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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& Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/20992/ on 05/02/2017 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 Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/20992/ on 05/02/2017 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. 1 Spodick DH: E l d o g r a p h i c studies in puhnonary disease. Circulation 20:1067-1074, 1959 2 Spodick DH, Hauger-Klevene JH,Tyler JM,et al: The ebmcadogram in puhnanary emphysema. Am Rev Respir Ms 88:1419, 1963 3 Selvester RH, Rubin HB: New criteria for the electroa d o g q h i c rliapnr#in of emphysema and cor pulmonale. Am Heart J g9:437-447,1985 4 Millard FJC: The ekctmcardiograrn in chronic lung disease. Br Heart J 29:4330, 1967 5 Calatapd JB,Abad JM, ghoi NB, et al: P wave changes in chronic obsbuctive ptdmmuy disease. Am Heart J 79 :444-453, 1970 6 gilcayne MM, Davis AL, Fen& MI: A dynamic electroaudiographk concept useful in diagnosis of cur pulm o d e . Circulation 42:903-924, 1970 7 Shmodc CL, Poumrantz B, Mitche1 RS, et al: The electrocardiogram in emphysema with and without chronic ainuays obstruction. Chest 60:328-334, 1971 8 Littman D: Tbe ehrocadiographic 6ndings in pulmonary emphysema. Am J Cardid 5:339348,1960 9 Rees H, Thomas AJ, Roesiter C: The recognition of coronary heart disease in the presence of pulmonary disease. Br Heart J 26:233-240, 1964 10 Grant RP: Left axis deviation. CirrJation 14:233-249, 1956 11 Pryor R, Blount SGB Jr: The clinical s i g d h m e of true 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 Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/20992/ on 05/02/2017