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Updated: Jun 29, 2026
Magnetic Resonance Derived Myocardial Strain Assessment Using Feature Tracking
Published on: February 13, 2011
Poor R-wave progression fails to detect anterior myocardial fibrosis in MESA
José Nunes de Alencar1, Paul Alejandro Salvador Morales2
1Electrocardiography Unit, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil; Research Division, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil.
Background:
Poor R-wave progression (PRWP) on the 12‑lead ECG is commonly interpreted as evidence of prior anterior myocardial injury, largely on the basis of small, biased studies from the 1970s-1980s. Whether PRWP identifies anterior-wall fibrosis on modern cardiac magnetic resonance (CMR) is unknown.
Methods:
We analyzed participants from the Multi-Ethnic Study of Atherosclerosis (MESA) Examination 5 with digital ECG and CMR. PRWP was prespecified as RV3 ≤ 3 mm with RV3 > RV2. A historical sensitivity analysis tested the Zema MI criterion (RV3 ≤ 1.5 mm or RI ≤ 4.0 mm). The strict CMR reference required ischemic and transmural scar plus either ≥2 LAD segments or LV scar burden ≥5%; the liberal CMR reference was scar in any LAD segment irrespective of transmurality or burden.
Results:
After exclusions, 2950 participants were included; PRWP was present in 163 (5.5%). CMR-defined anterior fibrosis occurred in 21 (0.7%, strict) and 57 (1.9%, liberal). With the strict reference, modern PRWP sensitivity was 0.0% (95% CI 0.0-15.6), specificity 94.4% (94.1-94.8), LR+ 0.00, and LR- 1.06. With the liberal reference, sensitivity was 5.3% (1.1-14.6), specificity 94.4% (94.1-94.8), LR+ 0.95, LR- 1.00. The Zema MI criterion performed similarly: strict-sensitivity 14%, specificity 90%, LR+ 1.48, LR- 0.95; liberal-sensitivity 11%, specificity 90%, LR+ 1.09, LR- 0.99.
Conclusions:
In a large, multiethnic community cohort, isolated PRWP did not detect anterior-wall fibrosis on CMR. PRWP should not be used as a diagnostic marker of anterior myocardial fibrosis without new, rigorously designed accuracy studies.
Insights
Poor R-wave progression (PRWP) on ECG does not reliably detect anterior myocardial fibrosis. New studies are needed to validate PRWP as a diagnostic marker for heart conditions.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Electrocardiography
Background:
- Poor R-wave progression (PRWP) on 12-lead ECG is traditionally linked to anterior myocardial injury.
- This interpretation is based on outdated, small, and potentially biased studies.
- The diagnostic accuracy of PRWP for anterior-wall fibrosis using modern Cardiac Magnetic Resonance (CMR) imaging is currently unknown.
Purpose of the Study:
- To evaluate the association between PRWP on ECG and anterior-wall fibrosis detected by CMR.
- To assess the diagnostic performance of PRWP in identifying myocardial fibrosis in a large, multiethnic cohort.
Main Methods:
- Analysis of participants from the Multi-Ethnic Study of Atherosclerosis (MESA) Examination 5, utilizing digital ECG and CMR data.
- PRWP was defined as RV3 ≤ 3 mm with RV3 > RV2.
- A historical Zema MI criterion was used for sensitivity analysis. Strict and liberal CMR references for anterior fibrosis were established.
Main Results:
- Out of 2950 participants, 5.5% exhibited PRWP.
- CMR-defined anterior fibrosis was present in 0.7% (strict) and 1.9% (liberal) of participants.
- Using the strict CMR reference, PRWP sensitivity was 0.0% and specificity was 94.4%. With the liberal reference, sensitivity was 5.3% and specificity was 94.4%.
Conclusions:
- Isolated PRWP on ECG did not demonstrate significant association with anterior-wall fibrosis identified by CMR in a large, multiethnic cohort.
- Current evidence suggests PRWP should not be used as a standalone diagnostic marker for anterior myocardial fibrosis.
- Further rigorous accuracy studies are required before PRWP can be reliably utilized for diagnosing anterior myocardial fibrosis.
