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Original Investigations
Editor Sodium levels and hospitalized Turkish patients: Multi-center, retrospective and observational
Zeki Öngen Burçak Kılıçkıran Avcı, et al; İstanbul-Turkey
Advisory Board of This Issue MMPS are targets in mct-induced pulmonary hypertension: effects of alagebrium and everolimus
Necmettin Akdeniz Özlem Atlı, et al; Eskişehir-Turkey
Tolga Aksu
Effects of aging on the expression of aquaporin 1 and aquaporin 4 protein in heart tissue
Jose Carlos Arevalo-Lorido Hikmet Bıçakçı, et al; İzmir-Turkey
Sergio Baptista
Thymopentin improves chronic heart failure
Nermin Bayar Cao Xiaojing, et al; Beijing-China
Atiye Çengel
Endothelial nitric oxide gene polymorphisms and their association with coronary disease in Tunus
Neslihan Çoban
Letaief Afef, et al; Sousse-Tunisia
Tatjana Damnjanovic
Umuttan Doğan Subendocardial viability ratio and, ventricular systolic improvement with cardiac rehabilitation
Emre Aslanger, et al; İstanbul-Turkey
Ahmet Barış Durukan
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Robert Ekart Sergio Bravo Baptista; Amadora-Portugal
Okan Erdoğan
Modified limb lead ECG system, ECG wave amplitudes and frontal plane axis in sinus rhythm
Tuvia Ben Gal Sivaraman Jayaraman, et al; Chennai-India
Ayşe Gelal Editorial comment: Modified limb lead system: amplitudes and axis in surface ECG
Demet Menekşe Gerede Vimal Prabhu Pandiyan; Telangana-India
M. Hariharan Epicardial adipose tissue, carotid intima-media thickness and atherosclerotic plaque; but LDL?
Sahin İşcan Sinan Altan Kocaman, et al; Ankara-Turkey
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Volume: 17 Issue: 1 January 2017 Page: 1-80
Parimala Narne
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Vimal Prabhu
Ümit Yaşar Sinan
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The Anatolian Journal of Cardiology® Anatol J Cardiol, Vol: 17, Issue: 1, January 2017
Editor-in-Chief
Bilgin Timuralp, Eskiflehir, Turkey
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Zeki Öngen, İstanbul, Turkey
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A-II
46 Original Investigation
Sivaraman Jayaraman, Venkatesan Sangareddi1, R. Periyasamy2, Justin Joseph2, Ravi Marimuthu Shanmugam1
Department of Biomedical Engineering, Vel Tech Multi Tech; Chennai-India
1Department of Cardiology, Madras Medical College, Rajiv Gandhi Government General Hospital; Chennai-India
2Department of Biomedical Engineering, National Institute of Technology; Raipur-India
ABSTRACT
Objective: Modified Limb Lead (MLL) ECG system may be used during rest or exercise ECG, or atrial activity enhancement. Because of modifica-
tion in the limb electrode placement, changes are likely to happen in ECG wave amplitudes and frontal plane axis, which may alter the clinical
limits of normality and ECG diagnostic criteria. The present study investigated the effects of the modified limb electrode position on the electro-
cardiographic waveforms, ST segment amplitudes (STa) and frontal plane axis.
Methods: The observational study included sixty sinus rhythm subjects of mean age 38.85±8.76 (SD) in the range 25 to 58 years. In addition to
12-lead ECG, MLL ECG was recorded with, the RA electrode placed in the 3rd right intercostal space to the right of the parasternal line, the LA
electrode placed in the 5th right intercostal space to the right of the mid-clavicular line and the LL electrode placed in the 5th right intercostal
space on the mid-clavicular line.
Results: The modification produced profound changes in ECG wave amplitudes and STa amplitudes in frontal plane leads. The QRS and T wave
axis shifted on the average by –17o and 41o, respectively, with considerable individual variation, which altered the diagnostic criteria.
Conclusion: The ECG amplitudes and STa changes produced by the MLL system showed that all remains within the clinical limits, except the R
wave amplitude in the modified lead I. It is evident that the MLL system produced deviations in frontal plane QRS axis which altered the diagnos-
tic interpretation. (Anatol J Cardiol 2017; 17: 46-54)
Keywords: electrocardiogram, modified limb lead, standard 12-lead, STa, QRS axis
Address for correspondence: Sivaraman Jayaraman, M.E., Ph.D., Department of Biomedical Engineering
Vel Tech Multi Tech Engineering College, Chennai- 600 062-India
Phone: +919840968282 E-mail: mountshiva@gmail.com
Accepted Date: 08.04.2016 Available Online Date: 29.06.2016
©Copyright 2017 by Turkish Society of Cardiology - Available online at www.anatoljcardiol.com
DOI:10.14744/AnatolJCardiol.2016.6843
Jayaraman et al.
Anatol J Cardiol 2017; 17: 46-54 Modified limb lead ECG 47
a a 200
100
50
0
-40 -20 0 20 40 60 80 100
-50
-100
b
-150
Standard mean QRS axis (degrees)
b 200
150
100
Δ axis (degrees)
50
0
Figure 2. (a) Standard 12-lead ECG of a male subject in sinus rhythm. -40 -20 0 20 40 60 80 100 120
The R wave has maximum amplitude in all the leads. (b) MLL ECG of the
-50
same male subject in sinus rhythm used in the standard 12 lead ECG.
The MLL ECG shows the presence of large P wave amplitudes and re-
-100
duced R wave amplitudes in the limb leads
-150
ded at standard ECG paper speed in supine position for healthy
Standard mean QRS wave axis (degrees)
male subjects is shown in Figure 2. It is noted that very large
amplitude changes take place with the MLL system. The MLL c 100
90
Clinical threshold
ECG showed significant R wave amplitude changes (23). As the 80
exceeds
Axis angle (degrees)
70
left arm electrode and left leg electrode are beside each other 60 Standard
in the MLL system, the modified lead III ECG is essentially seen 50 Modified
40
as flat trace in all the recordings. But still, small R wave ampli- 30
tude was noticeable in the modified lead III with no distinct P 20
10
and T wave. Since the amplitude, axis changes of the P wave 0
and the importance of the MLL system in detecting the atrial -10
-20
ECG components have been previously reported as a separate -30
Clinical threshold
QRS axis
paper (24) this study emphasis on other wave amplitudes (R, S, exceeds
and T), STa and deviations in frontal plane axis caused by the Figure 3. (a) Distribution of mean QRS wave axis in standard and modi-
MLL system. fied position and curvilinear regression calculated from the axis values
(b) Distribution of mean QRS wave axis in standard position (x-axis) ver-
Changes in QRS and T wave axis sus the change in the measurement when the electrodes are moved to
the torso and linear regression calculated from the axis values (c) Mean
Compared with the standard 12-lead ECG, MLL placement electrical axes of the QRS complex in standard and modified position
resulted in the frontal plane axis shift in P, QRS, and T waves. The showing the thresholds for clinical abnormality
axis measurements were generally more affected by the chan-
ges in the modified limb electrode placement. The distribution of modified and standard lead (M-S) of the QRS axis is found to be
the QRS and T wave axis changes between the standard and the –61o. There are considerable individual variations in the degree
modified position is shown in Figure 3, 4. The difference in the of this shift. The least square cubic fit for the modified axis (αm)
frontal plane axis (QRS and T) values between the MLL ECG and calculated from the standard axis (αs) from Figure 3a is given as
SLL ECG is shown in Table 1. The frontal plane mean QRS axis αm=–0.00004αs3 –0.010αs2+1.225αs –39.32 (1)
had significant changes in the MLL system, with an average axis The equation of the linear regression line from Figure 3b is given as
shift of –17±91o when the electrodes were moved from the limb ΔQRS axis (o)=20.14+0.927 x QRS (2)
to the torso of the subjects. The mean difference between the where QRS is the QRS wave axis.
Jayaraman et al.
Anatol J Cardiol 2017; 17: 46-54 Modified limb lead ECG 49
Table 1. Changes in the frontal plane axis with the standard and modified positions
70 40
a b
Modified mean T wave axis (degrees)
60 20
50
0
Δ axis (degrees)
40
-20
30
-40
20
10 -60
0 -80
0 10 20 30 40 50 60 70 0 10 20 30 40 50 60 70
Standard mean T wave axis (degrees) Standard mean T wave axis (degrees)
Figure 4. (a) Distribution of mean T wave axis in standard and modified position and curvilinear regression calculated from the axis values (b) Dis-
tribution of mean T wave axis in standard position (X-axis) versus the change in the measurement when the electrodes are moved to the torso and
linear regression calculated from the axis values
The T wave axis measurements were also affected likewise to –45o). It is clear evident that the modified limb electrode place-
in the P and QRS axis. The distribution of the T wave axis in the ment in the torso produced deviations in the frontal plane mean
SLL and MLL system is shown in Figure 4. The frontal plane mean QRS axis and this may have an effect on the clinical specificity.
T wave axis had an average shift of 40±17o in the MLL system,
when the electrodes are moved from the limb to the torso of the Changes in ECG amplitudes and waveforms
subjects. The mean difference between the modified and stan- Consequent to the changes in the frontal plane axis shift re-
dard (M-S) of the T wave axis is found to be 13o. The least square sulted by the modification in the position of the limb electrodes,
cubic fit for the modified axis (αm) calculated from the standard it is noted that very large amplitude differences takes place in
axis (αs) from Figure 4a is given as the frontal plane leads. As with the axis changes the largest vol-
αm=0.000αs3 –0.036αs2+0.881αs+33.51(3) tage changes are found when the electrodes are moved from the
The equation of the linear regression line from Figure 4b is given as limb to the torso. As expected, no significant changes are seen in
ΔT axis (o)=–36.77+0.870 x T (4) the ECG amplitudes of the transverse plane leads (V1–V6) as they
where T is the T wave axis. are unchanged during the recording of the modified positioning
of the limb electrodes. The MLL system produced significant R
QRS axis deviations wave amplitude changes when compared with the other fron-
Surawicz et al. (25) defined the clinical limits of mean fron- tal plane leads and produced false ECG changes in the modified
tal plane axis of QRS normality and abnormality (i.e., < > –30o to lead I of the R wave amplitude. The mean R wave amplitude of
+90o). The range of deviations in QRS axis in the MLL system was modified lead I is 0.17 mV, which is <0.2 mV defined as the clini-
–88o to 176o, whereas in the SLL system it was –26o to 96o. Al- cal threshold of abnormality (26). The plot of mean±SE of R wave
though the modification produced individual variations in degree amplitudes in MLL and SLL recordings is shown in Figure 5a. In
of the axis shift, the mean frontal QRS axis of the MLL system was frontal plane leads the R wave amplitude decreased in the modi-
–17o as seen in Figure 3c. Out of total 60 sinus rhythm subjects, fied leads I-aVF.
the MLL system in sinus rhythm subjects produced normal QRS Similarly, the modified limb electrode placement produced
axis shift [–30o to +90o, (n=6)], marked left axis deviation [–45o amplitude changes in S and T waves respectively as shown in
to –90o, (n=41)], moderate right axis deviation [90o to 120o, (n=1)] Figures 5b–c. The S wave amplitude decreased in all the frontal
and marked right axis deviation [120o to 180o, (n=12)]. No sinus plane leads of the MLL system. The T wave amplitude decreased
rhythm subjects produced any moderate left axis deviation (–30o in all the modified leads except the modified lead aVL. The R, S,
Jayaraman et al.
50 Modified limb lead ECG Anatol J Cardiol 2017; 17: 46-54
Figure 5. Plot of mean±SE of R, S, and T wave amplitudes of the frontal plane leads in the standard and the modified electrode positions
Table 2. ECG waves with the standard and modification of the limb electrode positions. Mean values are listed for the difference (M-S) in which
positive values indicate an increase in amplitude and negative values indicate a decrease caused by modification. Percentage gains in mean
amplitudes are also provided. Amplitudes are in microvolts. N/A=not applicable
and T wave amplitude values of the MLL system are shown in 100 µV is defined as the clinical threshold level in the frontal
Table 2. Mean values are listed for the difference between the plane. Compared with the SLL system, the MLL system had an
modified and standard lead (M-S) in which positive value indi- influence in the STa, as the values of STa reduced in all the modi-
cates an increase and a negative value indicates a decrease fied leads (I-aVF) for (J+0 ms) and (J+80 ms) which are found
caused by modification of the electrode positioning. to be well within the clinical limits. Increased values of STa in
modified lead aVF for J+20 ms, J+40 ms, J+60 ms were found
Changes in ST segment amplitudes (STa) level and all are within the normal clinical limits. The plot of mean±SE
Consequent to the changes in the ECG amplitudes, the modi- of ST (J) wave amplitudes in MLL and SLL recordings are shown
fication of the limb electrode produced changes in the STa in the in Figure 6. The ST segment amplitude between the values of
frontal plane leads. The STa is measured from the J point to 80 the modified and standard position is shown in Table 3 and the
ms after the onset of the J point (J+80 ms) in this study. The STa mean values are listed for the difference between the modified
deviations are analyzed for each 20 ms after the onset of the J and standard lead (M-S) in which positive value indicates an in-
point to validate whether the MLL system has any effect on the crease and a negative value indicates a decrease caused by the
ST segments. In general the ST segment elevation greater than modification.
Jayaraman et al.
Anatol J Cardiol 2017; 17: 46-54 Modified limb lead ECG 51
40 Standard Modified
Temporal changes in PR interval,
30
QRS complex, and QT interval
ST (J) amplitude (µV)
20
As expected the MLL system has no effect on the temporal
aspects of the ECG waveform as shown in Table 4.
10
0
Discussion
-10
-20
In this present study, the authors sought to investigate the
-30
changes in ECG wave amplitudes and deviations in the frontal
L1 L2 L3 aVR aVL aVF
Leads plane axis for the MLL system which was originally designed to
facilitate the study of atrial P and Ta waves in healthy male sub-
50 Standard Modified
40
jects and with a view to study the dynamics of Ta wave in patients
ST (20) amplitude in µV
60
40 clinically significant and above the clinical threshold for normality.
20 The ST segment is used as a key indicator of myocardial
0 ischemia during exercise stress testing and emergency monitor-
-20
ing. In this study, it was found that the MLL system did not alter
-40
-60
the STa values in any of the modified leads which were analyzed.
-80 The STa deviations were analyzed for each 20 ms after the onset
L1 L2 L3 aVR aVL aVF of the J point to (J+80 ms) and all the values are found to be
Leads
within the normal clinical limits.
120 Standard Modified In the present study, the deviations in frontal plane axis is
100
investigated in 60 sinus rhythm subjects and found that only 6
ST (80) amplitude in µV
80
60 subjects exhibited normal QRS axis shift. Marked left axis devia-
40 tion were seen in 41 subjects, marked right axis deviation in 12
20
0
subjects, and moderate right axis deviation in 1 subject, which
-20 is in the range of clinical threshold of abnormality. This result is
-40 in contrast to all the previous study done on the modification. In
-60
-80 this study, the deviations in the QRS axis produced false-positive
L1 L2 L3 aVR aVL aVF ECG changes in frontal plane axis, which would lead to false in-
Leads terpretation of heart diseases.
Figure 6. Plot of mean±SE of STa [J + ST (80)] of the frontal plane leads In previous studies it has been asserted that variations in
in the standard and the modified electrode positions ECGs obtained with modified limb electrode do not affect diag-
Jayaraman et al.
52 Modified limb lead ECG Anatol J Cardiol 2017; 17: 46-54
Table 3. STa with the standard and modification of the limb electrode positions. Mean values are listed for the difference (M-S) in which
positive values indicate an increase in amplitude and negative values indicate a decrease caused by modification. Percentage gains in mean
amplitudes are also provided. Amplitudes are in microvolts
Table 4. Modification produced no measurable temporal changes in the ECG waveform in all frontal planes
ECG intervals Standard limb lead (SLL) ECG Modified limb lead (MLL) ECG
Mean SD Range Mean SD Range P*
PR Interval 160.16 9.76 140 to 176 161.16 8.76 144 to 177 >0.05
QRS wave 94.38 8.71 78 to 109 92.98 9.23 78 to 106 >0.05
QT Interval 341.23 21.36 302 to 380 344.57 19.98 302 to 388 >0.05
SD - standard deviation; values are in miliseconds; *Paired sample t-test
Jayaraman et al.
Anatol J Cardiol 2017; 17: 46-54 Modified limb lead ECG 53
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