title: Precordial electrode placement for optimal ECG monitoring: implications for ambulatory monitor devices and event recorders.
abstract: BACKGROUND
  Detection of QRS complexes, P-waves and atrial fibrillation f-waves in electrocardiographic (ECG) signals is critical for the correct diagnosis of arrhythmias. We aimed to find the best bipolar lead (BL) with the highest signal amplitude and shortest inter-electrode spacing.
  
  
  METHODS
  ECG signals (120 seconds) were recorded in 36 patients with 16 precordial electrodes placed in a standardized pattern. An average signal was analysed for each of 120 possible BLs obtained by calculating the difference between pairs of unipolar leads. Peak-to-peak amplitudes of QRS waves (50ms around R-peak) and P waves (270-70ms before R-peak) were calculated. For patients with atrial fibrillation, power of the fibrillatory (f) wave was used instead. Maximum values at each distance were considered and differentiation analysis was performed based on incremental changes (amplitude to distance).
  
  
  RESULTS
  There was a significant correlation between distance and QRS-amplitude (r=0.78, p<0.001), P-wave amplitude (r=0.60, p<0.01) and f-wave power (r=0.79, p<0.001). The range of values was: QRS-amplitude 0.7-2.33mV, P-wave amplitude 0.07-0.18mV, and f-wave power 0.55-2.12mV(2)/s. The maximum value for the shortest distance was on a heart-aligned axis over the left ventricle for the QRS complex (1.9mV at 8.7cm) and over the atria for the P-wave (0.98mV) and f-waves (1.45mV(2)/s at 8cm, respectively).
  
  
  CONCLUSIONS
  There is a strong positive correlation between electrode distance and ECG signal-amplitude. Distance of 8cm on a heart-aligned axis and over the relevant heart-chamber provides the highest signal amplitude for the shortest distance. These findings are essential for the design and use of ambulatory monitoring devices.
authors.affiliation: Heart Center, University of Leipzig, Department of Electrophysiology, Strümpelstr. 39, Leipzig, Germany. Electronic address: snedios@gmail.com.
authors.forename: Sotirios
authors.initials: S
authors.lastname: Nedios
authors.affiliation: Holst Centre/IMEC, High Tech Campus 31, AE, Eindhoven, Netherlands.
authors.forename: Iñaki
authors.initials: I
authors.lastname: Romero
authors.affiliation: German Heart Institute Berlin, Department of Internal Medicine and Cardiology, Augustenburgerplatz 1, Berlin, Germany.
authors.forename: Jin-Hong
authors.initials: JH
authors.lastname: Gerds-Li
authors.affiliation: German Heart Institute Berlin, Department of Internal Medicine and Cardiology, Augustenburgerplatz 1, Berlin, Germany.
authors.forename: Eckard
authors.initials: E
authors.lastname: Fleck
authors.affiliation: German Heart Institute Berlin, Department of Internal Medicine and Cardiology, Augustenburgerplatz 1, Berlin, Germany.
authors.forename: Charalampos
authors.initials: C
authors.lastname: Kriatselis
mesh_terms: D000368:Aged; D001145:Arrhythmias, Cardiac / Q000175:diagnosis* / Q000503:physiopathology; D015716:Electrocardiography, Ambulatory / Q000379:methods*; D004566:Electrodes; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018570:Risk Assessment; D012307:Risk Factors
keywords: Ambulatory; Atrial fibrillation; Electrocardiography (ECG); Patient monitoring