Low QRS Voltage

Definition

The QRS is said to be low voltage when:

  • The amplitudes of all the QRS complexes in the limb leads are < 5 mm; or
  • The amplitudes of all the QRS complexes in the precordial leads are  < 10 mm
ECG myxoedema low voltage

Low QRS voltage due to myxoedema

Mechanisms

Low voltage is produced by…

  • The “damping” effect of increased layers of fluid, fat or air between the heart and the recording electrode.
  • Loss of viable myocardium.
  • Diffuse infiltration or myxoedematous involvement of the heart.

Causes

Specific causes of low voltage include:

The most important cause is massive pericardial effusion, which produces a triad of:

  • Low voltage
  • Tachycardia
  • Electrical alternans

Patients with this triad need to be immediately assessed for clinical or echocardiographic evidence of tamponade. 

ECG Examples

Example 1

Massive Pericardial Effusion

Massive Pericardial Effusion:

 

Example 2

Low voltage in V1-6 due to prior massive anterior MI

Prior Massive Anterior MI:

  • Low QRS voltage in V1-6. This diffuse loss of R wave height suggests extensive myocardial loss from a prior anterior MI.
  • This ECG also demonstrates biphasic anterior T waves (Wellen’s syndrome) indicating new critical occlusion of the LAD artery.

 

Example 3

Pulmonary disease pattern

Emphysema:

  • Low voltages in the limb leads is classically seen in patients with emphysema.
  • Other features of emphysema include:  rightward axis, peaked P waves (P pulmonale) and clockwise rotation (persistent S wave in V6)

 

Learn From The Experts!

Consolidate your learning with lessons from the masters of ECG interpretation. Follow the links below for expert commentary, video lessons, case-based discussion and detailed explanations to take your learning to the next level.

Take The Next Step.

You’ve made the ECG diagnosis, now what? Think beyond the ECG with lessons on advanced diagnosis and management.

  • Ultrasound Podcast  – How to diagnose pericardial tamponade on bedside echo, Part 1 and Part 2 (video lessons)

Related Topics

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