30/03/2023, 10:53 Delta Wave • LITFL Medical Blog • ECG Library Basics

Delta Wave
Mike Cadogan and Robert Buttner Feb 10, 2022
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Delta Wave Overview

The Delta wave is a slurred upstroke in the QRS complex. It relates to pre-
excitation of the ventricles, and therefore often causes an associated shortening
of the PR interval. It is most commonly associated with pre-excitation syndromes
such as WPW.

The characteristic ECG findings in Wolff-Parkinson-White syndrome are:

Short PR interval (< 120ms)
Broad QRS (> 100ms)
A slurred upstroke to the QRS complex (the delta wave)

Delta wave: Premature excitation of the ventricles causes a slurred upstroke to the QRS

ECG examples of Delta Waves

Delta wave
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Note that the remainder of the QRS remains normal — conduction still occurs
through the AV node and this is the dominant pathway. On arrival to the ventricles,
such conduction cancels out any pre-excitation that has occurred via an accessory
pathway

Negative delta waves (e.g. seen in lead aVR)

These changes are simply reciprocal to those seen in leads II, aVL, V5 and V6

History of the Delta wave

1930 – Wolff L, Parkinson J, and White PD publish the eleven cases as definitive
description of the syndrome – ‘Bundle Branch Block with Short P-R Interval in Healthy
Young People Prone to Paroxysmal Tachycardia.’ A review of the literature confirmed
and acknowledged the previously described cases as above. Wolff, Parkinson, and
White erroneously thought that the wide QRS complex was caused by a type of bundle-
branch block.

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Fig 6. Case III. WPW 1930

1933 – Wolferth and Wood suggested that the abnormal slurring of the initial part of
the QRS complex, and prolongation of the QRS complex were not due to bundle-branch
block but by:
…an actual acceleration of the passage of the impulse from the auricle to a section
of the ventricle…in keeping with the possibility that an accessory pathway of AV
conduction such as described by Kent between the right auricle and right ventricle
could be responsible for the phenomenon manifested by these cases

Wolferth CC, Wood FC. 1933

1944 – Marcel Segers along with Lequime and Denolin are credited with proposing the
Δ to represent the triangle shape at the base of the upsloping QRS complex. They
described the ‘… deformation of the PQ segment is the result of a supplementary
electrical deflection that we propose to call Δ‘ . This became more commonly
described as the ‘delta wave’

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However, Segers et al actually proposed that the Δ wave was a discrete and
autonomous wave between P and Q. They did state that the wave could fuse with the
base of QRS complex (figure C) to form a slurred upstroke, and attributed the Δ wave
fusion with the bundle branch phenomenon of WPW (Figure D)

Fig 1 (a, b, c, d) Segers et al 1944

Original English
Diagram a: Δ wave represented by a simple tilt of the PQ segment.
Diagram b; Plot with completely autonomous Δ wave: the Q point is clearly
marked after Δ , and under these conditions the PQ and QRS intervals actually
keep a normal value.
Diagram c: Plot with Δ wave forming a “foot” attached to QRS: the Q wave
corresponds to the point of inflection separating Δ and R. The dotted line shows
the evolution of the Δ wave continuing throughout the duration of the complex
ventricular, according to the hypothesis of Eckey and Schäfer; this diphasic
wave would come to be superimposed on the normal ventricular complex and
would thus determine the shift of ST and the deformation of T.
Diagram d: Δ and QRS waves are completely fused into a single, enlarged
bundle-branch block-like complex (Wolff-Parkinson-White syndrome); the Q
point and the R vertex are no longer visible and the T wave appears in a
“staircase shape”

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Segers et al 1944

Further reading
Buttner R, Burns E. Wolff-Parkinson-White syndrome. LITFL
Cadogan M. The history of Wolff–Parkinson–White syndrome LITFL
Cadogan M. Who’s Afraid Of The Big Bad Wolff? LITFL
Buttner R, Burns E. VT versus SVT with aberrancy LITFL
Burns E. Puzzling Paroxysmal Palpitations LITFL

References
Original articles
Wolff L, Parkinson J, White PD. Bundle-branch block with short P-R interval in
healthy young people prone to paroxysmal tachycardia. American Heart Journal.
1930; 5: 685-704 [Reprint: Ann Noninvasive Electrocardiol. 2006 Oct;11(4):340-53.
PMID 17040283]
Wolferth CC, Wood FC. The mechanism of production of short P-R intervals and
prolonged QRS complexes in patients with presumably undamaged hearts:
hypothesis of an accessory pathway of auriculoventricular conduction (bundle of
Kent). American Heart Journal. 1933; 8: 297-311.
Segers PM, Lequime J, Denolin H. L’activation ventriculaire précoce de certains
cœurs hyperexeitables. Étude de I’onde Δ de I’électrocardiogramme. Cardiologia.
1944; 8(3-4):113-167.
Review articles
Hurst JW. Naming of the waves in the ECG, with a brief account of their genesis.
Circulation. 1998 Nov 3;98(18):1937-42
Buttner R. Delta wave. Eponym A Day. Instagram

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ECG Library Basics

Delta Wave • LITFL Medical Blog • ECG Library Basics

P Wave
PR Interval
PR Segment
Q Wave
QRS Segment
QT Interval
J Point
ST Segment
R Wave
T Wave
U Wave
Osborn Wave
Epsilon Wave
Delta Wave

Advanced Reading
Online
Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course – Become an ECG
expert. Medmastery
Wiesbauer F, Kühn P. ECG Blue Belt online course: Learn to diagnose any rhythm
problem. Medmastery
Rawshani A. Clinical ECG Interpretation ECG Waves
Smith SW. Dr Smith’s ECG blog.
Textbooks
Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical
Care. 2e, 2019
Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
Hampton J. The ECG Made Practical 7e, 2019
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Grauer K. ECG Pocket Brain (Expanded) 6e, 2014

Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care
Electrocardiography 1e, 2009
Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and
Pediatric 6e, 2008
Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004
Smith SW. The ECG in Acute MI. 2002 [PDF]

LITFL Further Reading

ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
ECG A to Z by diagnosis – ECG interpretation in clinical context
ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
100 ECG Quiz – Self-assessment tool for examination practice
ECG Reference SITES and BOOKS – the best of the rest

Cite this article as: Mike Cadogan and Robert Buttner, "Delta Wave," In: LITFL -
Life in the FastLane, Accessed on March 29, 2023, https://litfl.com/delta-wave-
ecg-library/.

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Mike Cadogan
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Associate Professor Curtin Medical School, Curtin University.

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM Sir
Charles Gairdner Hospital.  Passion for rugby; medical history;
medical education; and asynchronous learning #FOAMed evangelist.
Co-founder and CTO of Life in the Fast lane | Eponyms | Books |
Twitter |

Robert Buttner
MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA)
Adult/Paediatric Emergency Medicine Advanced Trainee in
Melbourne, Australia. Special interests in diagnostic and procedural
ultrasound, medical education, and ECG interpretation. Editor-in-
chief of the LITFL ECG Library. Twitter: @rob_buttner

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