Poor R Wave Progression Revisited

Abstract

A significant portion of patients with previous anterior wall myocardial infarctions (AMIs) will masquerade merely having as poor R-wave progression (PRWP) on surface electrocardiography. Zema and Kligfield 1 Zema M.J. Kligfield P. ECG poor R wave progression Review and synthesis. Arch Intern Med. 1982; 142: 1145-1148 Crossref PubMed Scopus (24) Google Scholar showed years ago that PRWP may be caused by AMI, left ventricular hypertrophy, type C right ventricular hypertrophy or may occur in otherwise normal subjects. Although it has been suggested by some that electrocardiographic algorithms to better discriminate AMI from other causes of PRWP are worthless, these studies are open to a number of criticisms. For instance, in the study by Gami et al, 2 Gami A.S. Holly T.A. Rosenthal J.E. Electrocardiographic poor R-wave progression: analysis of multiple criteria reveals little usefulness. Am Heart J. 2004; 148: 80-85 Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar although the positive predictive value of our criteria for AMI in patients with PRWP was low (about 16%), the numbers were extremely small (1 of 6). In addition, with >1/2 the patients being women who underwent nuclear myocardial perfusion imaging, the presence of 5 false-positive results (electrocardiography PRWP positive for AMI with negative scan) might easily be attributed to the previously reported lack of specificity of this technique in female subjects. Including anterior ischemia, moreover, as the investigators did in a further analysis, while attempting to improve sensitivity for coronary artery disease, might further reduce specificity, because a not insignificant portion of patients with nontransmural myocardial infarctions will fail to demonstrate residual myocardial ischemia after myocardial infarction. 3 Zema M.J. The Q-wave, ST-segment and T-wave myocardial infarction A useful clinical distinction. Am J Med. 1985; 78: 391-395 Abstract Full Text PDF PubMed Scopus (24) Google Scholar Furthermore, our reported results using our algorithmic approach to patients with PRWP were associated with a high negative predictive value as opposed to positive predictive value, to more effectively exclude AMI in patients with PRWP. The work of Gami et al 2 Gami A.S. Holly T.A. Rosenthal J.E. Electrocardiographic poor R-wave progression: analysis of multiple criteria reveals little usefulness. Am Heart J. 2004; 148: 80-85 Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar provides no information in this regard. Utility of the Frontal Plane QRS Axis in Identifying Non–ST-Elevation Myocardial Infarction in Patients With Poor R-Wave ProgressionAmerican Journal of CardiologyVol. 104Issue 2PreviewPoor R-wave progression (PRWP) is a common electrocardiographic phenomenon in which the anticipated increase in R-wave amplitude in successive precordial leads, V1 to V5, fails to occur. PRWP is prevalent in approximately 10% of hospitalized adult patients, predominantly in those with coronary artery disease. Debate is ongoing on its association with myocardial infarction (MI). However, studies that showed no association failed to appraise the significance of the QRS axis in relation to PRWP among such patients with MI. Full-Text PDF