Of recent years there has been a good deal of controversy on the significance of the low-voltage electrocardiogram. Some authorities consider that such tracings indicate changes in the heart muscle, whilst others deny that their occurrence is of any special significance. Review of the, Literature The literature on the subject is not large. Almost vvithout exception, tracings showing low-voltage changes in all three leads have alone been considered. Sprague and White1 analysed fifty-seven cases, all curves having an excursion of not more than 5 mm. either side of the base-line. They found that the arteriosclerotic group Was the commonest (thirty-four cases), ten of these having definite occlusion of the % coronary arteries. Ten cases belonged to the hypothyroid group. The remaining thirteen included three cases in which syphilitic infection had been a~ marked feature. Finally, it was definitely stated that low-voltage curves were not found with normal hearts. Willius and Killins2 examined a large number of electro cardiograms, taking the same standard as above. They found low-voltage curves occurring in only 0.3 per of all cases, but those showing associated graphic changes were excluded. Of the 140 cases ultimately studied, 32 per cent, had cardiac disease as the predominant feature. Of the remaining 68 per cent., the largest number occurred in patients with either diabetes or chronic nephritis. Burnett and Piltz3 comment on the acceptance of a 5-mm. deflection as a standard for low-voltage curves, and suggest that excursions of a somewhat greater ampli tude should be included in this category. They con sider a number of cases that show deflections up to 8 mm., stating., however, that the smaller the excursion the greater its significance, especially in leads I and II. They conclude that the occurrence of low-voltage curves, even in the absence of demonstrable cardiac changes, may be considered as extremely suggestive of cardiac disease. Speckman and Rich4 record a study of fifty cases, forty-nine of which showed clinical evidence of heart disease. The standard adopted was that the total deflec tion of the QRS complex did not exceed 5 mm. in any of the three leads. They state that the occurrence of such low-voltage changes is of serious prognostic import. Arteriosclerosis, with or without hypertension, was the chief aetiological factor. The total deaths recorded were thirty-six. Thirty-two of these patients died within six months of the time the first electrocardiogram showing low voltage changes had been taken. Post-mortem examina tions were performed on fourteen of the cases ; ten of these showed some degree of sclerosis in the coronary arteries. On microscopical examination an abnormal myocardium was discovered in every case, some degree of fibrosis being the most usual finding. Criteria of Present Investigation Our work was undertaken in an attempt to determine two factors : (a) whether a low-voltage curve has any clinical significance, and (?>) whether this significance (i; existing) varies in any way according to the lead in whiciy it occurs. All electrocardiograms examined were taken with stan dard instruments supplied by the Cambridge Scientific Instrument Company, Ltd. ; immersion electrodes were used, except in the case of a few bed-ridden patients, where Kohn electrodes were substituted. The standard usually accepted for a low-vol tage electro cardiogram is an excursion of not more than 5 mm. eithei side of the base line. There appears to be, however, an obvious objection to such a standard. For example., an electrocardiogram showing an R wave 4 mm. high and an S wave 4 mm. in depth, would fall into this category, whereas one having an R wave 6 mm. in height and no S wave would not, although it seems reasonable to con sider that the.latter tracing belongs more correctly to the low-voltage variety :than the former. After consideration, it was agreed to include only such cases as showed 7 mm. or less between the top of the R wave and the bottom of the S wave. Should the tracing show only one of these waves, its height or depth must be 7 mm. or less. Type of Case The cases examined fall into two main categories: (1) those in which electrocardiograms show low-vol tage tracings in leads I or II (or both) ; and (2) those in which el ctrocardiograms show definite low-voltage tracings in all leads. It was found that over 10 per cent, of electro cardiograms show low-vol tage curyes in lead III. It is obvious, therefore, that this condition is quite common, and cannot be considered abnormal. The other two classes of case will now be considered separately.
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