Common ECG Lead Placement Errors. Part II: Precordial Misplacements
Keywords:Cardiology, Electrocardiography, Medical Errors, Precordial Lead Placement, Medical Education
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 Sclarovsky S, Garcia-Niebla J. Current role of electrocardiography in acute ischemic syndromes: Is it an outdated technique?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.
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