Common ECG Lead Placement Errors. Part II: Precordial Misplacements
Background: Electrocardiography is a very useful diagnostic tool. However, errors in placement of ECG leads can create artifacts, mimic pathologies, and hinder proper ECG interpretation. This is the second of a two-part series discussing how to recognize and avoid these errors.
Methods: 12-lead ECGs were recorded in a single male healthy subject in his mid 20s. Various precordial lead misplacements were compared to ECG recordings from correct lead placement.
Results: Precordial misplacements caused classical changes in ECG patterns. Techniques of differentiating these ECG patterns from true pathological findings were described.
Conclusion: As in Part I of this series, recognition and interpretation of common ECG placement errors is critical in providing optimal patient care.
2. Rosen AV, Koppikar S, Shaw C, Baranchuk A. Common ECG lead placement errors. part I: Limb lead reversals. Int J Med Students. 2014 Jul-Oct;2(3):92-8.
3. Sclarovsky S, Garcia-Niebla J. Current role of electrocardiography in acute ischemic syndromes: Is it an outdated technique? Rev Esp Cardiol. 2009 Apr;62(4):456-459.
4. Kligfield P, Gettes LS, Bailey JJ, Childers R, Deal BJ, Hancock B, et al. Recom¬mendations for the standardization and interpretation of the electrocardio¬gram: Part I: The electrocardiogram and its technology a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardio¬logy Foundation; and the Heart Rhythm Society endorsed by the Interna¬tional Society for Computerized Electrocardiology. J Am Coll Cardiol. 2007 Mar;49(10):1109-1127.
5. Baranchuk A, Shaw C, Alanazi H, Campbell D, Bally K, Redfearn DP, et al. Electrocardiography pitfalls and artifacts: The 10 commandments. Crit Care Nurse. 2009 Feb;29(1):67-73.
6. Koppikar S, Shaw C, Baranchunk A. ECG quiz: A tale of an abnormal ECG. J Electrocardiol. 2014 Feb;47(1):123-125.
7. Bayes de Luna A, Goldwasser D, de Porta V, Fiol-Sala M, Carrillo A, Gar¬cia-Niebla J, et al. Optimizing electrocardiographic interpretation in acute ST-elevation myocardial infarction may be very beneficial. Am Heart J. 2011 Jul;162(1):e1-2; author reply e5.
8. Batchvarov VN, Malik M, Camm AJ. Incorrect electrode cable connection during electrocardiographic recording. Europace. 2007 Oct 10;9(11):1081-1090.
9. Rudiger A, Hellermann JP, Mukherjee R, Follath F, Turina J. Electrocardiogra¬phic artifacts due to electrode misplacement and their frequency in different clinical settings. Am J Emerg Med. 2007 Feb;25(2):174-178.
10. Garcia-Niebla J, Llontop-Garcia P, Valle-Racero JI, Serra-Autonell G, Bat¬chvarov VN, de Luna AB. Technical mistakes during the acquisition of the electrocardiogram. Ann Noninvasive Electrocardiol. 2009 Oct;14(4):389-403.
11. Sejersten M, Pahlm O, Pettersson J, Zhou S, Maynard C, Feldman CL, et al. Comparison of EASI-derived 12-lead electrocardiograms versus paramedic-ac¬quired 12-lead electrocardiograms using mason-likar limb lead configuration in patients with chest pain. J Electrocardiol. 2006 Jan;39(1):13-21.
12. Garcia-Niebla J, Garcia PL. An unusual case of electrode misplacement: Left arm and V(2) electrode reversal. J Electrocardiol. 2008 Sept-Oct;41(5):380-381.
13. Garcia-Niebla J, Baranchuk A, de Luna AB. True Brugada pattern or only high V1-V2 electrode placement? J Electrocardiol. 2014 May 5;47(5):756-758.
14. Harrigan RA, Chan TC, Brady WJ. Electrocardiographic electrode misplace¬ment, misconnection, and artifact. J Emerg Med. 2012 Dec;43(6):1038-1044.
15. Wenger W, Kligfield P. Variability of precordial electrode placement during routine electrocardiography. J Electrocardiol. 1996 Jul;29(3):179-184.
16. Zema MJ, Luminais SK, Chiaramida S, Goldman M, Kligfield P. Electrocar¬diographic poor R wave progression III. the normal variant. J Electrocardiol. 1980 Apr;13(2):135-142.
17. Garcia-Niebla J, Rodriguez-Morales M, Valle-Racero JI, de Luna AB. Negati¬ve P wave in V1 is the key to identifying high placement of V1-V2 electrodes in nonpathological subjects. Am J Med. 2012 Sept;125(9):e9-10; author reply e13.
18. Garcia-Niebla J. Comparison of p-wave patterns derived from correct and incorrect placement of V1-V2 electrodes. J Cardiovasc Nurs. 2009 Mar- Apr;24(2):156-161.
19. Garcia-Niebla J. Morphologies suggestive of V1 and V2 lead misplacement. Rev Esp Cardiol. 2008 Oct;61(10):1109-1110.
20. Drew BJ. Pitfalls and artifacts in electrocardiography. Cardiol Clin. 2006 Aug;24(3):309-15, vii.
21. Bayes de Luna AB, Garcia-Niebla J, Baranchuk A. New electrocardiographic features in Brugada syndrome. Curr Cardiol Rev. 2014 Aug;10(3):175-180.
22. Bayes de Luna A, Brugada J, Baranchuk A, Borggrefe M, Breithardt G, Gold¬wasser D, et al. Current electrocardiographic criteria for diagnosis of Brugada pattern: A consensus report. J Electrocardiol. 2012 Sept;45(5):433-442.
23. Garcia-Niebla J, Serra-Autonell G, Bayes de Luna A. Brugada syndrome electrocardiographic pattern as a result of improper application of a high pass filter. Am J Cardiol. 2012 Jul 15;110(2):318-320.
24. Garcia-Niebla J, Serra-Autonell G. Effects of inadequate low-pass filter application. J Electrocardiol. 2009 Jul-Aug;42(4):303-304.
25. Diaz-Munoz J, Garcia-Niebla J. Brugada syndrome unmasked by oral fle¬cainide in a patient with a history of supraventricular tachycardia. Semergen. 2014 Apr 2;37(1):61-69.
26. Serra G, Baranchuk A, Bayes-De-Luna A, Brugada J, Goldwasser D, Cap¬luzini L, et al. New electrocardiographic criteria to differentiate the type-2 Brugada pattern from electrocardiogram of healthy athletes with r'-wave in leads V1/V2. Europace. Epub 2014 Mar 6.
27. Awad SF, Barbosa-Barros R, Belem Lde S, Cavalcante CP, Riera AR, Gar¬cia-Niebla J, et al. Brugada phenocopy in a patient with pectus excavatum: Systematic review of the ECG manifestations associated with pectus excava¬tum. Ann Noninvasive Electrocardiol. 2013 Sept;18(5):415-420.
28. Garcia-Niebla J, Serra-Autonell G, Fiol M, Bayes de Luna A. Brugada electrocardiographic pattern: Reality or fiction? J Electrocardiol. 2014 May- Jun;47(3):362-363.
29. Anselm DD, Evans JM, Baranchuk A. Brugada phenocopy: A new electro¬cardiogram phenomenon. World J Cardiol. 2014 Mar 26;6(3):81-86.
30. Garcia-Niebla J, Diaz-Munoz J, Fiol M. Type 2 Brugada pattern is suggestive but not diagnostic of the syndrome. Am J Emerg Med. 2014 Jan;32(1):97-98.
31. Peberdy MA, Ornato JP. Recognition of electrocardiographic lead mispla¬cements. Am J Emerg Med. 1993 Jul;11(4):403-405.
Authors who publish with this journal agree to the following terms:
- The Author retains copyright in the Work, where the term “Work” shall include all digital objects that may result in subsequent electronic publication or distribution.
- Upon acceptance of the Work, the author shall grant to the Publisher the right of first publication of the Work.
- The Author shall grant to the Publisher and its agents the nonexclusive perpetual right and license to publish, archive, and make accessible the Work in whole or in part in all forms of media now or hereafter known under a Creative Commons Attribution 4.0 International License or its equivalent, which, for the avoidance of doubt, allows others to copy, distribute, and transmit the Work under the following conditions:
- Attribution—other users must attribute the Work in the manner specified by the author as indicated on the journal Web site; with the understanding that the above condition can be waived with permission from the Author and that where the Work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license.
- The Author is able to enter into separate, additional contractual arrangements for the nonexclusive distribution of the journal's published version of the Work (e.g., post it to an institutional repository or publish it in a book), as long as there is provided in the document an acknowledgment of its initial publication in this journal.
- Authors are permitted and encouraged to post online a prepublication manuscript (but not the Publisher’s final formatted PDF version of the Work) in institutional repositories or on their Websites prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work. Any such posting made before acceptance and publication of the Work shall be updated upon publication to include a reference to the Publisher-assigned DOI (Digital Object Identifier) and a link to the online abstract for the final published Work in the Journal.
- Upon Publisher’s request, the Author agrees to furnish promptly to Publisher, at the Author’s own expense, written evidence of the permissions, licenses, and consents for use of third-party material included within the Work, except as determined by Publisher to be covered by the principles of Fair Use.
- The Author represents and warrants that:
- the Work is the Author’s original work;
- the Author has not transferred, and will not transfer, exclusive rights in the Work to any third party;
- the Work is not pending review or under consideration by another publisher;
- the Work has not previously been published;
- the Work contains no misrepresentation or infringement of the Work or property of other authors or third parties; and
- the Work contains no libel, invasion of privacy, or other unlawful matter.
- The Author agrees to indemnify and hold Publisher harmless from the Author’s breach of the representations and warranties contained in Paragraph 6 above, as well as any claim or proceeding relating to Publisher’s use and publication of any content contained in the Work, including third-party content.
Enforcement of copyright
The IJMS takes the protection of copyright very seriously.
If the IJMS discovers that you have used its copyright materials in contravention of the license above, the IJMS may bring legal proceedings against you seeking reparation and an injunction to stop you using those materials. You could also be ordered to pay legal costs.
If you become aware of any use of the IJMS' copyright materials that contravenes or may contravene the license above, please report this by email to email@example.com
If you become aware of any material on the website that you believe infringes your or any other person's copyright, please report this by email to firstname.lastname@example.org