The Diagnostic Utility of Precordial R Wave Progression in theClinical Electrocardiograms of Male Subjects

Poor R wave progression is used as an interpretative term in clinical electrocardiography to infer that the precordial R wave voltage is abnormal, most often secondary to previous ischemic damage. Specific definition and predictive value of the term are, however, lacking for most clinical settings. We developed several definitions of poor R wave progression from V(1) to V(6) peak R wave measurements in 50 normal subjects and evaluated them as screening criteria for left ventricular asynergy and history of infarction in a consecutive series of 50 male patients undergoing invasive cardiac investigation, principally for chest pain. In normals, peak R values and adjacent interlead differences tended to be greater in males; on average, however, there was a progressive increase from V(1) to V(4) and a progressive decrease from V(4) to V(6) in both males and females. All normals had a positive delta V(1) V(2), but 9 had negative delta V(2) V(3) and 2 others, negative delta V(3) V(4). Based on the normal distributions, the test criteria of poor R wave progression were selected to avoid oversensitivity and to encompass both adjacent lead and panprecordial R wave progression. Positive tests were defined as delta; (1) V(1) V(2) ≤ s 0; (2) V(1) V(2) ≤ normal male mean -1 SD; (3) V(3) V(4) ≤ 0; (4) V(3) V(4) ≤ normal male mean -1 SD; (5) V(1) V(4) ≤ normal male mean 1 SD; (6) V(1) V(4) ≤ normal male mean -2 SD. Overall, the defined R wave criteria were insensitive and had poor negative predictive value for wall asynergy and infarction history. However, delta R V(1) V(2) ≤ 0 and delta R V(3) V(4) ≤ 0 were ≥ 70% positively predictive for these standard clinical variables. In comparison, abnormal Q waves in any lead were 94% predictive for the presence of both variables, although they, too, were relatively insensitive (47% for asynergy; 64% for history of infarction) and had low negative predictive values. Thus, although no single 12-lead electrocardiographic criterion appears ideal as a screening test for ischemic left ventricular injury in male cardiac patients, abnormal Q waves have very high predictive value. With the exception of delta R V(1) V(2) ≤ 0 or delta R V(3) V(4) ≤ 0, the term ‘poor R wave progression’ is unwarranted for routine clinical use.

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