SUMMARY The relationship of changes in ventricular activation patterns and variations in R-wave amplitude on the surface ECG during the hyperacute phase of myocardial ischemia were studied in nine open-chest dogs. The sum of R-wave amplitude (2RWA) changes in surface ECG leads L2, V5 and Frank orthogonal leads X, Y and Z were correlated with changes in the conduction time along the specialized conduction.system and in intramyocardial conduction times, as well as with hemodynamic and echocardiographically determined left ventricular dimensional changes. The hyperacute phase of myocardial ischemia induced by a one-stage occlusion of the left circumflex coronary artery was marked by a progressive increase in left ventricular enddiastolic diameter and left ventricular end-diastolic pressure as well as a progressive decrease in cardiac output. At the same time, ZRWA and intramyocardial conduction time followed a synchronous biphasic pattern. In the first 30 seconds after coronary artery ligation, intramyocardial conduction time in the ischemic zone accelerated to a peak of 11.3% above control (p < 0.001). This acceleration of conduction was followed closely by a decrease in ZRWA to 16.8% below control (p < 0.001). A second phase ensued, characterized by a gradual slowing of intramyocardial conduction time in the ischemic zone to 135.1% above control (p < 0.001) and a synchronous increase in 2RWA to 53.1% above control (p < 0.001). Conduction time along the specialized conduction system did not change significantly.Thus, the asynchrony of ischemic 2RWA alterations with hemodynamic and left ventricular dimensional changes and the similarity of the biphasic responses of 2RWA to the changes in intramyocardial conduction time in the ischemic area suggest that ventricular activation patterns rather than hemodynamic and intracardiac dimensional changes may play the major role in determining R-wave amplitude responses to acute myocardial ischemia.INCREASED R-wave amplitude on the surface ECG at peak exercise has been observed frequently in patients with coronary artery disease. 1-4 Bonoris et al.1 claimed this sign to be a sensitive and specific marker for the diagnosis of coronary artery disease. Increases in R-wave amplitude may also indicate the extent of ischemia-induced left ventricular dysfunction.2 4 This suggestion is based on the assumption that R-wave amplitude changes are related, by the Brody effect,5 to an increase in left ventricular volume resulting from acute ischemia. However, studies in humans have not consistently corroborated these findings."8We designed a series of experiments using a canine model of acute myocardial ischemia to identify factors that contribute to ischemic R-wave amplitude alterations. In our initial studies we showed that ischemic Rwave amplitude changes could not be explained merely by intracardiac volume changes.9' 10 Other in- From vestigators have shown that ventricular activation patterns influence the R-wave amplitude response to volume changes in the normal heart."-"' The purpo...
