J.
ELECTROCARDIOLOGY, 3 (2) 161-168, 1970
A Study of the Normal QRS-T
Angle in the Frontal Plane*
BY RICHARD ZIEGLERt~ AND DANIEL K. BLOOMFIELD, M.D., F.A.C.C.~
SUMMARY
The noimal limits of A~ and A~ in the
frontal plane and their relationship to each other
have been defined. It has been shown that the
QRS-T angle in the frontal plane is not only a
function of magnitude but depends on the ab-
solute A~ direction itself. As A~ shifts
left, A~ lags behind so that when A~ is less
than 0 ~ the normal A~ is always to the right of
A~ A converse relationship has been demon-
strated in vertical hearts. These findings should be
of practical value to the interpretor of 12-1ead
electrocardiograms in which the Einthoven tri-
angle defines the frontal plane. However, we are
aware of the limitation of our results which are
obtained from a sample of hospitalized patients
with a normal cardiovascular system.
INTRODUCTION
Deviation of the mean electrical QRS axis of
the heart in the frontal plane (A~ from ap-
parent normal values 1-5 has been considered
evidence of electrocardiographic abnormality.
Similarly, the normal range of the mean electrical
T axis in the frontal plane (A~ has been de-
scribed~,6. The difference between A~ and
A~ the QRS-T angle, has also proven useful in
defining electrocardiographic normality and ab-
normality. It has generally been accepted that a
QRS-T angle in the frontal plane which exceeds
45 ~ 50 ~ or 60 ~176 is abnormal. We have
studied the value of the QRS-T angle in normal
and abnormal electrocardiograms, and have noted
the normal A~ ranges between --15 ~ and + 8 5 ~
on the hexaxial reference system4,s,12 and locates
centrally from normal QRS vectors that vary
from - 3 0 ~ to -[-95 ~. It is the purpose of this
*From the Division of Medicine, Mt. Sinai Hos-
pital, Cleveland, Ohio.
t Research Assistant.
Associate in Medicine.
Reprint Requests: D. K. Bloomfield, M.D., School
of Basic Med. Sci., Univ. of Illinois, Urbana, I11,
161
paper to describe the normal QRS-T angle rela-
tionships in the frontal plane for adults over 35
years of age and to provide a practical approach,
based upon the hexaxial reference system, for the
interpreter of electrocardiograms to use these
angles.
MATERIAL AND METHOD
Three hundred and one normal electrocardio-
grams (143 male, 158 female) were selected at
random from the records of hospitalized patients
over 35 years of age. These records had been pre-
viously read as normal by one of ten qualified
physicians. The criteria for a normal record were
that the interpreter, in his experience, had indi-
cated that the record was normal and that there
was no clinical evidence of heart disease. The age
distribution of these records is noted in Table 1.
In determining the vectorial direction of
A~ and A~ the transitional zone technique
using the QRS and T wave amplitudes as dis-
cussed by Graettinger, et al. 12 was used. In all
cases, estimations of both A~ and A~ were
made to the nearest five degrees on the hexaxial
reference system. The absolute magnitude of
A~ and A~ was not determined.
RESULTS
A~ of the 301 normal electrocardiograms
varied between --30 ~ and + 9 5 ~ with a mean of
+33.3 ~ -4- 28.1 ~ A~ for the sample fell be-
tween --15 ~ and + 8 5 ~ with a mean of +40.1 ~
-4- 17.2 ~. Both the range and standard deviations
indicate that the normal A~ varies less than the
normal A~
Fig. 1 shows the distribution of A~ with
respect to A~ for the sample. The line
A~ = A~ drawn through the distribution
shows that no simple value of the normal QRS-T
angle (such as 60 ~ can accurately and fully de-
scribe the normal limits of A~ with respect to
A~ The A~ values are not distributed
evenly on each side of the A~ = A~ line.
Even the two bordering lines encompassing ap-
162 ZIEGLERAND BLOOMFIELD

A~ T v s A~ O R S
FRONTAL PLANE
301 NORMAL ELECTROCARDIOGRAMS

90 o .
80 oJJ7 " "

70

6o
9 /~
50 ........................ ~>

40

~- 30

2O

10

-10
-20

-30

- 3 0i - 2 ~ 0 - l l 0 0I ]
10 210 30] 410 50
I
610 710 810 910 1~)0
A~
Fig. 1. A~ vs. A~ in the frontal plane for 30l normal electrocardiograms in persons over age 35. The
lines A~ --60 ~ = A~ and A~ +35 ~ = A~ encompass approximately 94 per cent of values.

proximately 94 per cent of the distribution do not A~ accurately. Since the slope of the curve
accurately describe the A~ population. Rather it of the mean A~ values becomes steeper past
can be seen that from A~ --30 ~ to 0 ~ the + 3 8 ~ regression lines for the A~ population
normal A~ is always to the right of A~ on each side of + 38 ~ were calculated, along with
(A~ always more than A~ This trend con- 95 7o confidence intervals for these lines. From
tinues from A~ 0 ~ to A~ + 3 0 ~ with a A~ --30 ~ to + 3 5 ~, the equation for the
majority of the A~ values lying to the right of regression line was found to be A~ = 0.059
A~ From A~ + 3 0 ~ to + 6 0 ~ A~ is A~ + 33.71~ with the expression 1.96
distributed evenly on each side of A~ From ~/292.91 + .006 (A~ -- 11.15) 2 13 repre-
A~ + 6 0 ~ to + 1 0 0 ~ nearly all of the A~ senting the 95 7o confidence limits of the normal
values lie to the left of A~ (A~ less than A~ for any A~ from - 3 0 ~ to + 3 5 ~ From
A~ A~ + 4 0 ~ to + 1 0 0 ~ the equation for
Fig. 2 is a plot of the mean and standard the regression line was found to be A~ =
deviations of A~ values for a given A~ A~ 0.317 A~ + 38.18 ~ with the expression 1.96
values have been grouped to make the number of ~]309.71 + .0076 (A~ - 57.14~ 2 represent-
A~ values ten or more for each A~ range. ing the 95 70 confidence limits of the normal A~
The curve of best fit through the mean A~ values for any A~ from + 4 0 ~ to + 1 0 0 ~. Fig. 3
of the sample indicates that two regression lines shows each regression line with its respective 95 70
with corresponding 95 7O confidence limits would limits, and Table 2 gives the 9570 confidence
describe the normal A~ related to a specific limits of the normal A~ at any A~ from
 FRONTAL PLANE NORMAL QRS-T ANGLE 163

A~ T vs A~ QRS

MEAN and STANDARD

DEVIATIONS for A~ T

100 -

90-

80

70 ,s j

60

50-
1~
18 14 1•
~Lfl~-~14
2 4 11
- 4- II
40-

30-

20-

10-

0-

-10

-20

-3 (

I I I I I I I I I I I I I I
-30-20 -10 0 10 20 30 40 50 60 70 80 90 100
A~ Q R S
Fig. 2. Normal A~ vs. A~ values plotted as mean and standard deviations of A~ values.

- 3 0 ~ to 4.100 ~ Both Fig. 3 and Table 2 also regression coefficient for the total sample popula-
compare our data with the earlier studies of tion (b = 0.227) was significantly different
Helm la. (p (.05) than the regression coefficients of the
The regression line for the total sample was also two separate regression lines (b = 0.059, b =
calculated. The equation for this line is A~ = 0.317).
0.227 A~ 4- 32.57 ~ with the expression 3. In comparing the mean A~ values of con-
1.96 ~/255.84 4" .0012 (A~ -- 33.31) 2 secutive 30 ~ ranges (approximately) of A~
representing the 95 % confidence limits of the (Table 3), it can be seen that the mean A~ values
normal A~ for any A~ value from --30 ~ for A~ -30 ~ to 0 ~ and for A~ 0 ~ to
to 4-100 ~ We believe that two separate regression 4-35 ~ are not significantly different. However, for
lines describe the interrelationship of A~ and the next two A~ ranges (A~ -t-40 ~ to
A~ better than one regression line. The fol- 4--60~ and A~ 4-60 ~ to 4,100 ~ the mean
lowing reasons are offered for this view: A~ values rise dramatically and, in each case,
1. The confidence limits found using two sepa- are significantly different from the mean A~
rate regression lines describe our sample popula- values of the A~ range immediately preced-
tion much better than the confidence limits found ing. This table indicates the need to describe our
by using one regression line (compare Figs. 1 sample population with two regression lines; one
and 3). line for the A~ values for A~ --30 ~ to -1-35~
2. By use of the t-test for the confidence limits and another line for the A~ values for A~
of a regression coefficient, it was found that the 4-40 ~ to 4-100 ~.
164 Z I E G L E R AND BLOOMFIELD

A~ T vs A~ ORS
REGRESSION LINES AND 5% FIDUCIAL LIMITS ~','
110 ..~

I00 v\~
90 O~ 0 ~ >

80, 5% F I D U C I A L LIMITS /

70 - r ~ * ~ 1 7 6

5o- ..... , . ~. . ~s, ?~( oo"~. _

40- REGRESSION LINE ~ ~02-a
~
...Ipv ~,rr..
,'s or'~~.O 1010
-30~ TO +35 ~ /.~ ,,,,.. ~A
< 30 - ,t.l',.~:.*~ ......
v,';. "~ . .....
,,.,I.!.---
.0~~176176176 --
I0- ~ ." _.~o
~.2;." ..- % FIDUCIAL LIMITS

0- __ o.~,~.
- I0 oO.**
-20 ~~ ~

-30" ....,1%o""
..o s
..&~o
-40-

-3'0--2'0--1~) (~ 1'0 2'0 3'0 4'0 5'0 6'0 7'0 8'0 9'0 1(30
A ORS
Fig. 3. Regression lines and 5 per cent fiducial limits of A~ vs. A~ for the data in this paper con]pared
to Helm 14.

DISCUSSION or horizontal direction, the normal T vector ac-

The purpose of this paper is to establish the
normal limits of the QRS-T angle in the frontal
plane using the hexaxial reference system and to
make this a useful tool for the individual who
interprets electrocardiograms. Several other
authors have commented in a general way on the
normal limits of the QRS-T frontal angle. Zao,
et al. s reported no normal QRS-T frontal angles
exceeding 45 ~ Arbeit, et al. n said that QRS-T
angles up to 60 ~ are within normal limits.
Graybiel et al. 9 said that the angle rarely exceeds
50 ~ Grant 7 indicated that for normal subjects,
the frontal QRS-T angle does not often exceed
45 ~. However, Grant explained further that the
mean T vector varied less in direction in the frontal
plane than the QRS vector. He pointed out that
when the mean QRS vector deviated to a vertical
companied it but showed less deviation that the
QRS vector. Dimond 1~ came to similar conclu-
sions, stating that the "-F vector should lie to the
left of the QRS in electrically vertical hearts and
to the right of it in electrically horizontal hearts.
In the intermediate area, the T vector may lie on
either side of the QRS vector." Our work con-
firms and provides statistical support and limits
for the above observations.
Helm 14 considered the problem of the normal
limits of A~ in relation to A~ more specifi-
cally. Using 241 electrocardiograms of patients
over 20 years of age, he obtained a single regres-
sion line (A~ = 0.514 A~ -}- 20.9) for his
sample population and also calculated the 5 % and
1% fiducial confidence limits of A~ for a ran-
domly chosen A~ The 5 % limits are pre-
sented in Table 2 and Fig. 3. Based on these
 FRONTAL PLANE NORMAL QRS-T ANGLE 165

limits H e l m concluded "that any designated represent the range of the n o r m a l A ~ with
upper limit o f normal (e.g. 50 ~) for the frontal respect to A ~ for his sample. Our data indi-
Q R S - T angle may be too large when A ~ is cate that two regression lines, one with a nearly
located on one side of A ~ and t o o small when zero slope and one with a decidedly steeper slope
A ~ is located on the other side of A ~ '' H e along with the respective confidence intervals of
points out that this is particularly true when each, best represent our sample population. The
A~ is in a nearly horizontal or nearly vertical regression coefficients for both of the regression
position. lines determined for our sample were significantly
Figs. 1, 2 and 3, and Table 2 show that our data different f r o m the regression coefficient of the
generally agrees with that of Helm. Table 2 regression line for H e l m ' s sample (b = .514) at
shows that the lower limits of the normal A ~ the .05 level. Because of differences in the regres-
in our sample vary from - - 2 ~ to + 2 ~ and the sion lines used, the limits of the n o r m a l A ~ of
upper limits vary f r o m + 66 ~ to + 70 ~ as A ~ the two samples show much disagreement at the
goes from - - 3 0 ~ to + 3 5 ~ These limits indicate extremes of the normal A ~ range. Even for
that in nearly electrically horizontal hearts, the A~ values at the extreme leftward limit of the
n o r m a l A ~ always lies to the right of A ~ normal A ~ range, our data suggest that any
and that the Q R S - T angle may be as large as 96 ~ A ~ value less than 0 ~ (T wave inverted in aVF)
For A~ + 4 0 ~ to + 1 0 0 ~ the lower limits of is abnormal. Simonson 15 and Hiss et al. 5 came to
the normal A ~ range from + 1 2 ~ to + 3 0 ~ and a similar conclusion with the former setting the
the upper limits range from + 6 9 ~ to + 8 9 ~, These lower limit of T amplitude in adults above 20
limits show that for nearly vertical hearts, A ~ years of age at --0.2 ram. in a V F and the latter
always lies to the left of A ~ and the Q R S - T giving no negative values for the T wave in aVF
angle may be as large as 70 ~. for adults above 20 years of age. However, H e l m ' s
Fig. 3 and Table 2 which compare the 95 ~o
confidence limits of our sample to those of H e l m
TABLE 2
show a general agreement between the two sam-
The Normal Relationship of A~ to A~ in
pies, especially between A ~ + 15 ~ and + 6 0 ~ Persons Over Age 35
However the two samples differ in several ways.
H e l m ' s data is based on a smaller sample with an 95 % Confidence Limits (in degrees)
A~ of A~
age range of 20 to 71 years of age. Our data is
(Degrees) Ziegler and Bloomfield Helm (14)
based strictly on persons over 35 years of age,
an age group in which nonspecific T wave changes --30 -- 2 t o + 6 6 --36 to +47
and variations in the Q R S - T angle may have in- --25 -- 2 t o + 6 6 --32 to +48
--20 -- lto+66 --29to+50
creased significance. H e l m used a single regression --15 -- 1 to +67 --25 to +51
line with the confidence limits of this line to --10 -- lto+67 --21 to +53
-- 5 0to +67 --18 to +54
0 0 to +67 --14 to +56
5 0 to +68 --11 to +58
TABLE 1 10 + lto+68 -- 8 t o + 6 0
Age Distribution of 301 Normal Electrocardiograms 15 + 1 to +68 -- 4 to + 6 2
in Persons Over Age 35 20 + lto+68 -- l t o + 6 4
25 + 2 t o +69 + 2 t o +66
Age Group N 30 + 2to+69 + 5to+68
35 + 2 to +70 + 7 to +70
35-40 39 40 +12 to +69 + 1 0 to +73
41--45 54 45 +14 to +71 + 1 2 to +76
46-50 45 50 +16 to + 7 2 +15 to +78
51-55 42 55 +17 to +74 +17 to +81
56-60 41 60 +19 to +76 +19 to +84
61-65 25 65 +20 to +77 +22 to +87
66-70 24 70 + 2 2 to +79 +24 to + 9 0
71-75 19 75 +23 to +80 +25 to +93
76-80 8 80 +25 to + 8 2 +27 to +97
Greater than 80 4 85 +26 to +84 +29 to +100
Total: 301 90 +28 to +86 +31 to +104
Mean age of sample = 53.05 95 +29 to +87
Median age of sample = 52.02 100 +30 to +89
166 Z I E G L E R AND BLOOMFIELD
data (Table 2, Fig. 3) indicate that the normal
A ~ can rotate as far left as - - 3 6 ~ If this were so,
the normal T wave could be inverted in both II
and aVF. Although one source ~6 lists a m i n i m u m
T wave in a V F of --0.6 ram. for adults over 20
years of age, none of the three sources 5,1~,~6 set
the lower limit of the T wave in II below 0 ram.
Furthermore, clinical expelience is strongly
against normal inverted T waves in aVF, even
though statistical treatment of the H e l m data
may have led to this conclusion.
At the extreme rightward limit of the normal
A~ range, our data suggests that the normal
A ~ never exceeds 89 ~ and thus that the normal
T wave is never inverted in I. Simonson ~5 placed
the lower limit of T wave amplitude for adults
over 20 years of age in lead I at 0.5 ram., and Hiss,
et al.:' show no negative T wave values for adults
over 20. However, Helm's data indicates that the
normal A ~ can rotate as far tight at 104 ~ This,
too, is contrary to clinical experience.
By using one regression line fol his entire popu-
lation, Helm did not observe the change in the
A ~ population as A ~ increases which we
have observed in our data. Since our data is based
on a larger sample and deals with an older popu-
lation, we believe the two separate regression lines
with corresponding confidence intervals more
accurately describe the relation of A ~ to A ~
in persons over age 35.
We recognize that the method used for the
determination of A ~ and A ~ is subject to
limitations. Zao, et al. s argued that the Einthoven
triangle upon which the hexaxial reference system
is based cannot give completely accurate results.
T h e Burger triangle s,~7,1s is said by some to be
more accurate, but it is harder and less practical
TABLE 3
Comparison of A~ Populations for Different A~
Ranges in Persons Over Age 35
P Value
Between
A~ Consecutive
A~ Range N (mean 4- s.d.) Means
--30 ~ to 0 ~ 48 33.4 ~ 4- 19.8 ~
>0.1
+ 5 ~ to +35 ~ 108 34.7 ~ 4- 16.3 ~
<0.001
+ 4 0 ~ to +60 ~ 97 43.0 ~ 4- 14.2 ~
<0.001
+ 6 5 ~ to +100 ~ 48 54.3 ~ 4- 13.8 ~
to use. Both Hiss, et al. 5 and Zao, et al. s have
stated that 15 degrees is the limit of accuracy
obtainable f r o m the hexaxial reference system.
M a r r i o t t 4 has given the system credit for greater
accuracy, perhaps even 5 degrees. Burch and
Winsor 19 and A s h m a n and Hull 2~ have pointed
out that true accuracy for A ~ and A ~ re-
quires measurement of the area encompassed by
the Q R S and T waves. However, Simonson, et
al. 21 reported a high positive correlation between
the areas and the amplitudes of both the Q R S
and T waves. We used the transitional zone tech-
nique t2 using only the wave amplitudes to de-
termine the angles because this method is the one
most useful to the day-to-day interpreter of
electrocardiograms who usually works with the
Einthoven triangle. Graettinger, et al. 12 point out
the fairly accurate results of this method.
The Q R S - T frontal angle should be determined
both in magnitude (the absolute number of de-
grees of the angle) and in direction (the position
of A ~ to the right or left of the A~ Since
the hexaxial reference system is useful for every-
day electrocardiographic interpretation, the limits
of normality demonstrated in Fig. 3 and Table 2
for A ~ in relation to A ~ should be of im-
mediate practical value.
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 FRONTAL PLANE NORMAL QRS-T ANGLE
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