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2008;17:273-274Am J Crit CareMary G. Carey and Michele M. PelterCornell Voltage Criteria

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www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE May 2008, Volume 17, No. 3 273

CORNELLVOLTAGE CRITERIA

ECG Puzzler

By Mary G. Carey, RN, PhD, and Michele M. Pelter, RN, PhD

Scenario:An 83-year-old woman with ischemic

cardiomyopathy comes in for a routine checkup. She is

receiving appropriate medical management with phar-

macological agents and has had no acute symptoms.

A regular feature of theAmerican Journal of Critical Care, the ECG Puzzleraddresses electrocardiogram (ECG) interpretation for clinical practice. To send an eLetter or to contribute to an online discussion about this article, visitwww.ajcconline.org and click Respond to ThisArticle on either the full-text or PDF view of the article. We welcome letters regarding this feature.

For every ECG, we recommend that readerssystematically examine the following 9 features(check all that apply):

1. RateK Normal (60-90 beats per minute)K Bradycardia (90 beats per minute)

2. RhythmK RegularK IrregularK Irregular-regular

3. P wavesK One P wave for every QRS complexK Fewer P waves than QRS complexesK More P waves than QRS complexes

K Cannot determine

4. PR intervalK Normal (0.20 seconds)K Short (0.20 seconds)K Cannot determine

5. QRS complex durationK Normal (0.12 seconds)KWide (>0.12 seconds)

6. QRS complex direction lead V1K Negative and 0.12 seconds (normal)K Negative and >0.12 seconds (LBBB)K Positive and >0.12 seconds (RBBB)K Cannot determine

7. ST segmentsK NormalK Elevated (2 mm)K Depressed (2 mm)K Elevation/depression 2 contiguous

(side by side) leads (1 mm)

8. T waveK

NormalK Inverted

9. QTcK NormalK Lengthened (>0.47 seconds)

About the AuthorsMary G. Carey is an assistant professor in the School of Nursing at the State University of New York at Buffalo.Michele M. Pelter is an assistant professor at the Orvis School of Nursing, University of Nevada, Reno.

aVL

V3

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InterpretationControlled atrial fibrillation at 83/min, with left

ventricular hypertrophy (LVH)

RationaleAtrial fibrillation is present with irregularly irregular

ventricular activity in the absence of discrete P waves for

every QRS. Although the third QRS complex has what

appears to be a P wave in front of it, this pattern is not con-sistent throughout the strip. The ventricular rate is fewer

than 100/min; therefore, the ventricular response is con-

trolled. The Q wave in aVL (nearly 40-ms duration)

suggests a prior myocardial infarction; given the patients

cardiomyopathy, the contiguous lateral leads, I and V6,

also should be evaluated. The amplitude of the S wave

in V3 suggests this patient may have LVH.

Although the Cornell Product is the best method for

ECG diagnosis of LVH (sensitivity, 51%; specificity,

95%), the calculations are tedious and require a calcula-

tor. It is simpler for bedside clinicians to use the Cornell

274 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2008, Volume 17, No. 3 www.ajcconline.org

Voltage Criteria (sensitivity, 42%; specificity, 95%),

where LVH is present if the sum of the R wave in aVL

and the S wave in V3 exceeds 20 mm (female) or 28

mm (male). In this example, lead aVL has R-wave

amplitude of 4 mm and V3 has an S wave of 24 mm.

The sum is 28 mm, meeting the ECG criteria for LVH.

Nursing Actions

Atrial fibrillation is the most common sustainedarrhythmia, and this patient is appropriately man-

aged because the ventricular rate is controlled. A

previous ECG, and preferably an echocardiogram,

would be helpful for evaluating ventricular enlarge-

ment (LVH). Patients with cardiomyopathy are vul-

nerable to remodeling of the left ventricle, so efforts

should focus on optimizing cardiac synchrony and

cardiac pump function, which is typically done with

pharmacological agents and, in some cases, a pacer.

Importantly, continued optimal cardiac care can

improve this patients long-term outcome.

ANSWERS1. Rate

KNormal (60-90 beats per minute)K Bradycardia (90 beats per minute)

2. RhythmK RegularKIrregularK Irregular-regular

3. P wavesK One P wave for every QRS complexK Fewer P waves than QRS complexesK More P waves than QRS complexesKCannot determine

4. PR intervalKNormal (0.20 seconds)K Short (0.20 seconds)KCannot determine

5. QRS complex durationKNormal (0.12 seconds)KWide (>0.12 seconds)

6. QRS complex direction lead V1K Negative and 0.12 seconds (normal)

K Negative and >0.12 secondsK Positive and >0.12 secondsKCannot determine

7. ST segmentsKNormalK Elevated (2 mm)K Depressed (2 mm)K Elevation/depression 2 contiguous

(side by side) leads (1 mm)

8. T waveKNormalK Inverted

9. QTcKNormalK Lengthened (>0.47 seconds)

aVL

V3

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