Electrocardiographic tall R waves in the right precordial leads: Comparison of recently proposed ECG and VCG criteria for distinguishing posterolateral myocardial infarction from prominent anterior forces in normal subjects

Abstract

Electrocardiographic tall R waves in the right precordial leads may be present in patients with posterior myocardial infarction, right ventricular hypertrophy, various conduction disturbances, and some forms of cardiomyopathy and in clinically otherwise normal subjects with prominent anterior electromotive forces. Clinical uncertainty most often arises in distinguishing possible prior posterolateral myocardial infarction (PMI) from the unusual normal variant (PAF). The ECGs and VCGs of 15 subjects with posterolateral infarction were compared with tracings from 12 subjects with no evidence of cardiac disease, all individuals demonstrating tall R waves ( R S > 1.0 in V 1 and/or V 2) in the right precordial leads on surface ECG. By standard ECG, the infarction group was characterized by taller T waves in leads V 1 and V 2, shorter T waves in V 6, greater T2–T6 index, and a more negative two variable function as described by Nestico. By VCG, the infarction group was characterized by a more anteriorly oriented T loop, more leftward maximal frontal plane QRS vector and a lower calculated −45°/ab, as described by Suzuki. An algorithm was proposed that permitted proper classification (PAF vs. PMI) based on ECG criteria in 75% of subjects with 90% accuracy. This compared favorably with performance of the Frank vectorcardiogram, including using more recently proposed criteria. Routine use of the VCG, therefore, in this clinical setting may no longer be justified.