From the Guidelines
Epsilon waves on an EKG are a highly specific marker for arrhythmogenic right ventricular cardiomyopathy (ARVC) and should prompt further evaluation with echocardiography, CMR, exercise ECG test, and minimum 24 h ECG monitor, as recommended by the international guidelines for electrocardiographic interpretation in athletes 1. The presence of epsilon waves is a major diagnostic criterion for ARVC, and their identification is crucial for the diagnosis and management of this condition. Epsilon waves are small, low-amplitude signals that appear between the end of the QRS complex and the beginning of the T wave, typically in leads V1-V3.
- They are caused by delayed activation of some areas of the right ventricle due to fibrofatty replacement of the myocardium, which is characteristic of ARVC.
- The presence of epsilon waves, along with other clinical and diagnostic criteria, can help in the diagnosis of ARVC.
- However, the absence of epsilon waves does not rule out ARVC, and further evaluation is necessary to confirm the diagnosis. The international guidelines for electrocardiographic interpretation in athletes recommend that epsilon waves be considered a highly specific ECG marker for ARVC, and that further evaluation be performed to confirm the diagnosis 1.
- This evaluation should include echocardiography, CMR, exercise ECG test, and minimum 24 h ECG monitor.
- The use of appropriate filter settings on the ECG machine is crucial for the proper identification of epsilon waves, as high-pass filters may obscure these small signals.
- A paper speed of 50 mm/s and an amplification of 20 mm/mV are often recommended for optimal visualization. While other studies have also highlighted the importance of epsilon waves in the diagnosis of ARVC, the most recent and highest quality study recommends a comprehensive evaluation for athletes with epsilon waves on their EKG 1.
From the Research
Significance of Epsilon Waves on an Electrocardiogram (EKG)
- Epsilon waves are associated with serious conditions such as arrhythmogenic right ventricular cardiomyopathy, posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia 2
- The presence of epsilon waves is a major diagnosis criterion for arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVD/C) and can be a marker of poor prognosis 3, 4
- Epsilon waves may be present in a variety of other medical conditions, including posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia 2
Detection and Characteristics of Epsilon Waves
- Epsilon waves can be detected on a standard 12-lead ECG and can be enhanced visually using higher right precordial leads or Fontaine bipolar precordial lead (F-ECG) 5
- The duration and precordial/inferior lead extension of epsilon waves can provide additional information about their clinical significance 6
- Epsilon waves are associated with right ventricular outflow tract (RVOT) abnormalities and increased RVOT diameter 6
Clinical Significance of Epsilon Waves
- The presence of epsilon waves is associated with episodes of sustained ventricular tachycardia, but not with heart failure or sudden cardiac death 6
- Epsilon waves can be a marker of significant RVOT involvement and poor prognosis in patients with arrhythmogenic cardiomyopathy 4, 6
- The detection of epsilon waves on a 12-lead ECG can reflect significant RVOT involvement and provide important information for diagnosis and management of arrhythmogenic cardiomyopathy 6