Precordial low voltage in patients with ascites

Electrocardiographic (ECG) changes in patients with ascites are not well studied. The aim of this study was to evaluate ECG changes in patients with ascites.

Prospective analysis of patients with ascites who were referred for paracentesis. Three ECGs were recorded before paracentesis. ECG 1 was a standard 12-lead ECG. For ECG 2 the precordial leads were placed 1 intercostal space (ICS) and for ECG 3, 2 ICS cranially. The sums (Sigma) of the QRS in ECG1 were compared with ECG 2 and 3. In six patients the same ECG protocol was performed after removal of ascites. Ten hospitalized patients without ascites served as controls. Twenty patients with ascites were analysed. Limbs leads low voltage was present in 11 patients and precordial low voltage in four patients. Cranial placement of the precordial electrodes increased SigmaQRS in all patients with ascites. The most prominent voltage changes appeared in the leads V4-V6 (+62%). Paracentesis of ascites normalized precordial leads low-voltage, while limbs leads low voltage remained. Cranial placement of the precordial electrodes in patients without ascites decreases SigmaV1-V6.

We describe a phenomenon of precordial voltage changes in patients with ascites, not reported in the literature yet. By placing the precordial electrodes 1 and 2 ICS cranially the voltage changes can be 'corrected' and this should be done in all patients prior to further diagnostic workup. Removal of the ascites normalizes the precordial leads low voltage.