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com

Journal of Electrocardiology 43 (2010) 302 – 309

www.jecgonline.com

When deriving the spatial QRS-T angle from the 12-lead

electrocardiogram, which transform is more Frank: regression or
inverse Dower?
Daniel L. Cortez, BS, a,b,c Todd T. Schlegel, MD c,⁎
a
University of Illinois College of Medicine, Champaign and Rockford, IL, USA
b
National Space Biomedical Research Institute, Houston, TX, USA
c
NASA Johnson Space Center, Houston, TX, USA
Received 20 January 2010

Abstract Introduction: Our primary objective was to ascertain which commonly used 12-to-Frank-lead
transformation yields spatial QRS-T angle values closest to those obtained from simultaneously
collected true Frank-lead recordings.
Materials and Methods: Simultaneous 12-lead and Frank XYZ-lead recordings were analyzed for 100
postmyocardial infarction patients and 50 controls. Relative agreement, with true Frank-lead results, of
12-to-Frank-lead–transformed results for the spatial QRS-T angle using Kors' regression versus inverse
Dower was assessed via analysis of variance, Lin's concordance, and Bland-Altman plots.
Results: Spatial QRS-T angles from the true Frank leads were not significantly different than
those derived from the Kors' regression-related transformation but were significantly smaller than
those derived from the inverse Dower-related transformation (P b .001). Independent of method,
spatial mean QRS-T angles were also always significantly larger than spatial “maximum”
(“peaks”) QRS-T angles.
Discussion: Spatial QRS-T angles are best approximated by regression-related transforms. Spatial
mean and spatial “peaks” QRS-T angles should not be used interchangeably.
Published by Elsevier Inc.
Keywords: Vectorcardiography; Spatial ventricular gradient; 3-Dimensional ECG; Lead reconstruction

Introduction demonstrate better performance in reconstructing the actual

Frank XYZ-lead signals.14,16 However, it remains unclear
The spatial QRS-T angle has repeatedly been shown to
from the literature which of these methods actually best
have diagnostic1-3 and prognostic4-12 value. Changes in spatial
reconstructs those secondarily derived parameters, such as
QRS-T angles, for example, may be useful in evaluating
the spatial QRS-T angle, that have enough clinical
efficacy of hypertension treatment,1 diabetes mellitus,3
importance to effectively drive a clinical need for 12-to-
incident coronary heart disease2,10 and heart failure,2,9,11 and
Frank-lead transformations.
most importantly the propensity for cardiac events2,4,12 and
Interestingly, in healthy, nonhospitalized individuals,
mortality.4-7,12 Of the various Frank-lead vectorcardiocardio-
mean values for the spatial mean (SM) QRS-T angle derived
graphic (VCG) reconstruction methods used for approximat-
from inverse Dower-related reconstructions have typically
ing spatial QRS-T angle values from conventional 12-lead
ranged from 66 to 81 degrees,8,17,18 whereas those derived
electrocardiogram (ECG) recordings,13–16 arguably the 2 most
from Kors' regression-related reconstructions have typically
common are the inverse Dower-related reconstruction
ranged from 44 to 65 degrees,19,20 the latter evidently closer
technique13 and the regression-related method of Kors
to mean values obtained from the true Frank leads (35-51
et al.14 Of these 2 methods, the latter has tended to
degrees).21,22 To further complicate matters, the spatial
QRS-T angle has often been measured as the angular
⁎ Corresponding author. NASA Johnson Space Center, Mail code SK3 difference between the “maximums” (peaks) of the 3-
Houston, TX 77058, USA. dimensional QRS and T loops (spatial “maximum” QRS-T
E-mail address: todd.t.schlegel@nasa.gov angle)1,3,23-25 rather than as the angle between the position
0022-0736/$ – see front matter. Published by Elsevier Inc.
doi:10.1016/j.jelectrocard.2010.03.010
 D.L. Cortez, T.T. Schlegel / Journal of Electrocardiology 43 (2010) 302–309 303

Table 1
Results for the control group, post-MI group, and total sample for the true Frank leads and for the Kors' regression-related and inverse Dower-related
transformations
Parameter Control group (n = 50) Post-MI group (n = 100) Total sample (n = 150)
SM QRS-T angle (°)-true Frank leads 54.4 ± 25.8 84.3 ± 39.8 74.3 ± 38.3
SM QRS-T angle (°)-Kors' regression 53.4 ± 26.0 91.4 ± 39.4 78.8 ± 39.7
SM QRS-T angle (°)-inverse Dower 70.0 ± 28a,b 98.3 ± 40.9a 88.9 ± 39.4a,b
SP QRS-T angle (°)-true Frank leadsc 41.7 ± 27.1 68.9 ± 40.9 59.8 ± 38.9
SP QRS-T angle (°)-Kors' regressionc 40.7 ± 23.5 76.4 ± 42.1 64.5 ± 40.6
SP QRS-T angle (°)-inverse Dowerc 58.4 ± 27.8a,b 87.9 ± 45.7a 78.1 ± 42.9a,b
SVG magnitude (mV ⁎ ms)-true Frank leads 98.3 ± 44.7 46.7 ± 22.0 63.9 ± 39.7
SVG magnitude (mV ⁎ ms)-Kors' regression 101.9 ± 44.1 51.6 ± 25.2 68.4 ± 40.3
SVG magnitude (mV ⁎ ms)-inverse Dower 97.3 ± 44.3 54.0 ± 28.0 68.4 ± 39.8
SVG elevation (°)-true Frank leads 32.1 ± 11.0 28.3 ± 33.6 29.2 ± 28.2
SVG elevation (°)-Kors' regression 32.6 ± 9.9 24.7 ± 29.1 27.3 ± 24.7
SVG elevation (°)-inverse Dower 28.5 ± 11.4 20.1 ± 26.9 22.9 ± 23.2a
SVG azimuth (°)-true Frank leads 20.0 ± 21.7 −8.1 ± 62.3 1.3 ± 53.9
SVG azimuth (°)-Kors' regression 19.9 ± 17.6 −0.5 ± 64.7 6.3 ± 54.5
SVG azimuth (°)-inverse Dower 11.5 ± 20.0 −5.4 ± 70.9 0.3 ± 59.4
a
Derived VCG result significantly differs from true Frank-lead result by ANOVA.
b
Derived VCG results significantly differ from one another by ANOVA.
c
SP QRS-T angle results significantly differ from SM QRS-T angle results.

vectors defined by the areas of these same loops (spatial
“mean” QRS-T angle4-11,17-22,26-29—see Appendix 1 for
our own understanding of the difference). Even more
confusingly, healthy subjects have also typically had higher
mean values for the spatial “mean” QRS-T angle than for the
spatial “maximum” QRS-T angle (means for the latter
ranging from 11 to 21 degrees for inverse Dower
transformations1,3,23 and from 42 to 51 degrees for the true
Frank leads).24,25 In the present study, we used Lin's
concordance correlation coefficient to ascertain the relative
concordance, to true Frank-lead results, of 12-to-Frank-
lead–transformed results derived from Kors' regression-
related versus inverse Dower-related reconstructions. Based
on the comparatively smaller mean quadratic deviations
from the true XYZ leads that have been noted for the Kors'
regression method in the past,16 we hypothesized that this
method would also better approximate important secondarily
derived VCG parameters such as the spatial QRS-T angle.
We also sought to better define any differences between
results for the SM versus spatial “maximum” (“peaks”) QRS-
T angles using both the true Frank leads and the 2 different
reconstruction methods.
Methods
Data collection
The data were obtained from a publicly available source,
the Physikalisch-Technische Bundesanstalt (PTB) Diagnos-
tic ECG Database30 available at http://www.physionet.org/
physiobank/database/ptbdb/. The PTB ECG data were
collected in the 1990s by Dr Michael Oeff et al at the
Department of Cardiology of University Clinic Benjamin
Franklin in Berlin, Germany, using a noncommercial
prototype recorder that allowed the simultaneous acquisition
of both 12-lead ECG and true Frank-lead VCG data stored at
1000 samples per second per channel. We focused our own
analyses on data from: (1) PTB patients 001 through 101, all
of whom were being evaluated for a recent myocardial
infarction (MI) and (2) the first 50 “healthy controls” in the
PTB database, beginning with PTB subject 0104, as
specified by the PTB demographic files that accompany
the recorded raw data. In the recent MI group, the mean (SD)
age was 58.8 (11.3) years, and 72% were males. In the
healthy control group, the mean (SD) age was 43.5 (14.7)
years, and 76% were males.
Data analyses
The raw binary data files from the PTB database were
processed using software developed by the authors at
NASA's Johnson Space Center.20,31 Initial analyses revealed
that all of the selected files except recent MI-patient file 079
(which demonstrated a paced rhythm and was not analyz-
able) had, at a minimum, 40 QRS-T complexes that were
acceptable for signal averaging in all channels when using a
minimum cross-correlation cutoff of 97% against the signal-
averaged QRS templates formed for each channel in each
file, as previously described.20,31 Thus, 40-complex signal
averages were ultimately constructed for each patient's file,
the principal purpose of signal averaging being to help
eliminate any transient or nonreproducible effects that would
more likely influence single complexes than signal averages,
such as the precise location of a given complex within the
respiratory cycle.
VCG parameters from the true and derived Frank leads
The principal VCG parameters studied were the SM and
spatial “peaks” (SP) QRS-T angles, the magnitude of the
spatial ventricular gradient (SVG), and the elevation and
azimuth angles of the SVG. Time integrals (areas) for the X,
Y, and Z signals were first determined separately for the
QRS and T complexes by measuring the areas of the
complexes above and below the baseline and subtracting
negative areas from positive areas. The time integrals of the
304 D.L. Cortez, T.T. Schlegel / Journal of Electrocardiology 43 (2010) 302–309

X, Y, and Z signals for the given complex (QRS or T) then Statistics

yielded the spatial QRS and T position vector components,
respectively. The magnitude of the sum of the spatial QRS
and T vectors in turn yielded the SVG, whereas the angle
between the same 2 vectors yielded the SM QRS-T angle.27
The SP QRS-T angle was calculated in a fashion similar to
the SM QRS-T angle except that instead of using areas as
position vector components, the vector magnitude peak
values in the QRS and T regions (“loops”) constituted the
vector components for the calculation of the angle. (For
further details, including the mathematical derivations of all
the above parameters, see Appendix 1.) For the directional
aspects of the SVG vector (ie, azimuth and elevation), the
coordinate system of Draper et al27 was used. Results for all
parameters were calculated both directly, from the true
Frank XYZ lead recordings themselves (which served as the
“gold standard”), and indirectly, from the inverse Dower13
and Kors' regression-related14 Frank-lead reconstructions
that used the simultaneously collected standard 12-lead
ECG recordings.
Statistical evaluations were performed for the entire
group and separately for the 100 post-MI patients and the
50 healthy control subjects using Stata version 10 (Stata,
College Station, TX). Analysis of variance (ANOVA) was
used to study differences in results from the true Frank
leads versus those from the Kors' regression-related and
inverse Dower-related reconstructions. All nonnormalized
data were log-normalized before applying the ANOVA,
with subsequent use of Bartlett's test to confirm equal
variances and Bonferroni pairwise post hoc testing when
the ANOVA revealed significant (P b .05) differences.
Wilcoxon rank-sum and matched pairs signed-ranked tests
were also used with appropriate adjustments for multiple
comparisons to assess differences between the post-MI and
healthy control groups, and between the SM and SP QRS-T
angles, respectively.
We also used Lin's concordance correlation coefficient32
to evaluate the relative agreement with the true Frank-lead–

Fig. 1. Representative 3-dimensional vectorcardiographic loops with accompanying diagrammatic SP QRS-T angles for 1 healthy subject. R indicates right;
L, left, A, anterior. The arrows shown (heavily dashed for the QRS loop, lightly dashed for the T loop) express only the vector direction from the origin to the
peak of the given loop, not the vector magnitudes. The SP QRS-T angle from the true Frank leads (A) was similar to that obtained from the Kors' regression
method (B) but notably smaller than that obtained from the inverse Dower method (C). In this particular case, the larger SP QRS angle obtained from the inverse
Dower method may have been driven in part by a QRS loop that was more posteriorly directed than that obtained from either the true Frank leads or the Kors'
regression method.
 D.L. Cortez, T.T. Schlegel / Journal of Electrocardiology 43 (2010) 302–309 305

Fig. 2. Line of concordance for the SM QRS-T angle as obtained from the true Frank leads versus the Kors' regression-related (A) and inverse Dower-related (B)
reconstructions, respectively, for the entire data set. The greater concord of the true Frank-lead results to the Kors' regression-related results than to the inverse
Dower-related results is readily apparent.

related results of the Kors' regression-related versus the Results

inverse Dower-related transformation results. Lin's con-
cordance correlation coefficient ρ combines measures of
both precision and accuracy to determine how far the
observed data deviate from the line of perfect concordance
(ie, the line at 45 degrees on a square scatterplot). ρ has a
value between 0 and 1 and increases as a function of the
nearness of the data's reduced major axis to the line of
perfect concordance (the accuracy of the data) and of the
tightness of the data about its reduced major axis (the
precision of the data). A ρ value of 1 would indicate
complete agreement with the results from the “gold
standard.” As a complement to the relationship-scale
approach of Lin, we also used Bland and Altman graphs
to assess limits of agreement.33
Table 1 shows the mean ± SD results for all ECG
parameters in both groups. Not surprisingly, independently
of the method, SM and SP QRS-T angles were smaller
and SVG magnitudes larger in the control group than in the
post-MI group (P b .001). On the other hand, there were
no significant differences in SVG elevations or azimuths
between the 2 groups, regardless of method. More
importantly, Table 1 also shows that all SM and SP QRS-
T angles from the true Frank leads were significantly smaller
than those derived from the inverse Dower method but not
significantly different from those derived from the Kors'
regression method. The SM and SP QRS-T angles from the
Kors' regression method were also often significantly

Fig. 3. Bland-Altman plots for the SM QRS-T angle as obtained from the true Frank leads versus the Kors' regression-related (A) and inverse Dower-related (B)
reconstructions, respectively, for the entire data set. Along with smaller absolute differences from the true Frank-lead results (Y axis values, middle lines), the
Kors' regression-related results also demonstrated closer 95% Bland-Altman limits of agreement (dashed lines at the top and bottom) to the true Frank-lead
results than did the inverse Dower-related results.
306 D.L. Cortez, T.T. Schlegel / Journal of Electrocardiology 43 (2010) 302–309

Table 2
Lin's concordance coefficient (ρ) and Bland-Altman 95% limits of agreement versus the true Frank leads for, respectively, the Kors' regression and inverse
Dower-related transformations
Kors' regression versus true Frank leads Inverse Dower versus true Frank leads
ρ (95% CI) Bland-Altman 95% ρ (95% CI) Bland-Altman 95%
limits of agreement limits of agreement
Control group (n = 50)
SM QRS-T angle 0.88 (0.81-0.94) −26.2 to 24.2 0.71 (0.59-0.83) −15.3 to 46.4
SP QRS-T angle 0.77 (0.66-0.88) −34.7 to 32.7 0.62 (0.48-0.77) −21.8 to 55.4
SVG magnitude 0.99 (0.98-0.99) −10 to 17 0.98 (0.97-0.99) −19 to 17
SVG elevation 0.76 (0.64-0.88) −12.7 to 15.5 0.73 (0.60-0.86) −18.0 to 12.8
SVG azimuth 0.70 (0.57-0.84) −30.0 to 29.8 0.63 (0.48-0.79) −40.9 to 23.9
Post-MI group (n = 100)
SM QRS-T angle 0.89 (0.85-0.93) −26.8 to 41.1 0.77 (0.69-0.84) −34.2 to 62.3
SP QRS-T angle 0.83 (0.77-0.89) −38.3 to 53.3 0.59 (0.47-0.71) −52.5 to 90.4
SVG magnitude 0.91 (0.88-0.94) −12 to 22 0.78 (0.71-0.85) −23 to 37
SVG elevation 0.93 (0.91-0.95) −25.7 to 18.6 0.86 (0.81-0.90) −36.6 to 20.3
SVG azimuth 0.74 (0.65-0.83) −81.3 to 96.4 0.60 (0.48-0.73) −113.7 to 119.1
Total sample (n = 150)
SM QRS-T angle 0.91 (0.88-0.93) −27.7 to 36.6 0.78 (0.73-0.84) −28.6 to 57.7
SP QRS-T angle 0.84 (0.80-0.89) −38.1 to 47.4 0.64 (0.55-0.72) −44.1 to 80.6
SVG magnitude 0.97 (0.97-0.98) −11 to 20 0.93 (0.91-0.95) −23 to 32
SVG elevation 0.92 (0.90-0.94) −22.2 to 18.4 0.85 (0.81-0.89) −31.7 to 19.0
SVG azimuth 0.75 (0.68-0.82) −69.8 to 79.7 0.62 (0.52-0.72) −98.3 to 96.2

smaller than those derived from the inverse Dower method.
On the other hand, SVG magnitudes, elevations, and
azimuths derived from the 3 different methods were not
significantly different, except that for the entire data set (N =
150); the SVG elevation derived from the inverse Dower
reconstruction was significantly smaller than that obtained
from the true Frank leads. Finally, the SM QRS-T angles
were also significantly larger than the SP QRS-T angles for
both groups and for the data set as a whole. Fig. 1 shows
example 3-dimensional VCG loops and accompanying
diagrammatic SP QRS-T angles from a healthy individual.
Consistent with data from both the healthy and post-MI
groups, this individual's SP QRS-T angle obtained from the
true Frank leads (Fig. 1A) was very close to that obtained
from the Kors' regression method (Fig. 1B) but was notably
smaller than that obtained from the inverse Dower method
(Fig. 1C).
Fig. 2 shows Lin's concordance line plots for the SM
QRS-T angle as obtained from the true Frank leads versus
the Kors' regression (Fig. 2A) and inverse Dower-related
(Fig. 2B) reconstructions, respectively, for the entire data set.
The dashed line represents the line of true concordance,
whereas the solid line represents a best-fit line to the true
Frank-lead data using the respective reconstruction tech-
nique. Fig. 3 shows the corresponding Bland-Altman plots
for the same comparisons. In Fig. 3, the centrally located
dashed lines represent the best-fit line obtained by the true
Frank leads, whereas the solid lines represent the lines
obtained by using the given reconstruction technique. Figs. 2
and 3 both visually demonstrate the greater concord of the
Kors' regression-related results than the inverse Dower-
related results to the true Frank-lead results.
Table 2 shows Lin's concordance coefficient (ρ) and its
accompanying confidence interval (CI) as well as the Bland-
Altman 95% limits of agreement for each parameter in each
group when the particular reconstruction technique was
tested against the true Frank leads. Of note are the
consistently larger (closer to 1) ρ values as well as tighter
ρ CIs and Bland-Altman 95% limits of agreement for
every single parameter measured in all 3 groups for the Kors'
regression-related method than for the inverse Dower-related
method when using the true Frank-lead results as the
criterion standard.
Discussion
The most important finding from this study is that spatial
QRS-T angle results derived from the Kors' regression-
related transformation more closely approximate those from
the true Frank leads than do corresponding results from the
inverse Dower-related transformation. Specifically, com-
pared with the use of the Kors' regression transformation, the
use of the inverse Dower transformation yields lower Lin's
concordance correlation coefficients and wider associated
CIs against the true Frank-lead criterion standard. The
inverse Dower transformation, but not the Kors' regression
transformation, also significantly overestimates the absolute
value for the SM and SP QRS-T angles both in healthy
subjects and post-MI patients. Therefore, results from
inverse Dower-related transformations for spatial QRS-T
angle should not be considered tantamount to results from
the true Frank leads, as has already been at least indirectly
discovered.17,18 In addition, absolute values for spatial
QRS-T angles and SVG that are “abnormal” when using
Kors' regression transformations may be falsely construed as
“normal” if referencing absolute values from inverse Dower
transformations. Thus, assignments of “normal versus
abnormal” should only be made on a transform-specific
basis. Table 3 provides, for rapid reference purposes, a
summary of prior studies according to the apparent type of
spatial QRS-T angle measured and to the specific transfor-
mation method used.
 D.L. Cortez, T.T. Schlegel / Journal of Electrocardiology 43 (2010) 302–309
Table 3
Grouping of prior studies according to the apparent type of spatial QRS-T
angle measured and, when transformation was used, its type
Type of angle Kors' regression Inverse Dower True Frank
measured transformation transformation leads
SM QRS-T (5-7, 19, 20) (8-11, 17, 18, 29) (21, 22, 28, 34)
angle
SP QRS-T (1, 3, 23) (24, 25)
angle
The other finding of interest from this study is that when
using the true Frank leads or either reconstruction, mean
values for the SM QRS-T angle are significantly larger than
those for the SP QRS-T angle, and thus, these 2 measures
should not be used interchangeably. We prefer to refer to
the angular difference between the “maximum” QRS and T
vectors1,3,23-25 as the spatial “peaks” rather than spatial
“maximum” QRS-T angle because the use of the word
“maximum” results in confusing nomenclature, inasmuch as
in most individuals, the angle between the peaks of the
spatial QRS and T loops is actually smaller than the angle
between the QRS and T position vectors defined by the areas
of the same loops. The mathematical derivations for both
types of angle are provided in Appendix 1, along with that
for the SVG.
Limitations
Although the public availability of the PTB database is
highly appreciated and made this study possible, the
database's demographic annotations are often not detailed.
For example, it is unclear whether risk factors such as
diabetes or hypertension might actually have been present in
many individuals whose data files are presently labeled as
“healthy” controls, particularly inasmuch as conventional
ECG abnormalities such as Cornell voltage criteria for left
ventricular hypertrophy occasionally occur in these control
files. The mean (SD) value for the SM QRS-T angle from the
true Frank leads in the “healthy” controls in this study was
54.4 (25.8) degrees, which lies above the limits of those
presented for nonhospitalized controls in previous studies
(35-51 degrees).21,22,28,34 Thus, the relatively increased
absolute QRS-T angle values in these PTB controls
compared with controls in other studies might be attributable
to the former's somewhat higher cardiovascular risk factor
profiles or possibly to a higher group mean age or male
gender prevalence.
Conclusions
Spatial QRS-T angle and SVG results derived from Kors'
regression-related transformations more closely approximate
results from the true Frank leads than do corresponding
results from inverse Dower-related transformations. In
addition, inverse Dower-related transformations, but not
Kors' regression-related transformations, significantly over-
estimate absolute values for spatial QRS-T angles, both in
healthy subjects and post-MI patients, such that absolute
values that are actually abnormal when referencing true
307
Frank-related or Kors' regression-related population means
may be falsely construed as “normal” when referencing
inverse Dower-related population means. Thus, assignments
of “normal versus abnormal” should only be made on a
transform-specific basis. In addition, population mean values
for the SM QRS-T angle are significantly larger than those
for the spatial “peaks” QRS-T angle such that these 2
parameters should not be used interchangeably.
Acknowledgments
The authors especially thank Oeff et al and physionet.org
for providing access to the PTB Diagnostic ECG Database.
They also thank Drs W.B. Kulecz, J.L. DePalma, and E.C.
Greco for programming and technical assistance and Dr R.
Ploutz-Snyder for statistical advice. Additional support was
provided by the National Space Biomedical Research
Institute and NASA/Wyle Laboratories medical student
internship programs (DLC) and NASA Technology Invest-
ment Funds (TTS).
Appendix 1: Derivation of VCG parameters
A usual first step in combining the signals from the X, Y,
and Z leads from the true or derived Frank leads is to form a
vector magnitude V, which is
pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
V = X 2 + Y 2 + Z2: ð1Þ
Denote the area under the curve for the QRS complex in
the X, Y, and Z leads, respectively, as QRSx, QRSy, QRSz
and denote the area under the curve for the T wave in the X,
Y, and Z leads, respectively, as Tx, Ty and Tz. By using any
one of several possible integration method formulas (eg, the
Trapezoidal rule, Simpson's rule, or Simpson's 3/8 rule—the
latter was used for the present investigation),35 the SM QRS
area (time-magnitude) can be calculated as
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
jQRSarea j ¼ ðQRSxÞ2 + ðQRSyÞ2 + ðQRSzÞ2 ; ð2Þ
the SM T-wave area (time-magnitude) as
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
j Tarea j¼ ðTxÞ2 + ðTyÞ2 + ðTzÞ2 ; ð3Þ
and the SVG area (time-magnitude) as
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
SVG ¼ ðQRSx + TxÞ2 þðQRSy + TyÞ2 þðQRSz + TzÞ2 ;
ð4Þ
with |QRSarea|, |Tarea|, and SVG all having units of mV ⁎ ms.
308 D.L. Cortez, T.T. Schlegel / Journal of Electrocardiology 43 (2010) 302–309

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