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J. Willis Hurst
Circulation 1998;98;1937-1942
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From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Ga.
Correspondence to J. Willis Hurst, MD, 1462 Clifton Rd NE, Suite 301, Atlanta, GA 30322.
(Circulation. 1998;98:1937-1942.)
© 1998 American Heart Association, Inc.
1937
1938 Naming the Waves in the ECG
of a supplementary electrical deflection that we pro- All J-wave deflections do not look alike. Some are merely
pose to call D.” elevations of ST segments in leads V1 and V2,37 whereas
others are of the spike-and-dome variety.26 This leads to the
conclusion that different mechanisms may be responsible for
Genesis of the Delta Wave the size and shape of J-wave deflections.
Wolferth and Wood pointed out that the abnormal slurring of
the initial part of the QRS complex and prolongation of the
QRS complex were not due to bundle-branch block as Genesis of the Osborn Wave
proposed by Wolff, Parkinson, and White but were caused by Knowing the work of Wilson and Finch38 relating the effect of
an “actual acceleration of the passage of the impulse from the drinking ice water on T waves of the ECG, I assumed that
auricle to a section of the ventricle.”16 intense total body hypothermia somehow delayed and slowed
They also stated, “all the data so far obtained are in keeping depolarization of a portion of the left ventricle. In our
with the possibility that an accessory pathway of AV con- patients,39 the mean vector illustrating the Osborn wave was
duction such as described by Kent [Reference 18] between directed to the left and parallel with the frontal plane or
the right auricle and right ventricle could be responsible for slightly anterior. This led to the view that the left anterior
the phenomenon manifested by these cases.” portion of the left ventricle was cooled more than other parts
of the left ventricle.
In 1996 Yan and Antzelevitch40 wrote
Osborn Wave
Our results provide the first direct evidence in
support of the hypothesis that heterogeneous dis-
Naming the Osborn Wave
The scholarly article by Gussak and associates19 served as the tribution of a transient outward current-mediated
spike-and-dome morphology of the action potential
source for most of the information that follows.
across the ventricular wall underlies the manifes-
The J point in the ECG is the point where the QRS complex
tation of the electrocardiographic J wave. The
joins the ST segment.19 It represents the approximate end of
presence of a prominent action potential notch in
depolarization and the beginning of repolarization as deter-
epicardium but not endocardium is shown to pro-
mined by the surface ECG. There is an overlap of '10
vide a voltage gradient that manifests as a J
milliseconds.20 The J point may deviate from the baseline in
(Osborn) wave or elevated J-point in the ECG.
early repolarization, epicardial or endocardial ischemia or
injury, pericarditis, right or left bundle-branch block, right or
left ventricular hypertrophy, or digitalis effect.21,22 The term J Epsilon Waves
deflection has been used to designate the formation of the Epsilon waves are often seen in the ECGs of patients with
wave produced when there is a large, prominent deviation of arrhythmogenic right ventricular dysplasia (Figure 4C).
the J point from the baseline. The J deflection has been called These waves are best seen in the ST segments of leads V1 and
many names,19 including camel-hump sign,23 late delta V2. They may be seen in leads V1 through V4. The duration of
wave,24 J-point wave,25 and Osborn wave.26 the QRS complex may be a bit longer in leads V1 and V2 than
The prominent J deflection attributed to hypothermia was in leads V5 and V6. Although the small wiggles may be seen
first reported in 1938 by Tomaszewski.27 The wave was in the routine ECG, they may be seen more readily in
observed by others, including Kossmann,28 Grosse-Brockhoff Fontaine leads. Fontaine described these leads in a letter to
and Schoedel,29 Bigelow et al,30 Juvenelle et al,31 and me dated September 5, 1997, and reproduced here with slight
Osborn.26 modifications:
Over the years, the unusual wave increasingly has been Such leads entail the placement of the right arm
called an Osborn wave (Figure 4B), probably because of electrode (negative) on the manubrium and the left
Osborn’s excellent article written in 1953.26 Clinicians la- arm electrode (positive) on the xiphoid. This pro-
beled the deflection an Osborn wave in honor of Osborn, one duces a bipolar chest lead. The recording of the
of the first American Heart Association research fellows. epsilon waves may also be enhanced by doubling the
Much has been written about the abnormal J deflection sensitivity of the record.
observed in patients with hypercalcemia.19 Other conditions In addition to the electrode placement described
have been reported to cause an abnormal J deflection, above, the placement of the foot lead (positive) in
including brain injury,32 subarachnoid hemorrhage,33 damage position V4 provides, instead of regular leads I, II, and
to sympathetic nerves in the neck,34,35 and cardiopulmonary III, three bipolar chest leads that can be called FI, FII,
arrest from oversedation.36 Brugada and Brugada37 reported and FIII. Tracings are then produced by setting the
patients with right bundle-branch block who exhibited non- machine on regular leads I, II, and III. This arrange-
coronary ST-segment elevation in the right precordial leads ment is used to record specifically the potentials
and experienced ventricular tachycardia or ventricular fibril- developed in the right ventricle, from the infundibu-
lation. A controversy now surrounds this condition because lum to the diaphragmatic area.
not all of the tracings show classic right bundle-branch block, The vertical bipolar lead FI, which is similar to VF,
and some patients might have arrhythmogenic right ventric- seems to be the most appropriate to record epsilon
ular dysplasia. waves; it also magnifies the atrial potentials. It could
Hurst November 3, 1998 1941
be useful in the search for AV dissociation in ven- alphabet, he would have other letters to label waves that
tricular tachycardia or to study abnormal atrial might be found before the P wave or after the T wave. He
rhythms when the P waves are too small on regular later discovered the U wave when he developed the string
leads. galvanometer. Why Einthoven mixed the old with the new
labeling in the tracing made with the string galvanometer
Naming the Epsilon Waves shown in the postage stamp created to honor him is
Fontaine named the epsilon waves. His personal account of his bewildering and unexplained.
discovery was described in his March 5, 1997, letter to me: Segers, Lequime, and Denolin named the delta wave. They
chose delta because 1 side of the slurred part of the QRS
. . . after discovering the first cases of late (or complex seems to parallel 1 side of the Greek letter delta.
delayed) potentials recorded at the time of surgery on Clinicians named the spike-and-dome wave caused by
the epicardium of patients with resistant ventricular hypothermia the Osborn wave in honor of Osborn. More
tachycardia. It was quite exciting to demonstrate that research is needed to determine the mechanisms responsible
these late potentials located on the free wall of the for the abnormal J deflections that appear in a diverse group
right ventricle of patients with arrhythmogenic right of conditions.
ventricular dysplasia could be recorded on the surface Fontaine discovered and named the epsilon waves. He
by signal averaging and in some circumstances by chose the epsilon because it follows delta in the Greek
increasing the magnification of ECG recording. alphabet and is the mathematical symbol for smallness.
As late potentials were supposed to be the result of
late activation of a limited group of fibers, the term
“post-excitation” looked logical, since it was ob- Acknowledgments
served after the main excitation of the ventricle, I wish to thank Dr Howard Burchell, Dr Charles Antzelevitch, Dr
Dennis Krikler, Dr Guy Fontaine, and Dr Clyde Partain for their help
leading to the QRS complex. The term “epsilon” was
in the preparation of this manuscript. This dissertation could not have
nice, because it occurs in the Greek alphabet after been written without their suggestions, but I wish to emphasize that
delta; thus, delta represents the preexcitation and any errors in the manuscript are mine and not theirs.
epsilon the post-excitation phenomenon. In addition,
epsilon is also used in mathematics to express a very References
small phenomenon . . . 1. The World Book Encyclopedia. Field Enterprises Inc; 1959:1954.
2. Waller AD. A demonstration on man of electromotive changes accom-
panying the heart’s beat. J Physiol. 1887;8:229 –234.
Genesis of Epsilon Waves 3. Burchell HB. A centennial note on Waller and the first human electro-
cardiogram. Am J Cardiol. 1987;59:979 –983.
Epsilon waves are caused by postexcitation of the myocytes
4. Snellen HA. Willem Einthoven (1860 –1927): Father of Electrocardiog-
in the right ventricle (Figure 4C). The young patient with raphy. Dordrecht, Netherlands: Kluwer Academic Publishers; 1995:
ventricular tachycardia or syncope and epsilon waves on the 23–27.
ECG usually has arrhythmogenic right ventricular dysplasia. 5. Einthoven W. Ueber die Form des menschlichen electrocardiogramms.
Arch Gesamte Physiol. 1895;60:101–123.
In this condition, myocytes are replaced with fat, producing
6. Henson JR. Descartes and the ECG lettering series. J Hist Med Allied Sci.
islands of the viable myocytes surrounded by fat. This causes April 1971;181–186.
a delay in excitation of some of the myocytes of the right 7. Snellen HA. Willem Einthoven (1860 –1927): Father of Electrocardi-
ventricle and causes the little wiggles seen during the ST ography. Dordrecht, Netherlands: Kluwer Academic Publishers;
1995:8 –9.
segment of the ECG. 8. DeWaart A. Het levenswerk van Willem Einthoven, 1860 –1927. Haarlem,
Epsilon waves have also been described in patients with Netherlands: Bohn; 1957.
posterior myocardial infarction.41 F.I. Marcus has observed 9. Durrer D. Electrical aspects of human cardiac activity: a clinical-
epsilon waves in a patient with sickle cell disease with right physiological approach to excitation and stimulation. Cardiovasc Res.
1968;2:1–18.
ventricular hypertrophy due to pulmonary arterial hypertension 10. Sicouri S, Quist M, Antzelevitch C. Evidence for the presence of M
(written communication, February 1997). Other diseases of the cells in the guinea pig ventricle. J Cardiovasc Electrophysiol. 1996;
right ventricle, including right ventricular infarction, infiltration 7:503–511.
disease, and sarcoidosis, might also produce the pathological 11. Wilson FN. A case in which the vagus influenced the form of the
ventricular complex of the electrocardiogram. Arch Intern Med. 1915;16:
substrate required for production of epsilon waves. 1008 –1027.
12. Antzelevitch C. The M cell. J Cardiovasc Pharmacol Ther. 1997;2:
73–76.
Conclusions 13. Wedd AM. Paroxysmal tachycardia; with reference to nomotopic
Einthoven named the waves in the ECG PQRST and tachycardia and the role of the extrinsic cardiac nerves. Arch Intern Med.
U. Having labeled the uncorrected waves made by the 1921;27:571–590.
14. Hamburger WW. Bundle-branch block: 4 cases of intraventricular block
Lippmann capillary electrometer ABCD, Einthoven
showing some interesting and unusual clinical features. Med Clin North
wanted to show how his mathematically corrected waves Am. 1929;13:343–362.
differed from uncorrected waves. Therefore, he had to use 15. Wolff L, Parkinson J, White PD. Bundle-branch block with the short P-R
labels other than ABCD. He chose PQRST because he was interval in healthy young people prone to paroxysmal tachycardia. Am
Heart J. 1930;5:685–704.
undoubtedly familiar with Descartes’ labeling of succes-
16. Wolferth CC, Wood FC. The mechanism of production of short P-R
sive points on a curve. Perhaps as an afterthought, he intervals and prolonged QRS complexes in patients with presumably
recognized that by choosing letters near the middle of the undamaged hearts: hypothesis of an accessory pathway of auricu-
1942 Naming the Waves in the ECG
loventricular conduction (bundle of Kent). Am Heart J. 1933;8: 31. Juvenelle A, Lind J, Wegelius C. Quelques possibilitiés offertes par
297–311. l’hypothermie générale profonde provoquée: une étude expérimentale
17. Segers PM, Lequime J, Denolin H. L’activation ventriculaire précoce de chez le chien. Presse Med. 1952;60:973–978.
certains coeurs hyperexcitables: etude de l’onde D de l’électrocardio- 32. Hersch C. Electrocardiographic changes in head injuries. Circulation.
gramme. Cardiologia. 1944;8:113–167. 1961;23:853– 860.
18. Kent AFS. A lecture on some problems in cardiac physiology. BMJ. 33. De Sweit J. Changes simulating hypothermia in the electrocardiogram in
1914;2:105. subarachnoid hemorrhage. J Electrocardiol. 1972;5:93–95.
19. Gussak I, Bjerregaard P, Egan TM, Chaitman BR. ECG phenomenon 34. Hugenholtz PG. Electrocardiographic changes typical for central nervous
called the J wave: history, pathophysiology, and clinical significance. system disease after right radical neck dissection. Am Heart J. 1967;74:
J Electrocardiol. 1995;28:49 –58. 438 – 441.
20. Mirvis DM. Electrocardiography: A Physiologic Approach. St. Louis, 35. Yanowitz R, Preston JB, Abildskov JA. Functional distribution of right
Mo: Mosby-Year Book; 1993. and left stellate innervation to the ventricles: production of neurogenic
21. Hurst JW. Abnormalities of the S-T segment, part I. Clin Cardiol. 1997; electrocardiographic changes by unilateral alteration of sympathetic tone.
20:511–520. Circ Res. 1966;18:426 – 428.
22. Hurst JW. Abnormalities of the S-T segment, part II. Clin Cardiol. 36. Jain U, Wallis DE, Shah K, Blakeman BM, Moran JF. Electrocardio-
1997;20:595– 600. graphic J waves after resuscitation from cardiac arrest. Chest. 1990;98:
23. Abbott JA, Cheitlin MD. The nonspecific camel-hump sign. JAMA. 1294 –1296.
1976;235:413– 414. 37. Brugada P, Brugada J. Right bundle branch block, persistent ST segment
24. Litovsky SH, Antzelevitch C. Rate dependence of action potential elevation and sudden cardiac death: a distinct clinical and electrocardio-
duration and refractoriness in canine ventricular endocardium differs graphic syndrome: a multicenter report. J Am Coll Cardiol. 1992;20:
from that of epicardium: role of the transient outward current. J Am Coll 1391–1396.
Cardiol. 1989;14:1053–1066. 38. Wilson FN, Finch R. The effect of drinking iced-water upon the form of
25. Hugo N, Dormehl IC, van Gelder AL. A positive wave at the J-point of the T deflection of the electrocardiogram. Heart. 1923;10:275–278.
electrocardiograms of anaesthetized baboons (Papio ursinus). J Med 39. Clements SD Jr, Hurst JW. Diagnostic value of electrocardiographic
Primatol. 1988;17:347–352. abnormalities observed in subjects accidentally exposed to cold. Am J
26. Osborn JJ. Experimental hypothermia: respiratory and blood pH changes Cardiol. 1972;29:729 –734.
in relation to cardiac function. Am J Physiol. 1953;175:389 –398. 40. Yan G-X, Antzelevitch C. Cellular basis for the electrocardiographic J
27. Tomaszewski W. Changements électrocardiographiques observés chez un wave. Circulation. 1996;93:372–379.
homme mort de froit. Arch Mal Coeur. 1938;31:525–528. 41. Fontaine G, Guiraudon G, Frank R, Vede K, Grosgogeat Y, Cabrol C,
28. Kossmann CE. General cryotherapy: cardiovascular aspects. Bull N Y Facquet J. Stimulation studies and epicardial mapping in ventricular
Acad Med. 1940;16:317. tachycardia: study of mechanisms and selection for surgery. In: Kulbertus
29. Grosse-Brockhoff F, Schoedel W. Das bild der akuten unterkuhlung im HE, ed. Re-entrant Arrhythmias: Mechanisms and Treatment. Lancaster,
tierexperiment. Arch Exp Path Pharmakol. 1943;201:417. Pa: MTP Publishers; 1977:334 –350.
30. Bigelow WG, Lindsay WK, Greenwood WF. Hypothermia: its possible
role in cardiac surgery: investigation of factors governing survival in dogs KEY WORDS: electrocardiography n ECG waves, naming of n ECG waves,
at low body temperatures. Ann Surg. 1950;132:849 – 866. genesis of