Goldberger’s Electrocardiographic Triad in Patients With Echocardiographic Severe Left Ventricular Dysfunction




In 1982, Goldberger described an electrocardiographic triad (SV 1 or SV 2 + RV 5 or RV 6 ≥3.5 mV, total QRS amplitude in each of the limb leads ≤0.8 mV, and R/S ratio <1 in lead V 4 ) that was 70% sensitive and >90% specific for detecting severe left ventricular (LV) dysfunction. To confirm his sensitivity results, in 51 consecutive patients (36 men) aged 28 to 84 years (mean 56) with LV ejection fractions ≤20%, the electrocardiographic triad was sought in the electrocardiogram (ECG) recorded closest in time to the echocardiographic study. All 51 patients had systemic arterial hypertension. Evidence of ischemia was present in 7 and absent in 38, and in 6 patients, ischemic status was unknown. In 49 patients, New York Heart Association functional class was available: class II in 8, class III in 32, and class IV in 9. LV ejection fractions ranged from 4% to 20% (mean 14%), and LV internal end-diastolic diameters ranged from 5.7 to 8.6 cm (mean 6.6). Left atrial anteroposterior diameters ranged from 2.9 to 6.1 cm (mean 4.7) and were ≥4.0 cm in 47 of the 51 patients. The right ventricular cavity was enlarged in 22 patients. SV 1 or SV 2 + RV 5 or RV 6 was ≥3.5 mV in 29 of the 51 ECGs; total QRS amplitude was ≤0.8 mV in each of leads I, II, and III in 10; and the R/S ratio was <1 in lead V 4 in 37. Only 1 of the 51 ECGs met all 3 criteria. In contrast to Goldberger’s finding of the triad to be 70% sensitive for severe LV dysfunction, in this study, the triad was found to be only 2% sensitive. The difference is likely due to his patients’ having idiopathic dilated cardiomyopathy, whereas those in this study had hypertensive cardiomyopathy with or without ischemia. Also, in this study, 1 specific ECG was used for each patient, whereas Goldberger reviewed all of the patients’ ECGs looking for the triad. In conclusion, Goldberger’s triad is a sensitive or insensitive marker for severe LV dysfunction depending on the patient population and the number of ECGs reviewed.


Thirty years ago Goldberger described an electrocardiographic triad (SV 1 or SV 2 + RV 5 or RV 6 ≥3.5 mV, total QRS amplitude ≤0.8 mV in each of the extremity leads, and R/S ratio <1 in lead V 4 ) with high specificity and sensitivity for severe left ventricular (LV) dysfunction. The triad appeared to be have positive predictive value >90% and specificity >90% for severe LV dysfunction in controls and patients with a wide variety of cardiac diseases. The sensitivity of 70%, however, was determined solely in a group of patients with idiopathic dilated cardiomyopathy. This study was undertaken to assess the sensitivity of the triad in a different group of patients. Although currently echocardiography is the prime tool for assessing LV function, the less expensive electrocardiographic study, if it has high sensitivity and specificity for detecting LV dysfunction, can help guide the use of echocardiography.


Methods


In 51 consecutive patients (36 men) aged 28 to 84 years (mean 56) with LV ejection fractions (LVEFs) ≤20%, Goldberger’s ECG triad (SV 1 or SV 2 + RV 5 or RV 6 ≥3.5 mV; total QRS amplitude in each of leads I, II, and III ≤0.8 mV; and R/S ratio < 1 in lead V 4 ) was sought in the electrocardiogram (ECG) recorded closest in time to the echocardiographic study. Our not using all 6 extremity leads for the second criterion, as Goldberger did, would, if anything, tend to increase the sensitivity of the triad.


Echocardiographic measurements and calculations were made according to the recommendations of the American Society of Echocardiography. Specifically, LV relative wall thickness (RWT) was calculated as 2 × LV diastolic posterior wall thickness (WT)/LV diastolic internal diameter, and LV mass was calculated as 0.8 × {1.04[(LV diastolic internal diameter + diastolic posterior WT + diastolic septal WT) − (LV diastolic internal diameter) ]} + 0.6 g.


All 51 patients had diagnoses of systemic arterial hypertension, and 17 had diabetes mellitus. In 49 patients, New York Heart Association functional class was available: class II in 8, class III in 32, and class IV in 9. All 51 patients were being treated for cardiovascular disease. Evidence of ischemia was present in 7 patients and absent in 38, and ischemic status was unknown in 6.




Results


LVEFs ranged from 4% to 20% (mean 14%), and LV internal diameters in diastole ranged from 5.7 to 8.6 cm (mean 6.6) and were higher than the reference ranges (3.9 to 5.3 cm for women and 4.2 to 5.9 cm for men) in all 15 women and 32 of the 36 men. Diastolic LV posterior WTs ranged from 0.7 to 2.2 cm (mean 1.12), and diastolic ventricular septal WTs ranged from 0.5 to 1.9 cm (mean 1.10). Compared to reference ranges for gender (0.6 to 0.9 cm for women and 0.6 to 1.0 cm for men), LV posterior WTs were normal in 19 patients and higher than normal in 32, and septal WTs were lower than normal in 1 patient, normal in 13, and higher than normal in 37. RWTs ranged from 0.20 to 0.75 (mean 0.34). Compared to reference ranges for gender (0.22 to 0.42 for women and 0.24 to 0.42 for men), RWTs were normal in 42 patients, low in 3, and high in 6. LV mass indexed to body surface area ranged from 82.5 to 339.5 g/m 2 (mean 178.3). Compared to reference ranges for gender (43 to 95 g/m 2 for women and 49 to 115 g/m 2 for men), LV mass index was normal in 3 patients and elevated in 48, severely so in 35 of these. A comparison of RWT with LV mass index categorized the geometry of the left ventricle as normal in 3 patients, concentric hypertrophy in 6, and eccentric hypertrophy in 42. Left atrial anteroposterior diameters ranged from 2.9 to 6.1 cm (mean 4.7), and were ≥4.0 cm in 47 of the 51 patients. The right ventricular cavity was enlarged in 22 patients.


In 29 of the 51 ECGs, SV 1 or SV 2 + RV 5 or RV 6 was ≥3.5 mV; total QRS amplitude was ≤0.8 mV in each of leads I, II, and III in 10 studies; and the R/S ratio was <1 in lead V 4 in 37 studies ( Figures 1 to 3 ) . Only 1 of the 51 ECGs met all 3 of Goldberger’s criteria ( Figure 1 ). Complete left bundle branch block was present in 10 of the 51 patients, incomplete left bundle branch block in 2, and nonspecific intraventricular conduction defects in 2.




Figure 1


ECG from a 62-year-old man with an LVEF of 4%, an LV internal diameter in diastole of 6.6 cm, and septal and posterior WTs in diastole of 1.1 cm. This patient was the only 1 of our 51 patients to meet all 3 of Goldberger’s criteria in the ECG recorded closest temporally to the echocardiographic study. The average S wave in lead V 2 (1.6 mV) plus the average R wave in V 6 (2.0 mV) equaled 3.6 mV. The total QRS voltage in each of leads I, II, and III was <0.8 mV. The R/S ratio in lead V 4 was <1. Other findings were sinus tachycardia, left atrial enlargement (left atrial anterior-posterior diameter on echocardiography 5.2 cm), and repolarization changes of LV enlargement. Our earliest ECG in this patient was recorded 7 years before this one and showed striking voltage criteria for LV hypertrophy (SV 2 + RV 5 = 8.2 mV), with no other abnormality. Two ECGs recorded <6 months before the ECG shown here had 1 ( Figure 2 ) and 2 ( Figure 3 ) of Goldberger’s criteria, respectively, pointing out how data will differ depending on how many ECGs are examined.



Figure 2


An ECG, recorded 6 months earlier in the same patient whose tracing is shown in Figure 1 , meets only 1 of Goldberger’s criteria (R/S ratio <1 in lead V 4 ). In addition, sinus tachycardia and changes of biatrial and LV (Cornell) enlargement can be seen.

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Dec 15, 2016 | Posted by in CARDIOLOGY | Comments Off on Goldberger’s Electrocardiographic Triad in Patients With Echocardiographic Severe Left Ventricular Dysfunction

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