Goldberger's Electrocardiographic Triad in Patients With Echocardiographic Severe Left Ventricular Dysfunction

In 1982, Goldberger described an electrocardiographic triad (SV 1 or SV 2 + RV 5 or RV 6 ≥3.5 mV, total QRS amplitude in each of the limb leads ≤0.8 mV, and R/S ratio 4 ) that was 70% sensitive and >90% specific for detecting severe left ventricular (LV) dysfunction. To confirm his sensitivity results, in 51 consecutive patients (36 men) aged 28 to 84 years (mean 56) with LV ejection fractions ≤20%, the electrocardiographic triad was sought in the electrocardiogram (ECG) recorded closest in time to the echocardiographic study. All 51 patients had systemic arterial hypertension. Evidence of ischemia was present in 7 and absent in 38, and in 6 patients, ischemic status was unknown. In 49 patients, New York Heart Association functional class was available: class II in 8, class III in 32, and class IV in 9. LV ejection fractions ranged from 4% to 20% (mean 14%), and LV internal end-diastolic diameters ranged from 5.7 to 8.6 cm (mean 6.6). Left atrial anteroposterior diameters ranged from 2.9 to 6.1 cm (mean 4.7) and were ≥4.0 cm in 47 of the 51 patients. The right ventricular cavity was enlarged in 22 patients. SV 1 or SV 2 + RV 5 or RV 6 was ≥3.5 mV in 29 of the 51 ECGs; total QRS amplitude was ≤0.8 mV in each of leads I, II, and III in 10; and the R/S ratio was 4 in 37. Only 1 of the 51 ECGs met all 3 criteria. In contrast to Goldberger's finding of the triad to be 70% sensitive for severe LV dysfunction, in this study, the triad was found to be only 2% sensitive. The difference is likely due to his patients' having idiopathic dilated cardiomyopathy, whereas those in this study had hypertensive cardiomyopathy with or without ischemia. Also, in this study, 1 specific ECG was used for each patient, whereas Goldberger reviewed all of the patients' ECGs looking for the triad. In conclusion, Goldberger's triad is a sensitive or insensitive marker for severe LV dysfunction depending on the patient population and the number of ECGs reviewed.