title: Electrocardiographic associations of right precordial Q waves help to distinguish anterior myocardial infarction from aortic stenosis.
abstract: Right precordial Q waves are ECG evidence of anterior myocardial infarction and can be present in patients with pathological left ventricular hypertrophy particularly caused by aortic stenosis. The aim of this study was to investigate the ECG features associated with Q waves in aortic stenosis and those in anterior myocardial infarction. We studied 16 patients with anterior myocardial infarction and 19 patients with aortic stenosis by means of ECG, echocardiography and clinical history. On the ECG, heart rate (70 +/- 20 beats/min vs. 83 +/- 20) and QT interval (380 +/- 65 ms vs. 390 +/- 50) did not differ between the two conditions. PR interval (160 +/- 15 ms vs. 185 +/- 30, P<0.05) and QRS duration (80 +/- 7.0 ms vs. 95 +/- 15, P<0.01) were both longer in patients with aortic stenosis than in those with myocardial infarction. The Q wave voltage in V1 (1.0 +/- 0.55 mV vs. 1.5 +/- 0.60) or V2 (1.3 +/- 0.5 mV vs. 1.8 +/- 0.85) and R wave voltage in V5 (0.7 +/- 0.7 mV vs. 2.1 +/- 0.9) or V6 (0.7 +/- 0.4 mV vs. 1.5 +/- 0.7, all P<0.01) were significantly less in patients with anterior myocardial infarction than in those with aortic stenosis. Q wave voltage over 1.3 mV in V1 or R wave voltage over 1.5 mV in V5 can differentiate aortic stenosis from anterior myocardial infarction with a sensitivity of 79% for each and specificities of 81 and 93.8%, respectively. Though the frontal QRS axis was similar in the two groups (28 +/- 45 degrees vs. 14 +/- 35, P>0.05), the horizontal QRS axis pointed laterally (-30 +/- 20 degrees) in aortic stenosis and posteriorly (-60 +/- 20 degrees, P<0.01) in anterior myocardial infarction. A horizontal QRS axis between zero and -45 degrees detected the presence of aortic stenosis with a sensitivity of 94.7% and a specificity of 81.3%. On echocardiography, left ventricular hypertrophy was found in most patients (94.7%) with aortic stenosis but not in those (0%) with anterior myocardial infarction. Left ventricular end diastolic dimensions (5.1 +/- 0.7 cm vs. 5.1 +/- 0.9, P>0.05) were similar in the two groups but the end systolic dimension was increased in patients with aortic stenosis (4.0 +/- 0.9 cm vs. 3.4 +/- 0.6, P<0.05). The systolic left ventricular function (shortening fraction: 23 +/- 8.0% vs. 34 +/- 7.0; Vcf: 0.8 +/- 0.26 circ/s vs. 1.3 +/- 0.26, both P<0.01) was significantly impaired in patients with aortic stenosis compared to those with myocardial infarction. In conclusion, in the presence of right precordial Q waves, the simple 12-lead ECG can provide important information on distinguishing anterior myocardial infarction from aortic stenosis. In particular, the QRS voltage in the chest leads and horizontal QRS axis can differentiate anterior myocardial infarction from aortic stenosis with high sensitivity and specificity.
authors.affiliation: Cardiology Unit, Central Middlesex Hospital, Acton Lane, London NW10 7NS, UK. hanbinxiao@hotmail.com
authors.forename: Han B
authors.initials: HB
authors.lastname: Xiao
authors.forename: Ihab S
authors.initials: IS
authors.lastname: Ramzy
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Bowker
authors.forename: Mark
authors.initials: M
authors.lastname: Dancy
mesh_terms: D000368:Aged; D001024:Aortic Valve Stenosis / Q000175:diagnosis* / Q000503:physiopathology; D003937:Diagnosis, Differential; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000503:physiopathology