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Failure of right precordial electrocardiography during stress testing to identify coronary artery disease
S Bokhari1, D K Blood, S R Bergmann
1Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
Insights
Right precordial leads are not as accurate as standard ECG for detecting coronary artery disease (CAD). This study found right precordial leads showed minimal diagnostic value compared to left-sided ECG and myocardial perfusion imaging in CAD detection.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Electrocardiography
Background:
- Previous reports suggested right precordial leads offer diagnostic accuracy comparable to thallium-201 exercise scintigraphy for coronary artery disease (CAD).
- This study aimed to re-evaluate the diagnostic utility of right precordial leads in detecting CAD.
Purpose of the Study:
- To evaluate the effectiveness of right precordial leads in diagnosing coronary artery disease (CAD).
- To compare the diagnostic accuracy of right precordial leads with standard left-sided electrocardiography and myocardial perfusion imaging.
Main Methods:
- 900 patients undergoing stress testing (exercise or pharmacologic) with electrocardiography (ECG) using 12 limb, left precordial, and 3 right precordial leads (V(3)R, V(4)R, V(5)R).
- ECG was analyzed for ST segment changes; results were correlated with myocardial perfusion imaging (MPI).
- Positive ECG was defined as ST segment elevation or depression ≥ 0.1 mV at 80 ms post-J point.
Main Results:
- Only 4 out of 900 patients showed positive changes in right precordial leads, compared to 158 in left-sided leads (P <.001).
- Of patients with positive ECG changes, 91 had normal right precordial leads.
- All 4 patients with positive right precordial leads also had positive left leads; 41% of patients had abnormal MPI scans without ECG evidence of ischemia.
Conclusions:
- The use of right precordial leads during stress testing does not provide diagnostic accuracy equivalent to standard left-sided electrocardiography.
- Right precordial leads are not a reliable tool for detecting coronary artery disease (CAD) when compared to established methods.
Background:
It has been reported that the use of right precordial leads results in the same diagnostic accuracy as thallium-201 exercise scintigraphy for the detection of coronary artery disease (CAD). The aim of this study was to evaluate the utility of right precordial leads in the detection of CAD.
Methods And Results:
We evaluated 900 consecutive patients (514 men, 386 women) ranging in age from 39 to 84 years (mean +/- SD, 64 +/- 11 years). Seven hundred forty patients underwent treadmill exercise testing, and 160 underwent pharmacologic stress testing for the diagnosis of chest pain or dyspnea. All received either Tl-201 or technetium-99m sestamibi during stress. During stress testing, the ECG was recorded every minute with 12 limb and left precordial leads and 3 right precordial leads (V(3)R, V(4)R, and V(5)R). The electrocardiogram was considered positive when the ST segment was either elevated or depressed by at least 0.1 mV at 80 ms after the J point, and results were also compared with single photon emission computed tomography myocardial perfusion imaging results. Of the 900 patients, 158 had significant positive changes in the limb or left precordial leads. Only 4 patients had positive changes in the right precordial leads (Fisher exact test, P <.001). Of the patients who had positive electrocardiographic changes, 95 (60%) had abnormal myocardial perfusion scans, with 91 in patients with normal right precordial leads. All 4 patients with ischemic changes in the right precordial leads had abnormal scans, but the left leads were also positive. Three hundred seventy-three of 900 patients (41%) had abnormal scans with no electrocardiographic evidence of ischemia.
Conclusions:
Our experience is far different than that published and suggests that the use of right precordial leads during stress testing fails to provide the same diagnostic accuracy as either the standard left-sided electrocardiography or myocardial perfusion imaging for the detection of CAD.