What is the management of late QRS (Quadrature Amplitude Modulation Signal) transition and abnormal R wave progression on electrocardiogram (ECG) in a 35-year-old female with palpitations?

From the Guidelines

For a 35-year-old female with palpitations who has late QRS transition and abnormal R wave progression on ECG, I strongly recommend a comprehensive cardiac evaluation including a 12-lead ECG, echocardiogram, and ambulatory cardiac monitoring (Holter or event monitor for 24-48 hours) to rule out underlying structural heart disease. These ECG findings may represent normal variants but could also indicate underlying structural heart disease such as right ventricular hypertrophy, posterior myocardial infarction, or cardiomyopathy, as suggested by the international recommendations for electrocardiographic interpretation in athletes 1. Initial management should focus on symptom control with beta-blockers such as metoprolol 25-50 mg twice daily or propranolol 10-20 mg three times daily while the evaluation is ongoing. The patient should be referred to a cardiologist for further assessment, particularly if symptoms are frequent or associated with dizziness or syncope. Some key points to consider in the evaluation and management include:

• The significance of late QRS transition and abnormal R wave progression lies in their potential to indicate altered ventricular depolarization patterns, which may reflect changes in cardiac structure or electrical conduction that could predispose to arrhythmias causing the patient's palpitations.
• Lifestyle modifications including caffeine reduction, adequate hydration, and stress management techniques are also important.
• If the workup reveals structural heart disease, treatment will be directed at the underlying condition, as outlined in the guidelines for electrocardiographic interpretation in athletes 1. It is crucial to prioritize a thorough evaluation given the potential for these ECG findings to be associated with significant cardiac conditions, as emphasized by the need for further diagnostic investigation for abnormal ECG findings in athletes 1.

From the Research

Management of Late QRS Transition and Abnormal R Wave Progression on ECG

• The management of late QRS transition and abnormal R wave progression on ECG in a 35-year-old female with palpitations can be approached by considering the potential causes of these ECG findings.
• Poor R-wave progression, which is often associated with late QRS transition, can be caused by several factors, including anterior myocardial infarction (AMI), left ventricular hypertrophy, right ventricular hypertrophy, and a variant of normal with diminished anterior forces 2.
• The study by 2 provides an interpretive approach to the ECG with poor R-wave progression, which has clinical relevance in the daily treatment of patients.
• Another study 3 found that arrhythmogenic right ventricular cardiomyopathy is a progressive disease, and tricuspid regurgitation is an independent predictor of structural disease progression, which may be exacerbated by the use of a transvenous implantable cardioverter defibrillator lead.
• The use of functional imaging techniques, such as Fourier transform parameter, can provide additional diagnostic information concerning the cardiovascular system, without imposing any further stress on the patient 4.

Potential Causes and Diagnostic Approaches

• The potential causes of late QRS transition and abnormal R wave progression on ECG include:
  • Anterior myocardial infarction (AMI)
  • Left ventricular hypertrophy
  • Right ventricular hypertrophy
  • A variant of normal with diminished anterior forces
  • Arrhythmogenic right ventricular cardiomyopathy
• Diagnostic approaches may include:
  • ECG interpretation using standard criteria to identify and distinguish the causes of poor R-wave progression 2
  • Echocardiography to assess structural and functional changes in the heart 3
  • Functional imaging techniques, such as Fourier transform parameter, to provide additional diagnostic information 4