Low QRS voltage and its causes

doi:10.1016/j.jelectrocard.2008.06.021

Journal of Electrocardiology

Volume 41, Issue 6, November–December 2008, Pages 498-500

https://doi.org/10.1016/j.jelectrocard.2008.06.021 Get rights and content

Abstract

Electrocardiographic low QRS voltage (LQRSV) has many causes, which can be differentiated into those due to the heart's generated potentials (cardiac) and those due to influences of the passive body volume conductor (extracardiac). Peripheral edema of any conceivable etiology induces reversible LQRSV, reduces the amplitude of the P waves and T waves, decreases the duration of P waves, QRS complexes, and QT intervals, and alters in turn the measurements of the signal-averaged electrocardiogram and T wave alternans, all with enormous clinical implications.

Section snippets

Cardiac causes of LQRSV

Multiple myocardial infarctions may lead to LQRSV because of cancellations and diminished electromotive force generation; LQRSV and QRS notches are seen in conjunction with severe post–myocardial infarction dysynergy.⁴ Infiltrative cardiomyopathies, a prototypical example being amyloidosis, may lead to LQRSV involving both the limb and the precordial leads,⁵ which occurs despite the marked cardiac hypertrophy or dilatation. Other infiltrative cardiomyopathies are reputed to be associated with

Pericardial causes of LQRSV

Pericardial effusion leads to LQRSV, the mechanism purported to be that of a short-circuiting of the heart's potentials as they are transmitted to the body surface; however, the mechanism may be more complex¹⁵ and may include even the intrapericardial pressure, like in tamponade, as the primary reason, along with the inflammation.16, 17 The delays in recovery of LQRSV after pericardiocentesis or alleviation of tamponade suggest that the effects on the ECG in pericarditis/pericardial

Extracardiac causes of LQRSV

It has been long realized that the pathology of the organs and tissues surrounding the heart impacts the transfer of heart's potentials to the body surface with resultant LQRSV.¹ Analysis of theoretical models and of relevant animal and clinical work has elucidated the influences of variation in resistivity of various body tissues and geometrical considerations of the heart/thorax on the transformation of what is generated at the epicardial surface and what is recorded at the body surface.8, 13

References (50)

BärF.W. et al.
Prognostic value of Q waves, R/S ratio, loss of R wave voltage, ST-T segment abnormalities, electrical axis, low voltage and notching: correlation of electrocardiogram and left ventriculogram
J Am Coll Cardiol
(1984)
WolffB. et al.
Acute reversible cardiomyopathy with cardiogenic shock in a patient with Addisonian crisis: a case report
Int J Cardiol
(2007)
SpodickD.H.
Low voltage with pericardial effusion: complexity of mechanisms
Chest
(2003)
BruchC. et al.
Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment
J Am Coll Cardiol
(2001)
SurawiczB. et al.
Cardiac alternans: diverse mechanisms and clinical manifestations
J Am Coll Cardiol
(1992)
CheslerE. et al.
The ECG of constrictive pericarditis—pattern resembling right ventricular hypertrophy
Am Heart J
(1976)
BrearleyW.D. et al.
Pneumomediastinum mimicking acute ST-segment elevation myocardial infarction
Int J Cardiol
(2007)
DudleyS.C. et al.
Reversal of low voltage and infarction pattern on the surface electrocardiogram after renal hemodialysis for pulmonary edema
J Electrocardiol
(1990)
MadiasJ.E. et al.
Anasarca-mediated attenuation of the amplitude of electrocardiogram complexes: a description of a heretofore unrecognized phenomenon
J Am Coll Cardiol
(2001)
MadiasJ.E.
Reversible attenuation of voltage of QRS complexes and P waves and shortening of QRS duration and QTc interval consequent to large perioperative intravenous fluid infusions
J Electrocardiol
(2006)

HeafJ.C.

Albumin-induced changes in the electrocardiographic QRS complex

Am J Cardiol

(1985)

MadiasJ.E.

Effect of changes in body weight and serum albumin levels on electrocardiographic QRS amplitudes

Am J Cardiol

(2002)

MadiasJ.E.

QTc interval in patients with changing edematous states: implications on interpreting repeat QTc interval measurements in patients with anasarca of varying etiology and those undergoing hemodialysis

Pacing Clin Electrophysiol

(2005)

Comprehensive electrocardiology

Theory and practice in health and disease

ChinitzJ.S. et al.

Electrocardiogram voltage discordance: interpretation of low QRS voltage only in the limb leads

J Electrocardiol

(2008)

GoldbergerA.L.

A specific ECG triad associated with congestive heart failure

Pacing Clin Electrophysiol

(1982)

PinamontiB. et al.

Cardiac amyloidosis. Invasive and noninvasive diagnosis

G Ital Cardiol

(1987)

GowrishankarK. et al.

Varied manifestations of viral myocarditis

Indian J Pediatr

(1994)

MadiasJ.E.

Low voltage ECG in myocarditis: peripheral edema as a plausible contributing mechanism

Pacing Clin Electrophysiol

(2007)

BrodyD.A.

A theoretical analysis of intracavitary blood mass influence on the heart-lead relationship

Circ Res

(1956)

OretoG. et al.

Electrocardiographic changes associated with haematocrit variations

Eur Heart J

(1992)

ErdölC. et al.

Relationship between changes in R-wave amplitude during left ventriculography and the seriousness of coronary heart disease

Ann Noninvasive Electrocardiol

(2002)

HirshfeldJ.W. et al.

Hemodynamic and electrocardiographic effects of ioversol during cardiac angiography. Comparison with iopamidol and diatrizoate

Invest Radiol

(1989)

GeddesL.A. et al.

The specific resistance of biological material—a compendium of data for the biomedical engineer and physiologist

Med Biol Eng

(1967)

TajiriJ. et al.

The cause of low voltage QRS complex in primary hypothyroidism. Pericardial effusion or thyroid hormone deficiency?

Jpn Heart J

(1985)

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Should ECG criteria for Low QRS voltage (LQRSV) be specific for Sex?
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Low QRS peak-to-nadir voltage (LQRSV) is associated with arrhythmogenic right ventricular cardiomyopathy (ARVC) and other cardiomyopathies. Recent studies have proposed criteria for LQRSV when screening athletes for cardiovascular disease. These criteria have not yet been evaluated in a large population of healthy young athletes.
The target population was 10,728 (42.5% female, 57.5% male, mean age 18.1 ± 4.3 years) athletes who participated in mass ECG screenings between 2014 and 2021 at multiple sites across the United States including grade schools (11%), high schools (32%), colleges (50%), and professional athletic teams (6%) with digitally recorded ECGs and a standardized protocol. Since by design, complete follow up for outcomes and the results of testing were not available. Including only ECGs from initial evaluation among athletes 14-35 years of age and excluding those with right bundle branch block, left bundle branch block, Wolf-Parkinson-White pattern, reversed leads and 3 clinically diagnosed cardiomyopathies at Stanford, 8,679 (58% males, 42% females) remained eligible for analysis. QRS voltage was analyzed for each ECG lead and LQRSV criteria were applied and stratified by sex.
QRS voltage was lower in all leads in female athletes compared to male athletes. Using traditional limb lead criteria or precordial lead criteria, the prevalence of LQRSV was significantly lower in males than females (P < .001). Strikingly, LQRSV using the Sokolow-Lyon Index was present in 1.9% of males and 9.8% of females (P < .001). Applying first percentile for LQRS amplitude criteria provided possible values for screening young athletes for LQRSV.
LQRSV is more common among female athletes than male athletes using established criteria. Using first percentile sex-specific cut points should be considered in future analyses. Proposed novel LQRSV criteria in young athletes should be specific for males and females.
An unusual presentation of low QRS voltage in a patient with aortic aneurysm
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There are many causes of low QRS voltage on the electrocardiogram (ECG). Although uncommon, there is evidence that an enlarged aorta can cause diminished QRS amplitude on ECG. In this case report, we describe an unusual presentation of low QRS voltage confined to the first three precordial leads (V1-V3) in a 77-year-old female with ascending aortic aneurysm. Analysis of the patient's medical history, echocardiogram and contrast-enhanced computed tomography indicates that the ECG pattern was caused by interposition of the aortic aneurysm between the heart and the skin electrodes (V1-V3), revealing a possible indirect sign for large aortic aneurysm on ECG.
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Anterior T wave inversion (TWI) is frequent in healthy adolescent individuals (juvenile ECG pattern), normalising after puberty. Its clinical implications are uncertain.
This study assessed a) national prevalence of anterior TWI, b) ST segment morphology, c) proportion of individuals with a juvenile ECG pattern whose ECG normalises and d) factors predicting TWI persistence >16 years.
Adolescents (mean 15y) in Malta were systematically invited to enrol in a cardiac screening program. Subjects completed a health questionnaire and an ECG at their school. Participants with TWI were labelled as TWI in V₁-V₂ or extended TWI (V₁-V₃/₄). The latter were followed at 1 year with a repeat ECG. Those with persistent extended anterior TWI were offered evaluation and surveillance.
The prevalence of isolated anterior TWI was 5.0%, commoner in females (6.3%) independent of athletic ability. Extended TWI was commoner in female athletes (4.2%, non-athletes 2.1%). Females often had shallow TWI without overt ST segment abnormalities. Deep TWI and ST segment changes were more frequent in males. Only 0.2% of cases persisted ≥16 years of age. ST segment characteristics were not able to predict T wave normalisation. No events took place during follow up (40 ± 9 months).
Anterior TWI is a frequent phenomenon in adolescents, especially in females. Female athletes are also more likely to have extended anterior TWI. Only 0.2% of cases have persistent anterior TWI at 16 years of age. Chest wall anatomy may explain this phenomenon in females. It is uncommon in males, hence why surveillance is more prudent.
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Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by extracellular deposition of amyloid fibrils, mainly derived from transthyretin, either wild-type or hereditary variants, or immunoglobulin light chains misfolding. It is characterized by an increased left ventricular (LV) mass and diastolic dysfunction, which can lead to heart failure with preserved ejection fraction and/or conduction disturbances. The diagnosis is based on invasive pathology demonstration of amyloid deposits, or non-invasive criteria using advanced cardiovascular imaging techniques. Nevertheless, 12-lead electrocardiogram (ECG) remains of crucial importance in the assessment of patients with CA, since they can manifest peculiar features such as low QRS voltages, in discordance with the LV hypertrophy, but also pseudo-infarction patterns, sinus node dysfunction, atrioventricular blocks, premature supraventricular and ventricular beats, which support the presence of a myocardial disease. Great awareness of these common ECG characteristics of CA is needed to increase diagnostic performance and improve patient's outcome. In the present review, we discuss the current role of the ECG in the diagnosis and management of CA, focusing on the most common ECG abnormalities and rhythm disorders.
Late cardiac toxicity of neo-adjuvant chemoradiation in esophageal cancer survivors: A prospective cross-sectional pilot study
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Although cure rates in esophageal cancer (EC) have improved since the introduction of neoadjuvant chemoradiation (nCRT), evidence for treatment-related cardiac toxicity is growing, of which the exact mechanisms remain unknown. The primary objective of this study was to identify (subclinical) cardiac dysfunction in EC patients after nCRT followed by surgical resection as compared to surgery alone.
EC survivors followed for 5–15 years after curative resection with (n = 20) or without (n = 20) nCRT were enrolled in this prospective cross-sectional pilot study. All patients underwent several clinical and diagnostic tests in order to objectify (sub)clinical cardiac toxicity including cardiac CT and MRI, echocardiography, ECG, 6-minutes walking test, physical examination and EORTC questionnaires.
We found an increased rate of myocardial fibrosis (Linear late gadolinium enhancement (LGE) 4 vs. 1; p = 0.13; mean extracellular volume (ECV) 28.4 vs. 24.0; p < 0.01), atrial fibrillation (AF) (6 vs. 2; p = 0.07) and conduction changes in ECG among patients treated with nCRT as compared to those treated with surgery alone. The results suggested an impact on quality of life in terms of worse role functioning for this patient group (95.0 vs. 88.8; p = 0.03).
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Low QRS voltage and its causes

Abstract

Section snippets

Cardiac causes of LQRSV

Pericardial causes of LQRSV

Extracardiac causes of LQRSV

J Am Coll Cardiol

Int J Cardiol

Chest

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Int J Cardiol

J Electrocardiol

J Am Coll Cardiol

J Electrocardiol

Am J Cardiol

Am J Cardiol

Pacing Clin Electrophysiol

Theory and practice in health and disease

Electrocardiogram voltage discordance: interpretation of low QRS voltage only in the limb leads

J Electrocardiol

A specific ECG triad associated with congestive heart failure

Pacing Clin Electrophysiol

Cardiac amyloidosis. Invasive and noninvasive diagnosis

G Ital Cardiol

Varied manifestations of viral myocarditis

Indian J Pediatr

Low voltage ECG in myocarditis: peripheral edema as a plausible contributing mechanism

Pacing Clin Electrophysiol

A theoretical analysis of intracavitary blood mass influence on the heart-lead relationship

Circ Res

Electrocardiographic changes associated with haematocrit variations

Eur Heart J

Relationship between changes in R-wave amplitude during left ventriculography and the seriousness of coronary heart disease

Ann Noninvasive Electrocardiol

Hemodynamic and electrocardiographic effects of ioversol during cardiac angiography. Comparison with iopamidol and diatrizoate

Invest Radiol

The specific resistance of biological material—a compendium of data for the biomedical engineer and physiologist

Med Biol Eng

The cause of low voltage QRS complex in primary hypothyroidism. Pericardial effusion or thyroid hormone deficiency?

Jpn Heart J