JULY

13,

1963

VOL.

89,

NO.

HARRY ABRAMSON, M.D.,* Toronto I T HAS been accepted by most workers in the field that the vectorcardiogram gives more information about the heart's electrical activity than does the electrocardiogram. It is the purpose of this paper to reaffirm this concept by discussing in detail the frontal plane QRS loops of a series of young subjects with normal hearts and comparing these to the corresponding loops of a group of patients with diaphragmatic myocardial infarction. Although considerable work has already been done in describing the normal vectorcardiogram, little of this has involved the use of the Frank lead system.1-3 Since this is the technique currently being used in this laboratory, it was felt that a report of our findings in the normal heart might prove of value. Abnormalities of the QRS loop alone are specific in transmural myocardial infarction. Criteria for diagnosis of such abnormalities in diaphragmatic infarction have been described previously, but these have usually been qualitative rather than quantitative.4' . Wolff6 has measured the maximal initial superior vector, making use of the Duchosal trihedron reference system. He feels that diaphragmatic infarction can be diagnosed when initial or early superior forces in the frontal plane exceed .12 my. or when the superior/inferior ratio exceeds .13 when the sweep is clockwise. Rather than the maximal initial superior vector, we have chosen to define the .02-second vector. Infarction involving the diaphragmatic surface of the heart is associated with a loss of initial inferior forces, the .02-second vector being abnormally elevated and usually of increased magnitude. Vector forces acting in an anteroposterior direction are not affected. The horizontal plane QRS loop does not deviate from the normal. Only frontal and sagittal plane QRS abnormalities result. However, changes in the former are adequately specific to allow vector
From the Cardlo-Pulmonary Laboratory, New Mount Sinai Hospital, Toronto. Research Associate, Department of Medicine, New Mount Sinai Hospital, Toronto.

ABSTRACT The efferent limb of the frontal plane QRS loop of the vectorcardiogram was studied quantitatively in 100 normal subjects and in 50 patients with electrocardiographic QRS evidence of diaphragmatic infarction. Efferent limb analysis consisted of determination of the position of the .02-second and maximal vectors in the triaxial reference frame and of the ratio born by the magnitude of the .02-second vector to that of the maximal vector. This ratio was not found to be greater than 0.16 in the normal heart with clockwise loop inscription and a superiorly dfrected .02-second vector. When 20 patients with only ST-T changes of diaphragmatic infarction in the electrocardiogram were similarly studied, 13 showed significant QRS loop evidence of this infarction.

48

ABRAMSON:

FRONTAL PLANE QRS Loon

Canad. Med. Ass. J. July 13, 1963, vol. 89

- 1.00
-'.90

- .80 o CLOCKWISE * COUNTERCLOCKWISE FIGURE-OF-EIGHT OR ED(.

H

'4

r.6O
.50
0 0. 0
Co

0 0

0
- .40 - .30

o
.20

0
0

&
0
a
I

0
I
K

0. 0

0 I 0 o A

0 o .00 A0b%.0.. A 00 0

. .10

0
40

%.. .
60

OP
80 100

I
U

0
I

-1.0 -130

-80

-60

..4Q

20

.02 6econd vector (an.1e) Fig. 2.-Analysis of efferent limb of frontal plane QRS loop in 100 subjects with normal hearts.

analysis to deal with the frontal plane QRS loop alone. Accordingly, the frontal plane QRS loops of three different groups of patients will be discussed: (A) the normal controls; (B) those showing QRS evidence of diaphragmatic infarction in the electrocardiogram; and (C) those showing only ST-T evidence of diaphragmatic infarction in the electrocardiogram. Some group A loops were recorded by means of a multichannel photographic recorder produced by Electronics for Medicine Inc. Others were recorded using a Sanborn-Visoscope and Beattie-Coleman polaroid camera. All loops of patients in Groups B and C were recorded by the latter method. The frontal plane .02-second vector could usually be determined without difficulty. In those cases in which interference in the vicinity of the isoelectric point prevented this being done, the .02-second vector was first isolated in the horizontal plane. By superimposing this vector on the frontal plane QRS loop, the frontal plane .02-second vector could be accurately defined. Group A consists of 100 subjects with no history suggestive of heart disease or evidence of cardiac abnormality on physical examination. Their ages ranged from 13 to 33 years. The group comprised 72 males and 28 females. All vectorcardkigrams were taken with the subject in the supine position. Fig. 1 is a scattergram which describes the magnitude and position of the .02-second vector. It is apparent that the normal controls have been divided into three groups: (a) those with clockwise inscription of the QRS loop, (b) those with counterclockwise inscription, and (c) those in whom the

loop is seen either on edge or forming a figure-ofeight. The counterclockwise group, comprising 60 subjects, was the largest. Clockwise rotation was found in 22 subjects, and in 18 the loop was seen either in the edge projection or forming a figure-ofeight. In the clockwise group, the .02-second vector usually was directed inferiorly, this angle ranging from 30 to 68g. Quite often this vector was of considerable magnitude (e.g. 0.88 my.) and in comparing it to the maximal QRS vector, one found this ratio as high as 0.60. Six of the clockwise group were found to have .02-second vectors which were directed superiorly, this angle ranging from .4o to ..77o. However, in all instances these were vectors of quite small magnitude, none being greater than 0.20 my. The ratio of .02-second vector to maximal QRS vector in these cases proved to be small. The greatest ratio found in a normal subject with clockwise loop inscription and a superiorly directed .02-second vector was 0.16. Those subjects showing counterclockwise inscription of the QRS loop usually had a .02-second vector which was directed inferiorly. This angle ranged from 180 to 990, These vectors varied greatly in magnitude, at times being quite small (e.g. 0.12 my.) and at other times quite large (e.g. 1.20 my.). The ratio of the magnitude of this vector to that -of the maximal vector varied accordingly from 0.05 to 0.86. In only three instances was the .02-second vector superiorly directed so as to fall in the negative range of the reference frame. As in the similar situation of subjects with clockwise loop inscription, these vectors were of small magnitude, resulting in

Canad. Med. Ass. J. July 13, 1963, vol. 89

TABLE 1.- SLMMAR. us FRONIAL PLANE MEAN \ALLI.5 IN 100 NORMAL SUBJECTS

ABRAM5ON: FRONTAL PLANE QRS Loon 49

-90
0

No. of subjects

QRS loop. inscription

02-scrond vector Maximal vector R Ratio of (mean) (mean) .02-second Degrees AlL Degrees AlL rector R 18 47

22 60 7 11 100

Clockwise Counter-clock" i. H Edge Figure-of eight

12 37

49

.36 .43 .37 .42

.48

48 42

53

1.58
147 1.46

1.31 1.30

.32 .32

.27

o 0
0

0
'C

o
.
0 00

0
S
0

0 0 0 0

43 44

.26
.30

0 oaOe .
o 0 0 00

00

small .02-second to maximal vector ratios, the largest of the three ratios being 0.22. Eleven of the 100 normal subjects presented a figure-of-eight pattern in the frontal plane. Of these, only t.vo showed a superiorly directed .02second vector, i.e. -136. and .143o. In both instances, the .02-second to maximal vector ratio was small, 0.12 and 0.15, respectively. In both instances the initial segment of the figure-of-eight loop was inscribed in a counterclockwise direction. Seven subjects presented with the edge projection in the frontal plane. In all seven, the .02-second vector was inferiorly directed. The relationship between the angle of the .02-second vector and the ratio borne by the magnitude of this vector to that of the maximal vector is plotted in Fig. 2. Table I summarizes our findings in these control subjects. Group B consists of 50 patients with unequivocal QRS evidence of diaphragmatic infarction in the electrocardiogram. In each instance, the electrocardiogram showed Q waves in leads 3 and aVF which were .03 second or greater in duration, and at least 25% of the height of the succeeding R wave. Some of the infarcts were recent, and some were old so that ST-T changes of infarction .vere not necessarily present.

180

0 CLOCKWISE * COUNTERCLOCKWISE PIBJRE-OF-EIGHT

.1 my.

90
Fig. 3.-Position and magnitude of .02-second frontal vector in su patients with QRS evidence of diaphragmatic infarction in the electrocardiogram.

The most common type of ioop was that of clock.vise inscription, present in 38 cases. A figure-ofeight with the initial segment of the loop inscribed in a clockwise direction was present in 10 patients. A counterclockwise superiorly situated loop was
TABLE I1.-Sr-.nARY OF FRONTAL PL4NE MEAN X4LUES IN 30 PATIENTS WITH DIAPHR4GMATIC INFARCTION

No. of patients

QRS loop inscription

.02-second rector Maximal t ector R Ratio of (InentI) (mean) .02-second Degrees .1II.. Degrees M F. vector R 5.3
.J.)

38 10 2 30

Clockwise Figure-of eight Counter-clockwise

.42
.37

67
54

.59
.41

71 2

11 16

1.14 1.11

.70 1.12

.41 .35

.85 .42

1.00
0 0 0 0 0
.90
0

h)

to C)

0 0-

o CLOCKWLSE

&
0

*.70
.60

9' 9'

i-'
C) C)

* COUNTERCLOCKWISE & FIGURE-OF-EIGHT

&
0 0 & 0 000 0 0 0 0 0 I -120 I
-100 I -80

0
..50

'1

0 0 0 0

& 0 o0 0 Oh I

..40
f-i.

&

.30 0 .20 - .10

. o-

r
-60 -40

20 .02 second vector (angle)

-20

40

.0

Fig. 4.-Analysis of efferent limb of frontal plane QRS loop in 30 patients with diaphragmatic infarction.

50 ABRAMSON: FRONTAL PIA. QRS Loot

Canad. Med. Ass. J. July 13, 1963, vol. 89

part of the eight clockwise; and of these, 46 showed a superior .02-second vector. Only four of this latter group of 46 patients had a ratio of .02-second vector to maximal vector which was equal to or less than .16, i.e. the upper limit in the normal controls. But the .02-second vector was abnormally elevated to .1O3O in one of these four patients. In the other three, although this vector was found at .350, 490 and -78., the maximal vector was more superiorly directed than in the normal, resulting in an elevation of the entire efferent limb of the QRS loop. In our normal subjects .vith clockwise loops, the maximal vector was always directed inferiorly and to the left, even though the .02-second vector might be directed superiorly. In those subjects with a superior .02-second vector, the maximal vector was never found to be less than 350. Usually it was much greater than this, viz. 560, 600, . In the three patients under discussion, the maximal vector was situated at .30, 40 and 9o. I. must be pointed out, however, that such an elevated maximal vector was not an invariable finding in the group B patients. The mean maximal vector in the 50 patients was 20, but one did see a maximal vector as inferiorly directed as 610.

Fig. 5.-Electrocardiogram showing ST segment coving, inverted T waves and deep Q waves of .03 second's duration in leads 2, 3 and aVF.

present in two. Regardless of the pattern, the .02second vector was almost invariably superiorly situated. In only two of the 50 cases was this not true, these two vectors being found at QO and 100, respectively. The degree of elevation of this vector was usually quite considerable. It ranged from .....30 to .110o, the mean angle for the entire group of 50 patients being .540. This, of course, is well superior to the mean of 370 for the .02-second vector in our normal subjects. The mean for the 22 normal subjects with clockwise loop inscription was
180.

The magnitude of the .02-second vector was quite variable; however, it bore a much different relationship to the maximal vector than it did in the normal. In the normal heart with clockwise loop
inscription, only six subjects showed a superiorly directed .02-second vector. This vector was always small compared to the maximal vector, so that the ratio of the former to the latter varied from .04 to .16. In the group of 50 infarcts, 48 presented with a clockwise or figure-of-eight loop with the initial

Fig. 6.-Vectorcardiogram in diaphragmatic with clockwise frontal plane QBS loop.

infarction

July 13,1963, vol. 89

Canad. Med. Ass. J.

Abramson: Frontal Plane

QRS

Loop 51

lllllitiH fiifeS m fff*

I
."21

mmsmsm

aVR

aVI

aVF

leads 2, 3 and aVF of the electrocardiogram of Case 1 (Fig. 5). The frontal plane projection of the vectorcardiogram is shown in Fig. 6. Note the small P loop directed inferiorly, the large QRS loop and the intermediate size T loop. The latter is directed superiorly and to the patient's left. The QRS loop shows clockwise inscription. The .02-second vector is situated at .95 with a magnitude of 0.38 mv. and the maximal vector at .5 with a magnitude of 1.10 mv. The ratio of the magnitude of the former to that of the latter is 0.35. The electrocardiogram of Case 2 (Fig. 7) is similar. Inverted T waves are present in leads 2, 3, aVF and V3.5 as well as ST segment elevation and coving. QS complexes may be seen in leads 3 and aVF. The frontal plane QRS loop (Fig. 8) shows a figure-of-eight pattern with the initial part of the loop inscribed in a clockwise direction. The .02second vector with a magnitude of 0.30 mv. falls at .37. The maximal vector is inferiorly directed to a slight extent at 14 with a magnitude of 0.70 mv. The ratio of the former to the latter is 0.43. The T loop is directed superiorly and slightly to the right. Case 3 showed evidence of a diaphragmatic infarction in the electrocardiogram (Fig. 9) but in this instance there bad been lateral wall involvement as well and the QS complexes and T waves are inverted in leads 2, 3, aVF and V6. The QRS plane of the vectorcardiogram loop of theisfrontal (Fig. 10) somewhat dissimilar to that of the previous two patients. This loop is entirely above

leads 2, 3, aVF and V3, 3 and aVF.

Fig. 7..Electrocardiogram showing inverted T waves in 4, 5. There are QS complexes in leads

The two counterclockwise loops were completely abnormal in that both loops were inscribed above the isoelectric point in their entirety, the .02-second vector being superiorly situated. The .02-second vector to maximal vector ratios were 0.37 and 0.97 in these two cases. Thus 48 of this group of 50 patients (96%) had frontal plane QRS loops which deviated from the normal by virtue of an elevated efferent limb. The magnitude and position of the .02-second vector in Group B patients is described in Fig. 3, the relationship between the angle of this vector and the ratio born by its magnitude to that of the maximal vector in Fig. 4. The following are representative of the three types of frontal plane QRS loops seen in Group B. There is a time interval of .0025 second between each time marker of the loop. Loop inscription is in the direction of the thick edge of the "dew drop". ST segment coving, inverted T waves and deep Q waves of .03 second's duration are present in

Fig. 8..Vectorcardiogram in diaphragmatic infarction with figure-of-eight frontal plane QRS loop. The initial part of the eight has been inscribed in a clockwise direction.

52

ABRAMSON:

FRONTAL PLANE QRS Loon

Canad. Med. Ass. J. July 13, 1963, vol. 89

Fig. 1 0.-Vectorcardiogram in diaphragmatic infarction with superiorly situated counterclockwise frontal plane QRS loop.

Fig. 9.-Electrocardiogram showing QS complexes and inverted T waves in leads 2, 3. aVF and V6.

the isoelectric point and inscribed in a counterclockwise direction. i.e. the afferent limb of the loop is superior to the efferent. The .02-second vector with a magnitude of 0.66 my. may be seen at .350, the maximal vector with a magnitude of 0.68 my. at .400, the ratio of the former to the latter being 0.97. The T loop is directed superiorly and somewhat to the right. Group C consists of 20 patients with ST-T evidence of diaphragmatic infarction in the electrocardiogram. In no instance were there significant Q .vaves in leads 3 and aVF, so that the diagnosis of non-transmural infarction only was made electrocardiographically. The frontal plane QRS loop showed a clockwise pattern in 13 of the patients, counterclockwise in three, and a figure-of-eight in four. The .02-second vector was superiorly directed in 10 of the clockwise loops, this angle ranging from .9O to .105.. When the .02-second vector was compared to the maximal vector, it was found that the ratio of the magnitude of the former to that of the latter was greater than the upper limit of normal in our control subjects in six natients. In these, the ratio

varied between 0.18 and 0.41. Although a seventh patient had a ratio of 0.16, the .02-second vector was elevated to .880. We concluded that this was abnormal, since .770 was the upper limit for the .02-second vector in a clockwise loop in the control subjects. As well, three of the Group C patients with a clockwise QRS loop and a superior .02second vector showed maximal vectors less than 350, viz. 270, 260 and 210, so that there was abnormal elevation of the efferent limb of the loop.

0 0
o CL0CKW.E * COUNT.L.CK.J$K PIWRE-OP-ItgIT

90 Fig. 11.-Position and magnitude of .02-second frontal vector in 20 patients with ST-T evidence of diaphragmatic infarction in the electrocardiogram.

Canad. Med. Ass. .*

July 13, 1963, vol. 89

ABRAMSON:

FRONTAL PLANE QRS Loon

53

*0

'.

1.00

.
o CLOCKWISE * COUNTERCLOCKWISE F'IQJRE-OF-EIGHT
U

A
A

.
..

.80
0

U
U *0

.70

g 0:
N

.60
.50
0

O
0

0
0
o

.40 .30

0 0 0
.10

.20

0
I
-100 -80 40

00
I
-40

0
I
-20

&
I
0 20

I
40

I
60

I
80

I
100

.02 second vector (angle) Fig. 12.-Analysis of efferent limb of frontal plane QRS loop in 20 pati6nts with ST-T evidence of diaphragmatic infarction.

Two of the four patients with figure-of-eight loops showed similar elevation of the efferent limb. In each instance, the limb was concave inferiorly, the .02-second vector falling at .5O and .27o. the maximal vector at 140 and 80, respectively. In both cases, the efferent limb started momentarily to the right and inferiorly, thus effectively masking the Q wave of infarction in the electrocardiogram. Of the three patients with counterclockwise loop inscription, one showed a definite abnormality in that the .02-second vector was elevated to -12. and bore a ratio of 0.56 to the maximal vector. Here too, the efferent limb was directed initially to the right and inferiorly. It was concluded that 13 (65%) of this group of 20 patients showed the same types of changes in the frontal plane QRS loop of the vectorcardiogram as were found in those patients with unequivocal QRS evidence of diaphragmatic infarction in the electrocardiogram. Fig. 11 describes the .02-second vector in group C. The relationship of the angle of this vector to the ratio of .02-second magnitude to maximal vector magnitude may be seen in Fig. 12. The following are representative of Group C. The electrocardiogram of patient 1 (Fig. 13) sho.vs inverted T waves and slight ST segment depression in leads 2, 3, aVF and V6. There is an rS pattern in lead 3 and an rSR' in lead aVF. Thus the 9 wave of infarction is lacking. The frontal plane of
Fig. 13.-Electrocardiogram showing inverted T waves and slight ST segment depression in leads 2, 3, aVF and V6. There is an rS pattern in lead 3 and an rSR1 in lead aVF.

v ...-.... "'
.

..'.'

.,
.

V5 aVF ;.:
.

54

ABRAMSON:

FRONTAL PLANE QRS Loon

Canad. Med. Ass. J. July 13, 1963, vol. 89

Canad. Med. Ass. J. July 13, 1963, vol. 89

ABRAMSON:

FRONTAL PLANE QRS Loon

55

L. 1. VI

4:

Frontal plane

V3
*

A
44. ....a.
I,

aVL.
A

Horizontal plane

Fig. 18.-Vectorcardiogram with counterclockwise frontal plane QRS loop. Both the efferent and afferent limbs are concave inferiorly.

V5
aVP' .

vector is large for it bears a ratio of 0.56 to the maximal vector.

SUMMARY AND CONCLUSIONS

Fig. 17.-Electrocardiogram showing T wave inversion in leads 2, 3, aVF and V5. o. Small R waves are present in leads 3 and aVF.

loop starts inferiorly and to the right. This was never seen in the group of normal subjects with figure-of-eight ioops, for this pattern is a vectorcardiographic variant of diaphragmatic infarction. The electrocardiogram of patient 3 (Fig. 17) has T wave inversion in leads 2, 3, aVF and V5-6. Small R waves are present in leads 3 and aVF. The frontal plane vectorcardiogram (Fig. 18) shows another QRS variant of diaphragmatic infarction, i.e. a counterclockwise loop with both the efferent and afferent limbs concave inferiorly. The .02-second vector at .12O and the maximal vector at -1' define an elevated efferent limb. The .02-second

The frontal plane QRS loop of the vectorcardiogram (Frank lead system) has been described in a group of 100 normal subjects and in a group of 50 patients with QRS evidence of diaphragmatic infarction in the electrocardiogram. Emphasis has been placed on the efferent limb of the loop, as defined by the .02-second and maximal vectors. When a third group of 20 patients with only ST-T evidence of diaphragmatic infarction in the electrocardiogram were similarly studied, 13 (65%) showed significant QRS loop evidence of this infarction in the vectorcardiogram.
REFERENCES

1. FRANK, E.: Circulation, 13: 737, 1956. 2. BRISTow, J. D.: Amer. Heart J., 61: 242, 1961. D.: Ibid., 62: 237, 1961. 4. BLTRCH, G. E. et al.: Circulation, 12: 418, 1955.
Chicago, 1960. 3. FORKNER, C. E., JR., HUGENHOLTZ, P. G. AND LEVINE, H. 5. MASsIE, E. AND WALSH, T. J.: Clinical vectorcardiography

and electrocardiography, Year Book Publishers, Inc.,

6. WoLF!', L. et al.: Circulation, 23: 861, 1961.