Incorrect lead placement may result in unnecessary therapeutic interventions. We present a case report of 53-year-old man with new inferior T-wave inversions in the 12-lead electrocardiogram (ECG) noted during routine followup of hypertension without any cardiovascular symptoms

Kjell C. Nikus

Sari U. M. Vanninen

Case Reports in Cardiology

English

PubMed

Incorrect lead placement may result in unnecessary therapeutic interventions. We present a case report of 53-year-old man with new inferior T-wave inversions in the 12-lead electrocardiogram (ECG) noted during routine followup of hypertension without any cardiovascular symptoms.</jats:p

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Hindawi Publishing CorporationCase Reports in CardiologyVolume 2011, Article ID 605874, 2 pagesdoi:10.1155/2011/605874Case ReportElectrocardiogram Acquisition Errors or Myocardial InfarctSari U. M. Vanninen and Kjell C. NikusDepartment of Cardiology, Heart Center, Tampere University Hospital, PL 2000, 33521 Tampere, FinlandCorrespondence should be addressed to Sari U. M. Vanninen, sari.vanninen@fimnet.fiReceived 25 July 2011; Accepted 24 August 2011Academic Editors: C. Firschke and D. RichterCopyright © 2011 S. U. M. Vanninen and K. C. Nikus. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.Incorrect lead placement may result in unnecessary therapeutic interventions. We present a case report of 53-year-old man withnew inferior T-wave inversions in the 12-lead electrocardiogram (ECG) noted during routine followup of hypertension withoutany cardiovascular symptoms.1. IntroductionThe common right arm/left arm lead switch is easily recog-nizable, but many other lead placement errors are possible.The less common ones are often diﬃcult to detect, but errorsare quite important clinically, as they may induce erroneousdiagnoses [1]. The proposed technical modification has thepotential to minimize the number of errors in electrodeplacement, with subsequent savings in money, time, andvaluable data [2].2. Case ReportA fifty-tree-year old man with new T-wave inversions inthe 12-lead ECG noted during a routine followup forhypertension. The patient also had dyslipidemia, but nohistory of coronary disease or diabetes. His hypertensionwas well controlled on a combination of beta-blocker andcalcium-blocker; in addition, he used a statin.The physical examination was entirely normal. The ECGobtained sinus rhythm at 54 beats per minute, with rSconfiguration in lead I and aVL, indicating a left posteriorfascicular block and narrow Q waves in III and aVFaccompanied by deeply inverted T waves in both leads. Inthe precordial leads, we observed an abrupt transition in V2with a qR complex and inverted T wave (Figure 1). Initially,the ECG was interpreted as a recent inferior and a posteriormyocardial infarction (MI).Before cardiological checkup, it was decided to perform anew ECG (Figure 2) that proved to be normal with aQRS axisat−13 degrees without deep S wave in aVF and III. Similarly,the transition zone appeared in V3 with a normal R-waveprogression and without the qR complex previously seen inV2. This control ECG was similar to an ECG one year earlier.At this point, it was evident that a technical mistake duringthe ECG acquisition had to be considered.3. DiscussionInterchange between electrodes of the left arm and the leftleg in a patient with left anterior fascicular block in thebasal ECG may raise the suspicion of inferior myocardialinfarction with inverted T waves in leads III and aVF [1, 3].Cross-over lead interchange between right arm and left legoften produces image of an inferior myocardial infarctionwith inverted T wave and nonsinus rhythm [1, 4].In our case, there was an abnormal transition in precor-dial leads with a qR complex morphology in V2 that did notconcur with either V1 or V3. If there is a marked discrepancyin the ECG pattern among leads that reflect electrical activityin a similar anatomical location, for example, if lead I andaVL QRS complex is diﬀerent from that of V5 and V6, leadreversal should be suspected [1].The ECG morphology registered in the frontal planein this case can be considered as a mixture of frontal andhorizontal planes because of interchange between electrodesof the left arm and V2 [5].Incorrect lead placement may include application ofthe electrode in a wrong location, connection of the cable2 Case Reports in Cardiology10mm/mV 100Hz 005E 12 SL 235 CID: 4IIIIIIaVRaVLaVF(a)V1V2V3V4V5V6(b)Figure 1: Electrocardiogram with right axis deviation, in leads I and aVL rS complexes with very deep S waves and prominent T waves notusually seen in these leads and more typical of V2 lead. Note the diﬀerent direction of the ORS complex in lead I and leads V5 and V6.10mm/mV 150Hz 005E 12 SL 231 CID: 44IIIIIIaVRaVLaVF(a)V1V2V3V4V5V6(b)Figure 2: Electrocardiogram from the patient of Figure 1 with electrodes in the right positions. Note that lead II is not modified, given thatthere was no interchange between electrodes of the right arm and the left leg. The R wave becomes incrementally larger from leads V1 to V6.to the wrong electrode, or both [3]. The explanation forthe accidental interchange between the electrode of theleft arm and V2 is that yellow color is present in bothelectrodes following recommendations of the InternationalElectrotechnical Commission [4, 5].References[1] M. A. Peberdy and J. P. Ornato, “Recognition of electro-cardiographic lead misplacements,” The American Journal ofEmergency Medicine, vol. 11, no. 4, pp. 403–405, 1993.[2] E. Z. Soliman, “Recording electrocardiograms using 3-limblead cables instead of the standard 4: a modification tominimize incorrect electrode placements,” Journal of Electrocar-diology, vol. 41, no. 5, pp. 391–392, 2008.[3] B. Surawicz and T. K. Knilans, Chou’s Electrocardiography inClinical Practice, Saunders, Philadelphia, Pa, USA, 6th edition,2008.[4] R. N. Garcia-Niebla, P. Llontop-Garcia, J. I. Valle-Raneco, G.Serra-Autonell, V. N. Batchvarov, and A. B. deLuna, “Technicalmistakes during the acquistion of the electrocardiogram,”Annals of Noninvasive Electrocardiology, vol. 14, no. 4, pp. 389–404, 2009.[5] J. Garcia-Niebla and P. L. Garcia, “An unusual case of electrodemisplacement: left arm and V2 electrode reversal,” Journal ofElectrocardiology, vol. 41, no. 5, pp. 380–381, 2008.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Electrocardiogram Acquisition Errors or Myocardial Infarct

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