Tan Tock Seng Hospital1
Goldberger described an electrocardiographic triad (SV1 or SV2 + RV5 or RV6≥3.5mV, total QRS amplitude in limb leads≤0.8mV, and R/S ratio<1 in lead V4) that was 70% sensitive and >90% specific for detecting severe left ventricular (LV) dysfunction. Pathophysiology of this triad probably relates to mechanical and vectorial factors associated with congestive heart failure. LV enlargement causes increased precordial voltage. The horizontal plane vector shifts posteriorly, orthogonal to the frontal plane, causing poor R wave progression and low limb lead voltage. Increased extracellular fluid preferentially attenuates QRS voltage in limb leads. We aimed to test sensitivity of this triad in patients with non-ischaemic cardiomyopathy (NICMP) and severe LV dysfunction.
386 patients, mean age 62.45 ± 13.96 years, male 72%, NYHA II-IV, with NICMP, 70 had bundle branch block (18%) and mean LV ejection fraction 22.57 ± 8.62%. 76% hypertension, 39% diabetes mellitus, 32% atrial fibrillation. The triad was sought in ECG recorded at time of echocardiogram. Mean LV end-diastolic diameter 5.81 ± 1.53cm.
56% patients had SV1 or SV2 + RV5 or RV6≥3.5mV, 85% had R/S ratio<1 in lead V4, 19% had total QRS amplitude in limb leads≤0.8mV. 50% had SV1 or SV2 + RV5 or RV6≥3.5mV and R/S ratio<1 in lead V4. Only 6% fulfilled the triad.
Goldberger’s triad is an insensitive marker for severe LV dysfunction. Using SV1 or SV2 + RV5 or RV6≥3.5mV and R/S ratio<1 in lead V4 had 50% sensitivity. 85% patients had R/S ratio<1 in lead V4, a simple way to select dilated LV.