Precordial low voltage in patients with ascites

Abstract

Aims Electrocardiographic (ECG) changes in patients with ascites are not well studied. The aim of this study was to evaluate ECG changes in patients with ascites.Methods and results Prospective analysis of patients with ascites who were referred for paracentesis. Three ECGs were recorded before paracentesis. ECG 1 was a standard 12-lead ECG. For ECG 2 the precordial leads were placed 1 intercostal space (ICS) and for ECG 3, 2 ICS cranially. The sums (S) of the QRS in ECG1 were compared with ECG 2 and 3. In six patients the same ECG protocol was performed after removal of ascites. Ten hospitalized patients without ascites served as controls. Twenty patients with ascites were analysed. Limbs leads low voltage was present in 11 patients and precordial low voltage in four patients. Cranial placement of the precordial electrodes increased SQRS in all patients with ascites. The most prominent voltage changes appeared in the leads V4-V6 (þ62%). Paracentesis of ascites normalized precordial leads low-voltage, while limbs leads low voltage remained. Cranial placement of the precordial electrodes in patients without ascites decreases SV1-V6. Conclusion We describe a phenomenon of precordial voltage changes in patients with ascites, not reported in the literature yet. By placing the precordial electrodes 1 and 2 ICS cranially the voltage changes can be 'corrected' and this should be done in all patients prior to further diagnostic workup. Removal of the ascites normalizes the precordial leads low voltage.

QT Interval Prolongation and QRS Voltage Reduction in Patients with Liver Cirrhosis

“…It is likely that ascites that induces an increase in intra-abdominal pressure impairs myocardial kinetics. The only study on this issue available in the literature demonstrated reduced QRS voltage in patients with ascites of various etiologies [11]. The study in question was conducted in a small and non-homogenous group of patients (20 with neoplastic ascites or in the course of alcoholic cirrhosis and 10 controls).…”

“…Low QRS voltage in the limb leads was observed in more than half of the patients, and in the precordial leads in 4 patients. Paracentesis, performed in only 6 patients, normalized QRS voltage in the precordial leads without affecting the limb leads [11].…”

“…The implicated ECG abnormalities in cirrhotic patients include chronotropic incompetence, electromechanical uncoupling and QT interval prolongation [11,12]. The QT interval measures the length of ventricular systole.…”

Authors’ Reply

“…Cuculi et al [2] have shown that the drainage of ascites normalized the electrocardiographic voltage in the precordial leads. Considering the fact that myxedema ascites is treated by hormone replacement therapy, we agree that the presence of ascites should be assessed in patients with predominant precordial low voltage.…”

Various Explanations for the Phenomenon of Low Voltage in Patients with Hypothyroidism

“…Pericardial effusion clearly increases resistance and can explain low voltage although little is known to what extent the volume and composition of the effusion affects eration. We assessed the phenomenon of low voltage in patients with ascites and demonstrated that attenuated voltage could be partially corrected if the precordial electrodes were placed one or two intercostal spaces cranially [4] . Having in mind that severe hypothyroidism is associated with ascites [5] and that there was a trend toward lower albumin values in the study by Yamanaka et al [1] , we believe that the presence of ascites should be actively assessed when severely hypothyroid patients are diagnosed with low voltage.…”