The Lewis Lead

HomeCirculationVol. 119, No. 24The Lewis Lead Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBThe Lewis LeadMaking Recognition of P Waves Easy During Wide QRS Complex Tachycardia Annelies L.M. Bakker, Gerard Nijkerk, Björn E. Groenemeijer, Reinier A. Waalewijn, Egbert M. Koomen, Richard L. Braam and Hein J.J. Wellens Annelies L.M. BakkerAnnelies L.M. Bakker From the Department of Cardiology, Gelre Hospitals, Apeldoorn (A.L.M.B., G.N., B.E.G., R.A.W., E.M.K., R.L.B.), and Cardiovascular Research Institute, Maastricht (H.J.J.W.), the Netherlands. Search for more papers by this author , Gerard NijkerkGerard Nijkerk From the Department of Cardiology, Gelre Hospitals, Apeldoorn (A.L.M.B., G.N., B.E.G., R.A.W., E.M.K., R.L.B.), and Cardiovascular Research Institute, Maastricht (H.J.J.W.), the Netherlands. Search for more papers by this author , Björn E. GroenemeijerBjörn E. Groenemeijer From the Department of Cardiology, Gelre Hospitals, Apeldoorn (A.L.M.B., G.N., B.E.G., R.A.W., E.M.K., R.L.B.), and Cardiovascular Research Institute, Maastricht (H.J.J.W.), the Netherlands. Search for more papers by this author , Reinier A. WaalewijnReinier A. Waalewijn From the Department of Cardiology, Gelre Hospitals, Apeldoorn (A.L.M.B., G.N., B.E.G., R.A.W., E.M.K., R.L.B.), and Cardiovascular Research Institute, Maastricht (H.J.J.W.), the Netherlands. Search for more papers by this author , Egbert M. KoomenEgbert M. Koomen From the Department of Cardiology, Gelre Hospitals, Apeldoorn (A.L.M.B., G.N., B.E.G., R.A.W., E.M.K., R.L.B.), and Cardiovascular Research Institute, Maastricht (H.J.J.W.), the Netherlands. Search for more papers by this author , Richard L. BraamRichard L. Braam From the Department of Cardiology, Gelre Hospitals, Apeldoorn (A.L.M.B., G.N., B.E.G., R.A.W., E.M.K., R.L.B.), and Cardiovascular Research Institute, Maastricht (H.J.J.W.), the Netherlands. Search for more papers by this author and Hein J.J. WellensHein J.J. Wellens From the Department of Cardiology, Gelre Hospitals, Apeldoorn (A.L.M.B., G.N., B.E.G., R.A.W., E.M.K., R.L.B.), and Cardiovascular Research Institute, Maastricht (H.J.J.W.), the Netherlands. Search for more papers by this author Originally published23 Jun 2009https://doi.org/10.1161/CIRCULATIONAHA.109.852053Circulation. 2009;119:e592–e593An 80-year-old man was admitted to our hospital because of complaints of dizziness and palpitations. His medical history revealed an anteroseptal myocardial infarction 26 years earlier. The patient was hemodynamically stable with a blood pressure of 95/60 mm Hg and a heart rate of 120 bpm. The ECG (Figure 1A) showed a wide QRS complex tachycardia, 120 bpm. The electric axis was northwest. From the tracing, atrioventricular dissociation was suggested but not readily apparent. QRS morphology in leads V1 (qR) and V6 (R/S <1) was consistent with a diagnosis of ventricular tachycardia.1Download figureDownload PowerPointFigure 1. A, ECG at admission showing a regular broad complex tachycardia of 120 bpm. B, The Lewis lead configuration with the right arm electrode applied to the right of the sternum at the second intercostal space and the left arm electrode applied to the fourth intercostal space. After recording, this tracing should be interpreted in lead I. The presence of atrioventricular dissociation is indicated by vertical black bars.A Lewis lead (Figure 1B) also was recorded. This is a special bipolar chest lead with the right arm electrode applied to the right side of the sternum at the second intercostal space and the left arm electrode applied to the fourth intercostal space. The recording of the tracing can be seen in lead I.2 Calibration should be adjusted to 1 mV=20 mm. In Figure 1B, atrioventricular dissociation is obvious, confirming without any doubt the diagnosis of ventricular tachycardia. After electric cardioversion, sinus rhythm was obtained.The Lewis lead configuration can help to detect atrial activity and its relationship to ventricular activity. This technique was described by Sir Thomas Lewis (1881 to 1945) in his book Clinical Electrocardiography.3 Sir Lewis developed the lead configuration with the purpose to magnify atrial oscillations present during atrial fibrillation, which he referred to as auricular fibrillation. As shown in Figure 2A, he applied 3 electrodes to the right of the sternum instead of 2, recording the maximal atrial oscillations in the leads indicated by 1 and 2 (Figure 2A). Download figureDownload PowerPointFigure 2. A, Sir Thomas Lewis’ original diagram illustrating the concept of the Lewis lead configuration. From: Lewis T. Auricular fibrillation. In: Clinical Electrocardiography. 5th ed. London, UK: Shaw and Sons; 1931:92. Reproduced with permission from the publisher. B, The Lewis lead configuration used to register the tracing shown in Figure 1B. IC indicates intercostal space.Atrioventricular dissociation during a wide QRS tachycardia is a hallmark of ventricular tachycardia.1 Although not used regularly in clinical practice, we would like to promote the use of the Lewis lead configuration (Figure 2B) in those situations in which differentiation between a supraventricular or ventricular origin of an arrhythmia is difficult.DisclosuresNone.FootnotesCorrespondence to Richard L. Braam, Department of Cardiology, Gelre Hospitals, Postbus 9014, 7300 DS Apeldoorn, Netherlands. E-mail [email protected]References1 Wellens HJJ. Wide QRS tachycardia. In: The ECG in Emergency Decision Making. 2nd ed. St Louis, Mo: Saunders Elsevier; 2006: 128–157.Google Scholar2 Goldman MJ. Principles of Clinical Electrocardiography. 12th ed. Norwalk, CT: Lange; 1986: chap 1.Google Scholar3 Lewis T. Auricular fibrillation. In: Clinical Electrocardiography. 5th ed. London, UK: Shaw and Sons; 1931: 87–100.Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. 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Prasanna Venkatesh N and Sivaraman J (2021) A study on standard and atrial lead system for improved screening of P-wave using random forest classifier 2021 IEEE Bombay Section Signature Conference (IBSSC), 10.1109/IBSSC53889.2021.9673216, 978-1-6654-1758-7, (1-6) Eschbach T and Fessele K (2021) SOP Präklinisches Management von Breitkammerkomplextachykardien, Notfallmedizin up2date, 10.1055/a-1368-5667, 16:02, (131-136), Online publication date: 1-Jun-2021. Venkatesh N, Bharadwaj A, Sivaraman J and Dhananjay B (2021) A new lead system for improved recording of P-wave amplitude and its significance with existing optimal leads 2021 Seventh International conference on Bio Signals, Images, and Instrumentation (ICBSII), 10.1109/ICBSII51839.2021.9445183, 978-1-6654-4126-1, (1-5) El‐Chami M, Bhatia N and Merchant F (2020) Atrio‐ventricular synchronous pacing with a single chamber leadless pacemaker: Programming and trouble shooting for common clinical scenarios, Journal of Cardiovascular Electrophysiology, 10.1111/jce.14807, 32:2, (533-539), Online publication date: 1-Feb-2021. 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Goldwasser D, Bayes de Luna A, Serra G, Elosua R, Rodriguez E, Guerra J, Alonso C and Vinolas Prat X (2011) A new method of filtering T waves to detect hidden P waves in electrocardiogram signals, Europace, 10.1093/europace/euq518, 13:7, (1028-1033), Online publication date: 1-Jul-2011. (2011) Analytical Study of an Arrhythmia Clinical Arrhythmology, 10.1002/9781444391749.ch7, (266-277) (2011) Appendix Clinical Arrhythmology, 10.1002/9781444391749.app1, (386-418) Alzand B and Crijns H (2010) Diagnostic criteria of broad QRS complex tachycardia: decades of evolution, Europace, 10.1093/europace/euq430, 13:4, (465-472), Online publication date: 1-Apr-2011. June 23, 2009Vol 119, Issue 24 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.109.852053PMID: 19546393 Originally publishedJune 23, 2009 PDF download Advertisement SubjectsArrhythmiasElectrocardiology (ECG)