The QS
complexes remain normal. Mirror example, right bundle-branch block is complex in leads V„ V2, and V3 can be
dextrocardia, on the other hand, almost always an acquired lesion and due to a low-lying diaphragm with a
shows a gradual loss of precordial R indicative of anatomical abnormality, relatively high position of the elec¬
amplitude from right to left, simulat¬ despite the fact that it is often trodes in relation to the heart, and
ing clockwise rotation or, rarely, myo- recorded in the absence of clinically placement of electrodes one or two
cardial infarction. When all precor¬ evident heart disease and is frequent¬ interspaces lower will display an R
dial complexes are identical to the ly associated with a favorable long- wave. Failure to register an R wave

aV„ the lead switch was not moved term prognosis. Despite the latter, suggests an organic cause for its
from the aVF to the precordial V right bundle-branch block is rarely a absence.
position. false-positive finding. The absence of Presence of a tall R wave in V„
Availability of the standardization clinical evidence of organic heart dis¬ although suggestive of right ventricu¬
signal is important for proper ECG ease and a favorable prognosis are lar hypertrophy or posterior myocar-
interpretation. Incorrect standardiza¬ not necessarily assurances of a nor¬ dial infarction, may be seen in the
tion may result in either abnormally mal heart. Despite these reservations absence of heart disease and is most
low or high voltage. Similarly, inspec¬ regarding our ability to exclude heart likely positional in origin. The latter
tion of the standard signal would disease, abnormal tracings may be is suggested by absence of other signs
alert the reader to the presence of recorded in patients with unequivo¬ of right ventricular hypertrophy or
excessive stylus inertia, which may cally normal hearts and in the myocardial infarction. Although ab¬
prove a source of serious errors of absence of extracardiac disorders ca¬ normally high voltage registered over
interpretation. Stylus "drag" may pable of affecting the heart. the left ventricle may indicate left
obscure low-amplitude waves such as The ECG abnormality in the pres¬ ventricular hypertrophy, the sensitiv¬
the Q waves, simulate intraventricu- ence of a normal heart may be that of ity and specificity of voltage alone for
lar conduction delay or ST-segment the P wave, QRS complex, ST seg¬ such a diagnosis are relatively low.
depression, and negate minor but ment, or T wave. The criteria are not applicable, for
important ST-segment elevation. Ex¬ The P Wave.—The occasional high example, to individuals younger than
cessive (50 mm/s) paper speed may amplitude of P waves in leads II, III, age 25 or to patients in other age
lead to an erroneous diagnosis of and aVF, the so-called P pulmonale, groups with thin chest walls.
intra-atrial, atrioventricular, and in- may be recorded in the absence of Although the accepted upper limit
traventricular conduction delays and cardiac abnormality.3 Abnormally tall of QRS complex duration is 0.10 s,
QT prolongation. Recognition of inap¬ P waves may be seen during sinus QRS complex duration between 0.10
propriate paper speed should be sim¬ tachycardia or can be recorded in tall and 0.12 s may be seen in the absence
ple because of a uniform prolongation asthénie individuals with a low dia¬ of heart disease, particularly in well-
of all the ECG components. Incorrect phragm and a vertical position of the developed athletic individuals.
mounting, particularly of the precor¬ heart. Similarly, the specificity of an The pattern of RR' can be recorded
dial leads, may result in an "abnor¬ abnormal left atrial P wave, "P in many young individuals from the
mal" R-wave progression with an mitrale," for heart disease is relative¬ V, position and in most, if not all,
erroneous diagnosis of myocardial ly low. A falsely abnormal P wave from positions to the right of V,. The
disease. should be suspected in the absence of R' is a normal reflection of late
Artifacts.—As a rule, artifacts sim¬ other ECG changes indicative of activation of the posterior septum. It
ulate atrial arrhythmias. Muscle right- or left-sided heart involve¬ can be differentiated from incomplete

tremor may suggest atrial fibrillation ment. right bundle-branch block by the R'
or flutter; infusion pumps, atrial QRS Complex.—Abnormalities of amplitude being lower than that of
tachycardia with block or atrial flut¬ the QRS complex include abnormal Q the R and especially if the R' is of
ter. Hiccough has been mistaken for waves, usually in leads aV,, III, and brief duration, the wave being simply
atrial parasystole and intra-atrial aV,; QS complex in leads V„ V2, and, a "spike."
dissociation. The artifacts simulating rarely, V3; tall R wave in leads V, and Abnormal left axis or axis in excess
arrhythmias can be recognized by the V2; abnormal voltage in "left ventric¬ of —30°, also referred to as left ante¬
presence of a normal sinus rhythm in ular" leads I, aV,, V„, V5, and V6; rior divisional block or left anterior
some leads with an RR interval iden¬ intraventricular conduction delays; fascicular block, is found in 1.4% of
tical to that in the leads with the and an altered sequence of ventricu¬ individuals younger than 25 years
suspected artifacts. lar activation. without heart disease and in a signifi-

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cantly higher proportion of individu¬ ventricular leads is frequently associ¬ give the appearance of a saddle. It is
als older than 70 years.14 Whether in ated with an RR' pattern in the same most often recorded in leads V«, V5,
the young without heart disease or in leads. The diagnosis of "early repolar- and V6 and less commonly in leads I
the aged reflecting an acquired ana¬ ization" is fairly secure in the young and aV,.
tomical disorder, abnormal left axis is and especially when accompanied by Occasionally, an isolated precordial
frequently registered in the absence slow heart rates. In the presence of T-wave negativity may be a normal
of clinically evident heart disease and symptoms or in older age groups, variant. It may manifest, for exam¬
is often associated with a good long- serial tracings and clinical correla¬ ple, by upright T waves in leads V,, V2,
term prognosis. In essence, the prog¬ tion may be essential to rule out an V5, and V„ and inverted T waves in
nosis of abnormal left-axis deviation organic cause for the ST-segment leads V3 and V4.7
is that of the underlying heart dis¬ elevation. Frequently, abnormal T waves are
ease. Of all the ECG abnormalities, fail¬ registered in leads V,, V2, and V, in
Atrioventricular Conduction.—The ac¬ ure to appreciate the fact that the middle-aged women in the absence of
cepted upper limit of 0.22 s for the T-wave inversion is not necessarily a heart disease. The genesis of such
PR interval may be exceeded in the marker of disease is the most com¬ T-wave inversion is obscure. The T
absence of heart disease. Occasion¬ mon and most serious form of iatro- wave is usually "shallow" and its

ally, especially in the asthénie or genic ECG form of "heart disease." limbs asymetrical, in contrast to the
athletic vagotonic individual with a Normal juvenile, symmetrically in¬ symetrical inversion of the T wave
slow resting heart rate, second-degree verted T waves in leads V„ V2, V3, and when caused by ischémie heart dis¬
atrioventricular block or Wencke- occasionally V„ may persist into the ease.
bach's type 1 block may be present. teens and occasionally into the 20s Conclusion
The block usually disappears with and rarely into the 30s.' On the basis
exercise or after administration of of morphologic conditions alone, such These ECG abnormalities may be
atropine. T waves cannot be differentiated from recorded in the presence of a clini¬
ST Segment and T Wave.—A com¬ T-wave inversion due to organic heart cally normal heart. Since the preva¬
monly encountered deviation of the disease. A correlation with available lence of such abnormalities is rela¬
ST segment in the absence of heart laboratory and clinical findings may tively rare, it is prudent that these
involvement is an elevation, so-called be essential to establish the benign should be viewed with suspicion and
early repolarization.56 The elevated nature of such T-wave changes. correlated with the available clinical
ST segment is usually concave, most In the young, usually younger than and other laboratory data.
often present in leads II, III, and aV„ 20 years, one can record an elevated This investigation was supported in part by
less commonly in lateral leads V4, V5, ST segment probably due to "early the Herman C. Krannert Fund, grants HL-06308
and HL-07182 from the National Heart, Lung,
and V6, and least commonly in leads repolarization" with a terminal T- and Blood Institute, and the American Heart
V„ V2, and V3. Elevation in right wave inversion. The combination may Association, Indiana Affiliate, Inc.

References
1. Fisch C: The electrocardiogram in the aged. 4. Fisch C: Theelectrocardiogram in the aged: 6. Spodick DH: Differential characteristics of
Cardiovasc Clin 1981;12:65-74. An independent marker of heart disease? Am J the electrocardiogram in early repolarization
2. Manning GW: Electrocardiography in selec- Med 1981;70:4-6. and acute pericarditis. N Engl J Med 1976;
tion of Royal Canadian Air Force crew. Circula- 5. Parisi AF, Beckman CH, Lancaster MC: 295:523-526.
tion 1954;10:401-412. The spectrum of ST-segment elevation in the 7. Grant RP: Clinical Electrocardiography:
3. Chou T-C, Helm RA: The pseudo P pulmo- electrocardiograms of healthy adult men. J The Spatial Vector Approach. New York,
nale. Circulation 1965;32:96-105. Electrocardiol 1971;4:137-144. McGraw-Hill Book Co, 1957, p 47.

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