Download Pseudo Left Axis Deviation and the SIStSl

Pseudo Left Axis Deviation and the
SIStSl
Syndrome in Chronic Airway Obstruction*
John W. Scheffer, M.D., a d Ray Pym, M.D.
umerous reports are available on the electrocardiographic bdings in chronic airway obstruction.14 Many authors have noted that a small
percentage of patients with pulmonary emphysema
have left axis deviation in the absence of clinical
coronary artery disease, systemic hypertension, or
other causes of myocardial failure.'-lo In the Denver
area, where there is a significant reduction in the
ambient oxygen pressure contributing to an increased frequency of chronic airway obstruction,
we have been impressed with the number of patients
who have pseudo left axis deviationl1or the SlSbSs
syndrome, presumably due to chronic airway obstruction. The following report illustrates these electrocardiographic and vectorcardiographic findings.
Of the group of 58 patients with severe chronic
h a y obstruction who were evaluated by right
cardiac catheterization, 11 patients were found to
have pseudo left axis deviation, and three patients
had the SIS& syndrome. Table 1 is a summary of
the relevant data on hernodynamic and pulmonary
function documenting severe chronic airway obstruction in these 14 patients ( 24 percent ) . Of the
14 patients, only bvo had clinical coronary artery
disease, and none had systemic hypertension. The
results show a signifkant increw in pulmonary
artery pressure due to chronic airway obstruction
with little change in the other hernodynamic measurements.
Table -1
FatheWpartofm~hrdy,a~po)58patientswftb
A a b d by
right cardiac catheterization wem studded. AU were men patients fdlowsd-upextensively in the && clinic at the Denver
veterans A-on
Hoapital. A . &dks wexe done duringoptimPlclinicalstatus.Thaejectionfra&onandcardioc
iradex were measared using radioactive isotopic teehniquee
previously r e p o d . 1 2
Far the second part of the study, 100 patients from the
University of Colorado Medical Center*Denver, wem d m -
from 14 P.tisAu aei& Severe Chroaic
A i m Ob&ructioA Who Had E i b P d o Lsft
Axt. LkWionor the SIS& Syndrome *
severe chronic airway obst~ctianwho wen
lysdectedonthebasisof~chronicairwayobstructioa
de!termiaed by puhnonary fimclian testing. AU of these patients had a ratio of forced expiratory volume in one d
to vital capadty (FEV,/VC) of less tban 45 pqrcent. There
were 25 m e n and 75 men patients, with an average age
of61 years.
- -
*From tbe~ivisionof &lo&
Denver Veterans Administration Hospital and the University of Colorado Medical
Center, Denver.
Manuscript received August 5; accqted August 12.
Repd?tt tequ4wts: Dr. P q o r , 4#W)Easi Ninth Aumue* Der#wr
802%
Measurement
Age, Yr
-,
Mean(Range) Normal
64 64-79]
=Ht3
Right atrium
-0nar~
arfery
--7mwedge
.. .
9 (3-15)
6 f 2
17 f 3
12 f 2
Ejection fraction, percent
60 (39-71)
65 f 10
Cardiac index, L/min/eq m
3.4 (2.7-3.9)
2.7-3.8
FEVl/VC, percent
44 (2330)
>75
PH
Arterial csrbon dioxide
tension, mm Hg
7.41 (7.32-7.45) 7.36-7.45
5 (0-13)
30 (1562)
41 (2858)
Arterisl oxygen pressure, mm H g 65 (33-74)
37 f 2
70 f 5
'Eleven patients with peeudo left axis deviation and three
patienta with S8r8, syndrome.
PSEUDO LLFT AXIS DEVIATION AND S,S&
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SYNDROME 453
I
I
L.SAGITTAL
I
FRONTAL
ORIZONTAL
I MV
Fkum
M
( u p p e ) . ECG i
'
g pseudo left axls devfatioa
gramofpatient~ECCisbowninFlgure1 . .
Figure 1 illustrates the electrocardiogram and
vectorcardiogram in pseudo left axis deviation with
right ventricular hypertrophy due to chronic airway
obstruction. The salient features include an inferior
P vector giving prominent P waves in leads 2, 3,
and aVF and an inverted P wave in lead aVL. There
is low voltage in both the frontal and horizontal
I
III
1B (h)
. Vectorcardio-
planes. In the frontal plane the QRS loop is counterclockwise with the mean frontal QRS axis (AQRS)
at no0,
with rightward and superior terminal forces
giving tenninal R waves in leads aVR and aVL of
similar magnitude and configuration. In the horizontal plane the terminal QRS loop is rightward and
posterior, causing a deep S in leads Vs to Vs and a
AVR AVL AVF
I
II
CHEST, 71: 4, APRIL, 1977
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shallow notched S in lead V1. Figure 2 illustrates
syndrome, which is quite simthe ECG of the S~S~SS
ilar to pseudo left axis deviation in terms of the P
vector and low voltage. The initial QRS for& is
leftward and inferior, which then swings rightward
and superior with the loop rotating through the electrical center of the heart and the terminal forces
arriving at 210'.
Of the 100 randomly selected patients with severe
chronic airway obstruction documented by pulmonary function testing, there were 14 patients with
pseudo left axis deviation. One patient had dinical
coronary artery disease, and one patient had systemic hypertension. There were also nine patients
who had the SlS2Ss syndrome. Thus, 23 percent of
these patients with severe chronic airway obstruction
had an ECG showing pseudo left axis deviation or
the SiSeSs syndrome.
Considerable debate exists as to the relative frequency and diagnostic value of the various electrocardiographic findings in chronic airway obstruction. The most frequently reported abnormalities
are ( 1 ) an inferior P vector, (2) P-pulmonale, (3)
right axis deviation with a superior and posterior
terminal QRS vector, and ( 4 ) low voltage. The incidence of left axis deviatim in chronic airway obstruction has been reported to vary between 2 and
13 percent.'-lo Some of these patients had coronary
artery disease, hypertension, etc, to explain the
presence of left axis deviation, but the majority did
not. Although the SiS2Ss syndrome has been reported
in chronic airway obstruction, it is frequently seen
in "normal" subjects, and the incidence in chronic
airway obstruction is unknown. The cause for this
pseudo left axis deviation is unknown but presumably related to a marked reduction in the electrical
CHEST, 71: 4, APRIL, 1977
conductance in the emphysematous lungs and to the
thoracic deformity which causes the heart to shift
leftward and posterior in position and not due to
anterior fascicular block.1° Our experience suggests
that pseudo left axis deviation and the SlSzSs syndrome are frequently seen in patients with severe
chronic airway obstruction.
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disease. Circulation 20:1067-1074, 1959
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ebmcadogram in puhnanary emphysema. Am Rev
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Br Heart J 26:233-240, 1964
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1956
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left axis deviation: Left intravenfriah blocks. Am Heart
J 72:391,1986
12 Steele PP, VanDyke D, Trow RS, et al: Simple and safe
bedside method for serial measurement of left ventricular
ejection fraction, cardiac output, and pulmonary blood
volume. Br Htxut J 36: 122-131, 1974
PSEUDO LEn AXIS DEVIATION AND SSS, SYNDROME 455
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