Goldberger reported a triad of changes in the electrocardiogram which is seen in patients with congestive heart failure (CHF). The author is from the University of California at San Diego and the San Diego Veterans Administration Medical Center.


Triad of changes seen with congestive heart failure:

(1) high QRS voltage in precordial leads due to left ventricular enlargement

(2) poor R wave progression due to a shift of the horizontal plane vector posteriorly

(3) relatively low voltages in the limb leads due to peripheral edema


ECG Changes


high QRS voltages in precordial leads

(SV1 or SV2) + (RV5 + RV6) >= 3.5 mV

poor R wave progression

R/S ratio < 1 in lead V4

low voltage in limb leads

total QRS amplitude <= 0.8 mV in each of the 6 extremity leads


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