effusion. Low electrocardiographic voltage in pericardial

Low electrocardiographic voltage in pericardial effusion. R Parameswaran, A R Maniet, S E Goldberg and H Goldberg Chest 1984;85;631-634 DOI 10.1378/chest.85.5.631 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/85/5/631

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Low Electrocardiographic Pericardial Effusion* R. Parameswaran, Steven E. Goldberg,

M.D.;t M.D.;

Although low ECC voltage dial effusion, its diagnostic

Alan and

Voltage in

R. Maniet, D.O.; Harry Goldberg,

has been

pericar-

with

associated

usefulness

in such

M.D.,

of

the

standard

leads

(absolute

low

voltage).

is

There

was no significant correlation between the volume of the effusion and the QRS amplitude (r = -0.30). This correlation did not improve (r = -0.37) when patients with left

ow

ECG

voltage

dial insulating ever,

has

been

effusion and effect of the

has fluid

the relationship

of the

effusion

with

with

and

its diagnostic effusion

In a recent the volume

have

to the How-

to the volume

F 60mm

however,

We have

recently

be unreliable.3

underestimate

may

the

volume

both

shown

overestimate

of effusion

mV)

and

substantially.4

coexisting left ventricular hypertrophy (LVH) affect the QRS voltage in patients with pencardial We

effusion.

relationship

undertook

this

measured

during

surgical

by calculation of the mode echocardiograms.

drainage. left

Patients

who

diagnosis

Electrocardiograms corded

within

6From

the

several Cardiology

from

M-

failure, with block

M-mode

days

prior

Section,

idiopathic

recent

and

review. or

were

effusion

The

clinical

pericarditis,

and

remote

myocardial

excluded.

echocardiograms to

Albert

and

York and Tabor Roads,

following

Einstein

Philadelphia

of QRS in each

standard

the

surgery. Medical

19141

definitions six standard

in the

F 30 mm

precordial of the

coexisting

LVII

voltage

standard

to or modified

amplitudes

leads

leads,

or (3) QRS

standard

leads

may

influence

criteria

may

F 30 mm

in the

standard

amplitude

(absolute the

be

(3 mV),

and

leads, of 5 mm

low

(0.5

voltage).’

QRS

voltage

obscured

by

and

since

pericardial

we calculated the left ventricular mass to identify LVH using the standard M-mode convention.6 A mass greater than 203 g in men and 141 g in women was considered to represent LVH.7 Pericardial drainage was performed using a subxiphoid approach. The volume of effusion was measured and the pericardial cavity

explored to determine present. The pencardial Correlation was tested tivity,

specificity,

false

by conventional

whether adhesions or loculations thickness was also noted. using linear regression techniques. positives,

false

negatives

were

Sensidefined

RESULTS

Technically

adequate ECGs and echocardiograms in 28 patients who underwent pericar-

available

(Table 1). There were ages ranging between

(mean 51.6). The interval ECG and the pericardial several hours to ten days, Postoperative ECGs were patients.

Except

The

recorded

three

Center,

and

were

terminology.

re-

were

Philadelphia. tAssociate Professor of Medicine, Temple University School of Medicine. lProfessor of Medicine, Temple University School of Medicine. Manuscript received July 13; revision accepted December 14. Reprint requests: Dr Parameswaran, Albert Einstein Medical

Center,

or less

Since

similar

amplitudes

dial drainage women, with

for

in

from the peak of the and the precordial from those of previous for low voltage: (1) the

measured

in the

the following

used

in the

was

S wave

detected

of pericardial

chosen

renal

Patients

or left bundle branch

infarction

was mass

drainage

were

chronic

disease.

LVH

METHODS

surgical

therapy

included

malignant

the

and pericardial of effusion was

ventricular

AND

underwent or

examine

sum

were

PATIENTS

diagnosis

to

between the QRS voltage in patients in whom the volume

effusion

for

study

Following

increased

effusion,

Further, may

excluded.

amplitude

complex

of the

criteria

we

of QRS

QRS

nadir

Using

adequately was shown voltage.’ effusion,

to the

studies,’

not

and the QRS of pericardial

may

leads. sum

as esti-

of the

R wave

(2) the

been

were

QRS

the

study.

in patients

study, no correlation of pericardial effusion

echocardiography

drainage,

usefulness

mated by echocardiography Echocardiographic estimates that

pericar21 of 24 patients and decreased in three. Low voltage persisted in nine patients; the pericardium was thickened in seven of the nine. Analysis of the sensitivity and specificity revealed acceptable sensitivity only with large effusions and no left ventricular hypertrophy. Absolute low voltage appeared to be specific in the diagnosis of moderate and large effusions among patients with pericardial effusion selected for this dial

amplitude

pericar-

attributed the heart.’

of this abnormality

pericardial

evaluated. between

associated been around

hypertrophy

ventricular

patients

unclear. When we examined the relationship between the volume of pericardial effusion and low voltage in 28 patients who underwent pericardial drainage, 14 patients exhibited low voltage (sum of limb lead QRS amplitudes of 30 mm or less). In eight patients, the QRS amplitude was 5mm or less in each

F.C.C.P4

mean interval the pericardial Among

the

for weeks

between the preoperative drainage ranged between with a mean of 2.75 days. available in 24 of the 28 patients in whom it was

two and

between drainage 25 patients

12 men and 16 23 and 79 years

three

the was

months

postoperative 1.95 days.

in whom

later,

the

ECG

and

preoperative

chest

roentgenograms were available, 13 had small or moderate left or bilateral pleural effusions. The volume of pericardial

effusion

ranged

between CHEST


100 and 2,000 / 85 / 5 I MAY,

1984

ml. 631

Table

,_

Patient Age,

Li mb

(yr.)

.

Sex

Preop

Postop

and

ECG

Voltage,

Pre cordial

Leads

,-

Leads .

ECG,

1-Clinical,

Data

Echocardiographic mm

Pericardium .

.

Preop

Postop

Effusion,

ml

1/24/M

34.5

47.0

101.25

102.5

750

2171/F 3/64/F

12.75 26.0

19.75 26.5

52.50

87.0

1,140

35.75

31.0

700

4/58/M

21.75

20.0

53.50

51.75

5/72/F

49.75

62.25

86.5

65.00

6/57/M

41.25

53.00

99.75

106.50

7/48/F

19.5

22.00

65.50

55.50

8/37/M

20.00

51.50

85.75

9/58/M

Thickness

1,000

LV Mass,

Thick

132.90

Thick Normal

176.93

Thick

127.52

149.26

200 800

Normal

95.09

Normal

261.41

240

Thick

83.77

1,000

Thick

82.43

42.25

52.25 59.25

122.00

154.00

NA5

284.52

10/57/F

26.50

29.75

61.50

60.50

750

Thick

158.24

11/47/M

33.5 63.25 35.25

148.25

129.50

300

Thick

193.55

112.00

118.00 74.50

700

Thick

231.79 92.01

120.5

Normal

228.01

117.00

114.50

147.50

300 450 200

Normal

NA

15/71/F

39.25 52.00 26.50 59.00 83.00

Normal

193.54

16/29/M

65.50

57.50

103.50

117.00

250

Thick

204.10

17/58/F

23.00

NA

NA

18/50/M 19/79/F 20/55/M 21/47/M 22/62/F 23/59/M 24/26/F 25/41/F

16.25 40.50

19.00 65.50

260 1,200 400

13.50

15.50

43.50

63.25

26.25

NA

29.25

36.00 57.80 22.50

12160/F 13/27/M

14/33/F

27/23/F

37.25 17.75 33.75 71.00

28/54/F

9.00

26/78/F

*NA

=

not

51.75

NA

59.00 65.25 67.50 38.75 64.50 64.00

72.00 77.25 33.50 90.00 NA

81.50

76.00 54.50

500 2,000

73.00

700

Thick

107.00

77.25

100

Thick

127.51

49.25

700

NA

230.32

113.50

165.25

143.50

NA

750

520 1,200

46.00

28.75

900

90.62 128.70 122.36 132.84

Normal

159.25

Thick

178.19

Thick

99.32

available.

six patients the effusion was small (less than 300 ml), in six moderate (300 to 600 ml), and in the remaining 16 large (700 to 2,000 ml). The pericardium was thickened in 18 patients and normal in eight. In two patients no data were available 90

n28 ,‘-030

O-NoLVH A-LVH

L.-mcs

A

pe,,can,om

-

A

70

#{163} 60-

C C

#{163} o

50

124.76 236.65

NA

In

80

Normal

Thick Thick Thick Thick Thick

43.5 14.00

1,200

g

‘U

A 4Q.

.

A

LVH

#{149}

A

A

were

relationship

30-

#{149} A

excluded

from

between

the

analysis volume

precordial lead voltage was even The lowest QRS voltages appeared with pencardial thickening.

A

0

20-

with regard to pencardial thickness. No patient had loculation of pericardial fluid. The volume of effusion tended to be larger (mean 771 ml) in patients with pericardial thickening than in those without (mean 328 ml). LVH was present in 13 of the 28 patients. Fourteen patients fulfilled the simple standard lead criteria for low voltage. Only nine patients exhibited low voltage when both the standard and precordial lead amplitudes were required fur the diagnosis. Absolute low voltage’ was present in eight patients. The relationship between the volume of effusion and the QRS voltage is shown in Figure 1. There was a weak correlation between the standard lead voltage and the volume of effusion (r = -0.30). This correlation did not improve significantly when patients with

A

(r

=

The

-0.37).

of effusion

poorer

and

(r

to be

=

-

the

0.13).

associated

A

to

-

0

Effects 200

I

I

400

600

PERICANDSAL

FIGURE

and

632

the

1. Relationship sum of QRS

I

800

000

EFFUSION

ml

between amplitudes

the volume in the limb

I 200

I

I400

of pericardial leads.

I 1600

200

effusion

of Pericardial

Drainage

The effects of pencardial drainage on the QRS voltage are shown in Figure 2. Among the 24 patients in whom a postoperative ECG was available, the QRS amplitude increased in 21 and decreased in three. Low ECG bItage

in POIlCardial


Effusion

(Parameswaran

et at)

24 40

]

&LVH

-

LVH

0-No #{149} ,A-Thic*

30

specificity

was

with

improved

LVH

decreased

the

A A I

-/0

800

/600

/200

2000

have been diographic

-

effects -20

The highest low voltage5

in a

was

a de-

increase in were applied

specificities were noted was used as the criterion.

-

-40

related estimates

of

LVH

to

on

the unreliability of of pericardial effusion

the

QRS

tempted to overcome these the volume of pericardial

-

-30

-

2. Change in the drainage of pericardial

voltage

persisted

fulfilled

the

limb

did not appear pleural effusion. nine

resulted

there

have been uncertain as to the correlation between finding and the size of the pericardial effusion.8 lack of correlation between low voltage and the ume of pericardial effusion in a recent study’

IPE.mI

400

Low

but

expected,

Although low voltage may result from a number causes, it has been noted to the be the most consistent ECG abnormality in pencardial effusion. Clinicians

-

.

had

of patients

DiscUsSioN

/0

FIGURE

sensitivity,

As

20

following

Exclusion

sensitivity and a significant when more rigid criteria

for low voltage. when absolute

E

higher.

specificity.

crease in the the specificity

Pericardium]

-

somewhat

QRS

amplitude

in

in nine lead

of the

criteria

exceeded

limb

14 patients

preoperatively

to be related to The mean volume

patients

the

800 ml.

Although voltage was

present in 14 of the 28 only weakly correlated with

effusion

(Fig

1). Nine

effusions

had

LVH.

who

tween

and

but not the

In the

the presence of a of effusion in these

not appear (Table 2).

Further,

patients

of

volume study

to have Sensitivity with

of the

large

study

at-

patients, the volume

16 patients

of these

exhibited

with

low of large

low

volt-

Thus, in our study group, influence the relationship

of effusion

group

echocarand the

LVH.

Five

four did not. significantly

this The volmay

by measuring directly and by

patients

age, did

seven

limitations effusion

Our

identifying

leads

fluid,

with

voltage.

of

and

as a whole,

the low

QRS QRS

LVH be-

voltage. voltage

did

significant diagnostic usefulness and specificity improved when effusions

were

considered.

In

these nine patients exhibited pericardial thickening. It was of interest that pericardial thickening was also noted in the three patients in whom the QRS ampli-

patients with large effusions and without tivity was acceptable. High specificities when rigid criteria were applied.

tude decreased following pericardial drainage. The sensitivity and the specificity of low QRS voltage is shown in Table 2. Using the simple limb lead criteria, the overall sensitivity was low, but the

The genesis of low voltage in pencardial elhision has been traditionally attributed to the insulating effects of the pericardial fluid. The observation that low voltage may occur in other clinical situations’#{176}

Table

2-Sensitivity

and

Specificity

of QRS

Voltage Pericardial

300 for Low

Criteria Sum

of limb

Voltage

lead

QRS

30

mm

amplitudes

All patients Without Sum

LVH

of QRS

30

amplitudes

mm

in

Sensitivity,

%

in Pericardial Effusion

700 %

sensinoted

Effusion

ml Specificity,

LVH, were

Sensitivity,

%

ml Specificity.

54.54

66.66

63.60

50.00

68.75 85.70

75.00 62.50

39.00

80.00

43.75

83.30

31.80

83.3

43.70

91.66

%

limb

leads

and

60

mm

precordial QRS

amplitude

in each (absolute

in

leads 5

limb low

mm

lead voltage)

CHEST/85/5/MAY,


1984

633

suggests

that

other

Although

our

study

the frequency ders, ECG permit patients crease fluid,

factors

of low changes

certain with

may

could

not

voltage following

speculations pericardial

also

test

be

the

in various drainage

following between

minant

of the

tween of the

First,

there

was

the increase in the QRS fluid removed. Second,

following

drainage.

creased

in

pericardium of patients

patients.

That the only deter-

no relationship

the It

QRS is

notable

was thickened in a substantial who failed to show an increase following

suggest tributed

that to made

pericardial

a thickened low voltage. by others

drainage. pericardium Similar

in the

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Heart

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proportion in the QRS These

Braunwald 1524

be-

voltage

authors gratefully acknowledge the Rabin and Bonnie Swink in performing Yankowitz in the preparation of the

manuscript.

by a number

voltage and the volume low voltage persisted

Finally,

three

voltage

been

is suggested

The of Carole of Harriet

in in-

drainage of the the presence

and the decreased QRS amplitude. of pericardial effusion was not the voltage

ACKNOWLEDGMENT: technical assistance the studies and

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of fluid volume

of observations.

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Low ECG

Voftage

In Pericardlal


EffUSIOn

(Parameswaran

stat)

Low electrocardiographic voltage in pericardial effusion. R Parameswaran, A R Maniet, S E Goldberg and H Goldberg Chest 1984;85; 631-634 DOI 10.1378/chest.85.5.631 This information is current as of July 12, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/85/5/631 Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
