Electrocardiographic poor R-wave progression: analysis of multiple criteria reveals little usefulness

Poor or reverse R-wave progression (PRWP) is a common statement on electrocardiogram (ECG) interpretations, but its value in diagnosing anterior myocardial infarction (MI) is disputed. We assessed the accuracy of PRWP criteria in diagnosing anterior MI.

We searched MEDLINE (1960-1998) and found 3 criteria for PRWP. We included a modified version of the Marquette Muse system's criteria and multiple novel criteria. We interpreted resting ECGs of consecutive patients undergoing pharmacologic stress tests with dual isotope gated single photon emission computed tomography. Subjects with Q-wave anterior MI, bundle branch block, or Wolf-Parkinson-White syndrome were excluded. We established whether patients met the PRWP criteria. A nuclear cardiologist blinded to PRWP classifications reviewed the scintigrams. Chi2 methods were used for statistical analysis.

Inclusion criteria were met by 122 subjects. The standard PRWP criteria were met in 15% to 42% of ECGs. Of subjects meeting PRWP criteria, 2% to 9% had anterior MI and 27% to 33% had anterior MI or ischemia. These proportions were similar to those expected by chance. The performance of PRWP criteria did not improve when subjects with electrocardiographic left ventricular hypertrophy were excluded or when more stringent criteria for right precordial R-wave amplitude were tested.

In our study of patients undergoing cardiac stress tests, only a small percentage of patients who met various criteria for PRWP (a proportion no different than would be expected by chance) had anterior MI. Conclusions about the presence of anterior MI solely on the basis of PRWP have little usefulness.