Baylor University Medical Center Proceedings April 2017 - 228

Two causes in one patient for extremely low voltage on the
electrocardiogram
William C. Roberts, MD, Melody Joy Sherwood, MD, and Paul A. Grayburn, MD

Figure 1. Electrocardiogram in the patient described. The standard is 20 mm, rather than the usual 10 mm.

An 80-year-old woman is described with two different causes (pericardial
effusion and cardiac amyloidosis) for low QRS voltage on the electrocardiogram. Total 12-lead QRS voltage (from the peak of the R wave to the
nadir of either the Q or the S wave, whichever is deeper) was only 34 mm
(10 mm standard in all leads), the lowest we have encountered among
331 previously reported patients with 10 different cardiac conditions.

A

mong the causes of extremely low voltage on the electrocardiogram are large pericardial effusions and cardiac amyloidosis. The occurrence of both conditions in the same
patient can lead to extremely low voltage on the electrocardiogram. The occurrence of such a situation prompted this report.
CASE DESCRIPTION
An 80-year-old woman with dementia was hospitalized because of worsening confusion and lower leg edema. She was known
to have systemic hypertension and diabetes mellitus. She was in no
acute distress. Her blood pressure was 85/60 mm Hg. Her body
mass index was 18 kg/m2. No abdominal organs or subcutaneous
228

lymph nodes were palpated. The electrocardiogram showed total
12-lead QRS voltage of 17 mm (standard ≈ 20 mm; double standard) (Figure 1). An echocardiogram disclosed pericardial effusion,
thickened right and left ventricular walls, and low (≈20%) ejection
fraction (Figure 2). Both ventricular cavities were of normal size.
DISCUSSION
Total 12-lead QRS voltage was introduced in 1982 as a means
to predict the presence of left ventricular hypertrophy (1) (Figure 3).
Subsequently, total 12-lead QRS voltage has been described in 10
different disease states involving 331 patients and compared in all
to heart weight (2). It has been found to be a better predictor of
left ventricular hypertrophy than any previous criteria.
The concept of low QRS voltage was described initially when
only three electrocardiographic leads were available. The 12-lead
From the Baylor Heart and Vascular Institute and the Department of Internal
Medicine, Division of Cardiology, Baylor University Medical Center at Dallas, Texas.
Corresponding author: William C. Roberts, MD, Baylor Heart and Vascular
Institute, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas,
TX 75246 (e-mail: william.roberts1@bswhealth.org).
Proc (Bayl Univ Med Cent) 2017;30(2):228-229



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