The Veterinary Journal 268 (2021) 105592

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The Veterinary Journal

journal homepage: www.elsevier.com/locate/tvjl

R-peak time in clinically healthy dogs with different thoracic

conformations
M. Mateos Pañeroa , S. Battaiaa,b , L. Rameraa , M. Peregoa,b , R.A. Santillia,c,*
a
Clinica Veterinaria Malpensa - AniCura, Viale Marconi 27, 21017, Samarate, Varese, Italy
b
Ospedale Veterinario I Portoni Rossi - AniCura, Via Roma 57, 40069, Zola Predosa, Bologna, Italy
c
Department of Clinical Sciences, Cornell College of Veterinary Medicine, Ithaca, NY 14853-6401 USA

A R T I C L E I N F O A B S T R A C T

R-peak time (RPT) is an electrocardiographic parameter that represents the time taken for electrical
Keywords: activation to spread from the endocardium to the epicardium. In human medicine, right ventricular RPT is
Arrhythmias
measured from lead V1 to lead V2, and left ventricular RPT from lead V5 to lead V6. The aim of the present
Intrinsicoid deflection
R wave peak time
study was to define RPT duration in a group of clinically healthy dogs with different thoracic
Ventricular activation time conformations. Sixty clinically healthy dogs underwent a 12-lead electrocardiogram recorded using a
previously described precordial system. The dogs were allocated into three morphologic groups.
In the brachymorphic group, the median and 25th–75th percentiles for RPT in V1 were 10.5 ms (10 12
ms); V2, 18 ms (16.5 20 ms); V3, 19 ms (18 22 ms); V4, 20 ms (17 23.5 ms); V5, 21 ms (18.5 24 ms); and
V6: 22 ms (18.5 25.5 ms). In the mesomorphic group, RPT in V1 was 16 ms (14 18 ms); V2, 22 ms (20 24
ms); V3, 23 ms (21 25 ms); V4, 23 ms (22 25 ms); V5, 25 ms (23 27 ms); and V6, 28 ms (25 30 ms). In
the dolichomorphic group, RPT in V1 was 15 ms (13 17 ms); V2, 29 ms (26 32.5 ms); V3, 30 ms (27 33.5
ms); V4, 29.5 ms (26 35 ms); V5, 30 ms (28 34 ms); and V6, 31.5 ms (28 35 ms). RPT in V1 was
significantly shorter than RPT in V2 to V6 in all morphotypes (P < 0.05). In all precordial leads, RPT was
significantly different between morphotypes (P < 0.05). These results are in agreement with previous
findings in humans and with the observation that V1 reads the right ventricle and V2 to V6 read the left
ventricle. These preliminary data provide RPT ranges in clinically healthy dogs of different morphotypes.
© 2020 Elsevier Ltd. All rights reserved.

Introduction was recorded with an Einthoven string galvanometer. Afterwards,

the use of unipolar precordial leads allowed this interval to be
In the 12-lead electrocardiogram (ECG), the time from the onset measured without the need for thoracotomy, and the term
of the QRS complex, identified as the Q or R wave, to the peak of R ‘intrinsicoid deflection’ was coined (Macleod et al., 1930). With
or to R' (when present) is referred to as the R-peak time (RPT). This respect to the electrocardiographic appearance of intrinsicoid
parameter represents the early phase of ventricular depolarisation, deflection, an upright deflection is recorded as the activation front
specifically the time during which the wave of excitation spreads approaches the electrode. As soon as the activation front reaches
from the endocardial to the epicardial surface of the ventricles the electrode, the direction of the impulse reverses and a rapid
(Pérez-Riera et al., 2016). In precordial leads, it can be interpreted negative deflection is recorded (Surawicz and Knilans, 2001).
as the time from the onset of ventricular depolarization to the Finally, because by definition intrinsicoid deflection can only be
instant that the activation wavefront reaches the area under the measured from unipolar precordial leads, the American Heart
electrode (Macfarlane and Veitch Lawrie, 2011). Association, American College of Cardiology Foundation and the
This interval was first described through experimental studies Heart Rhythm Society recommendations for the standardization
performed in dogs in 1914, and was referred to as ‘intrinsic and interpretation of the electrocardiogram advise that the term
deflection’ (Lewis and Rothschild, 1914). In these studies, electro- RPT is used, as this can be measured using limb and precordial
des were placed directly on the epicardium and electrical activity leads (Surawicz et al., 2009).
In humans, there are precise reference intervals for RPT for both
the right ventricle (RV) and left ventricle (LV). The RPT for the RV is
usually measured from lead V1 or V2, and 35 ms is considered the
* Corresponding author at: Clinica Veterinaria Malpensa - AniCura, Viale Marconi
upper limit of the reference range. The RPT for the LV is measured
27, 21017, Samarate, Varese, Italy.
E-mail address: r.santilli@ecgontheweb.com (R.A. Santilli). from leads V5 to V6, and 45 ms is considered the upper limit of the

http://dx.doi.org/10.1016/j.tvjl.2020.105592
1090-0233/© 2020 Elsevier Ltd. All rights reserved.
M. Mateos Pañero, S. Battaia, L. Ramera et al. The Veterinary Journal 268 (2021) 105592

reference range (Pérez-Riera et al., 2016). Reference ranges for RPT literature, in order to avoid excessive filtering that could eliminate small amplitude
waves and affect interval measurements (Dvir et al., 2002; Kligfield et al., 2007). All
are also available for bipolar lead II, and one study on 2400 Chinese
ECG recordings were evaluated for quality and lead positioning adequacy by the
adults demonstrated that the RPT at lead II was significantly longer main author (RAS). RPT was digitally measured (Easy View Plus, ATES Medica
in males than in females (29.73  5.01 ms vs. 29.71  4.06 ms in Device) for each of the six standard limb leads and six precordial leads for three
females; Deng et al., 2016). These reference ranges are clinically subsequent heartbeats; the mean was calculated and used for analysis purposes. A
valuable, particularly in the identification of volume overload, convenience sample of beats were selected by RAS over a period of 5 min. RPT was
measured in ms from the earliest onset of the QRS complex to the peak of the R wave
hypertrophic cardiomyopathy, RV hypertrophy in the absence of or R' if present (Fig. 1). Measurements were made by an experienced cardiologist
echocardiography, and intraventricular conduction disturbances. (LR), masked to dog morphotype.
Furthermore, this parameter can be helpful in the differential
diagnosis of wide QRS complex tachycardia, differentiating Statistical analysis
between epicardial and endocardial ventricular tachycardias
Commercially available software was used to perform all statistical analyses
(VT), the assessment of risk for sudden cardiac death, and (SAS version 9.2, SAS Institute). Descriptive statistics (mean, standard deviation,
predicting the response to resynchronisation therapy (Pérez-Riera median, first and third quartiles, interquartile range) for each numeric parameter
et al., 2016). To our knowledge, there are no published data for were calculated for each morphotype. Normality of data distribution was assessed
canine RPT reference intervals and their clinical utility remains using the Shapiro–Wilks test. Mean  standard deviation was used to summarise
normally distributed continuous data, and median and 25th–75th percentile was
unexplored. used to summarise non-normally distributed continuous data. To evaluate
The aim of this pilot study was to define RV and LV RPT values in differences between morphotypes and leads, the Kruskal–Wallis test (a non-
clinically healthy dogs with different thoracic conformations, using parametric test), was used as the data were not normally distributed, followed by a
a new precordial system which evaluates right ventricular pairwise comparison test (Bonferroni). P < 0.05 was considered statistically
significant. In order to take into account for repeated measures within dogs, a 2-way
depolarization more accurately in most dogs, regardless of thoracic
ANOVA for repeated measures (i.e., mixed generalized linear model [GLMM]) was
conformation (Santilli et al., 2019). A secondary aim of this study used to evaluate the effect of different precordial leads, thoracic morphotype and
was to evaluate differences in RPT between the three different dog their interaction on the dependent variable (RPT). The model included fixed effects
morphotypes (brachymorphic, mesomorphic, and dolichomor- for thoracic morphotype and all precordial leads and a random effect for dogs. A
phic). similar model was performed for leads I, II, III and for leads aVR, aVF, aVL.

Results
Materials and methods
Population summary
Study population

This prospective study was approved by the ethical committee of the Clinica Descriptive characteristics for the study population are
Veterinaria Malpensa in Samarate, Italy (Approval Number, 003-2017; Approval summarized in Table 1.The mean thoracic index was 100.5 
date, September 2017). All diagnostic investigations were performed with the 12.1 for the brachymorphic group, 74.4  7.5 for the mesomorphic
informed consent of the dog owners. Sixty clinically healthy dogs were enrolled in
group, and 56.4  3.9 for the dolichomorphic group. Sex
the study between July and December 2015. Electrocardiograms from this
population have also been described in a previous publication reporting the distribution (P = 0.20) and mean age (P = 0.65) did not differ
development of a novel precordial lead system (Santilli et al., 2019). Dogs were significantly among the three groups.
recruited from local breeders or were examined at the hospital for screening
purposes. Each dog underwent a morphometric study and was assigned to one of RPT measurements
three morphotype groups on the basis of thoracic conformation. With the dog in a
standing position, a thoracic caliper was used to measure the depth (maximum
distance from the dorsum to sternum) and width (maximum distance from the left Descriptive statistics for RPT in the brachymorphic, mesomor-
to right side of the thoracic cavity) of the thorax. The thoracic index (thoracic width phic, and dolichomorphic groups are presented in Table 2. RPT was
[cm]  100/thoracic depth [cm]) was calculated. Thoracic indices were as follows: significantly shorter in V1 than in V2 to V6 for all morphotypes (P <
brachymorphic, 90–100; mesomorphic, 60–89; and dolichomorphic 50–59 (Bone-
0.05; Fig. 2). RPT differences were statistically significant for leads
tti, 1995). Recruitment continued until 20 dogs for each thoracic morphotype were
included. Dogs in the three groups were not matched for age, sex, or bodyweight. I, II, and III (test F, 4.5; P < 0.05), for each morphotype (test F, 18.9; P
Each dog enrolled in the study was clinically healthy, as determined by a < 0.0001) and for the interaction between standard leads and
physical examination and cardiovascular evaluation. A digital radiography system morphotypes (test F, 7.6; P < 0.001). RPT differences were
(Agfa Healthcare) was used to obtain right lateral and dorsoventral thoracic images statistically significant for lead aVR and aVF (test F, 63.3; P <
for each dog. Radiographic assessment was performed by the same investigator
0.0001) and the interaction between these leads and morphotype
(RAS) who was masked to morphotype, and cardiomegaly was excluded on the basis
of measurement of vertebral heart scale on lateral radiographs, as previously (test F, 6.8; P < 0.001).
described (Hansson et al., 2005). Each dog underwent a complete standard
transthoracic echocardiographic examination in right and left lateral recumbency.
Standard views were obtained using 2-D, M-mode, spectral and color-flow Doppler
echocardiography (GE Medical Systems). All echocardiographic examinations and
measurements were performed by the same investigator (RAS) who was masked to
morphotype. Arrhythmia and conduction disturbances were excluded on the basis
of a 5-min standard 12-lead surface ECG (ATES Medica Device,).

ECG

Each dog underwent a standard 12-lead surface ECG while positioned in right
lateral recumbency; sedation was not used. The dogs were instrumented with
bipolar limb leads, unipolar augmented limb leads, and precordial leads, according
to Wilson’s precordial lead system modified by Santilli (precordial lead V1 was
positioned at the costo-chondral junction of the right first intercostal space; Santilli
et al., 2019). The sixth intercostal space was used for all left-sided leads (V2 to V6).
Lead V2 was positioned adjacent to the sternum; V3 was positioned midway
between V2 and V4; V4 was positioned at the costo-chondral junction; and V5 and V6
were sequentially positioned dorsal to V4, at a distance equal to that between V3 and
V4 (Kraus et al., 2002). The ECG tracings for all leads were simultaneously recorded
for 5 consecutive min. Filter settings were set at 70 Hz for low-pass and 0.05 Hz for Fig. 1. R-peak time was measured from the earliest onset of the QRS complex to the
high-pass. These filters were chosen on the basis of current human and veterinary peak of the R wave or R' if present.

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M. Mateos Pañero, S. Battaia, L. Ramera et al. The Veterinary Journal 268 (2021) 105592

Table 1
Demographic data from 60 dogs included in this study.

Brachymorphic dogs (n) Mesomorphic dogs (n) Dolichomorphic dogs (n)

Breed English bulldogs (10), French Golden retriever (7), Mixed-breed (3), Greyhounds (12), Dobermann pinscher (5),
bulldogs (6), Pugs (4) Australian sheperds (2), boxers (2), Segugio Afghan hound (1), Borzoi (1), Hibizan hound (1)
Italiano (2), German shepherd (1), Cane corso
(1), Jack Russell terrier (1), Labrador retriever
(1)
Sex Intact females (7), spayed females Intact females (8), spayed females (2), intact Intact females (5), spayed females (2), intact
(6), intact males (7) males (6), neutered males (4) males (2), neutered males (11)
Age 4.8  3.7 4.7  2.7 4.9  1.8
(mean  SD)
Thoracic index (mean  SD) 100.5  12.1 74.4  7.5 56.4  3.9

SD, Standard deviation.

Table 2 epicardial direction. Our results showed that RPT in V1 was

Median (25th–75th percentile) for R-peak time.a significantly shorter than RPT in V2–V6 in all three morphotypes.
Lead Brachymorphic dogs Mesomorphic dogs Dolichomorphic dogs These results are in agreement with findings reported in human
I 24 (22 29.5) 30 (25 32) 27.5 (23 30) medicine, where the upper limit of the RPT for the RV (measured
II 22 (19 27.5) 30 (27 33) 35 (31.5 36) from V1 or V2; 35 ms), is shorter than the upper limit of the RPT for
III 19 (14.5 25) 30 (27 32) 34 (29.5 36.5) the LV (measured from V5 to V6; 45 ms). This result could be related
aVR 9.5 (6 12) 10 (9 11) 11.5 (8.5 13.5) to the thickness of the RV wall compared to the LV wall, as
aVL 26 (0 32) 9 (7 12) 10 (10 15)
previously reported in humans (Pérez-Riera et al., 2016). In
aVF 21.5 (17 27.5) 30 (26 33) 35.5 (30 37)
V1 10.5 (10 12)b,c,d 16 (14 18)b,d 15 (13 17)b,c humans, V2 still reads the RV because the transition zone (the site
V2 18 (16.5 20)c,d 22 (20 24)d 29 (26 32.5)c in precordial leads at which the pattern changes from rS to Rs)
V3 19 (18 22)c,d 23 (21 25)d 30 (27 33.5)c normally occurs in lead V3 or V4, in contrast to dogs, where the
V4 20 (17 23.5)c,d 23 (22 25)d 29.5 (26 35)c
transition zone occurs in lead V1–V2 (Aro et al., 2017; Santilli et al.,
V5 21 (18.5 24)c,d 25 (23 27)d 30 (28 34)c
V6 22 (18.5 25.5)c,d 28 (25 30)d 31.5 (28 35)c
2019).
Based on previous human studies, RPT  40 ms in leads V1–V2
a
All data expressed in ms. could be associated with RV hypertrophy, as demonstrated in
b
P < 0.05 compared to left precordial leads (V2 to V6).
c individuals with pulmonary hypertension secondary to chronic
P < 0.05 compared to mesomorphic dogs.
d
P < 0.05 compared to dolicomorphic dogs. obstructive pulmonary disease and in asthmatic children (Miya-
moto et al., 1960; Murphy and Hutcheson, 1974). In this group of
patients with RV hypertrophy, there was no prolongation in LV RPT
values (V5–V6). In right bundle branch block, RPT is prolonged in
leads V1–V2 (50 ms), but remains normal in the left precordial
leads. The time difference between the right and left RPT is due to
electrical activity being directed to the right or towards lead V1
(Pérez-Riera et al., 2016).
Another important finding of our study was that RPT differed
between the three morphotypes in all precordial leads. This
observation is likely due to variation in cardiac shape and in the
dorsoventral diameter of the thorax among dogs with different
thoracic conformations. This variation alters the axis of the heart in
the horizontal plane and the relative position of the unipolar
exploring electrode in relation to the cardiac vector. These
variables can influence the ECG pattern obtained by precordial
leads. This has been clearly described in an experimental study
Fig. 2. R-peak time distribution by precordial leads on brachymorphic, mesomor-
phic and dolichomorphic dog. Results of ANOVA are shown on the figure. ns, not which investigated the influence of geometrical factors on the 12-
significant; *, P < 0.05; **, P < 0.01; ****, P < 0.0001. lead ECG signal (Nguyên et al., 2015). This was performed with the
aid of computer simulation, using tailored models of patients with
Discussion a wide range of QRS durations and QRS morphologies. Geometrical
modifications were induced by shifting and rotating the heart and
In this pilot study, RPT was measured in a population of shifting the precordial electrodes, demonstrating that morpholog-
clinically healthy dogs using 12-lead ECG, according to Wilson’s ical features of the ECG, including RPT and notching/slurring of the
precordial lead system modified by Santilli et al. (2019). To our QRS, and voltage-dependent parameters (QRS amplitude, QRS
knowledge, this is the first study to assess the duration of this area, T-wave amplitude, and T-wave area) are severely affected by
interval in dogs to provide a basis for the application of this geometrical modifications (Nguyên et al., 2015). In particular, RPT
parameter in clinical practice. On the basis of experimental studies changes were observed in leads I, V5, and V6, often in the presence
conducted by Hamlin and Smith (1965), dogs have a similar of multiple peaks in the R wave due to notching, which could
ventricular activation process to humans (from endocardium to therefore have contributed to RPT alterations (Nguyên et al., 2015).
epicardium); however, it is important to point out that in most Our preliminary study provides values for RPT in clinically
large mammals (horses, cows, pigs and sheep), the myocardial healthy dogs, which could be applied in the future in dogs with LV
Purkinje system is activated simultaneously in a subendocardial to and/or RV pathologies. An increase in RPT > 50 ms in lead V5 or V6

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M. Mateos Pañero, S. Battaia, L. Ramera et al. The Veterinary Journal 268 (2021) 105592

can help identify concentric and eccentric LV hypertrophy in were not considered and may have affected RPT duration, QRS
humans (Pérez-Riera et al., 2016). In addition to right bundle duration, QT interval and mean electrical axis in the frontal plane,
branch block, RPT can have utility for the diagnosis of common as previously reported (Constable et al., 1994). Additionally, CBC
intraventricular conduction disturbances in humans. In complete and serum biochemistry were not performed to assess subclinical
left bundle branch block, RPT is >60 ms in leads V5 and V6, but disease. Another limitation of the present study is related to the
within the reference range in leads V1, V2, and V3. RPT could also possible influence of filtering and chamber size on RPT duration
help identify incomplete left bundle branch block, left septal measurements, although we used a setting recommended for dogs
fascicular block, left anterior fascicular block, and left posterior (Brody, 1956; Dvir et al., 2002; Ker et al., 2009). Lastly, we did not
fascicular block (Deharo, 2000; Pérez-Riera et al., 2016). RPT may study the influence of sex on RPT duration, which has previously
potentially be useful in the differential diagnosis of wide QRS been investigated in humans (Deng et al., 2016), and we did not
complex tachycardia, and this could be investigated in dogs. An investigate the possible effects of age and ventricular wall
electrophysiological study of 218 human patients identified an thickness on RPT duration.
increase in RPT  50 ms in lead II as an accurate criterion
(sensitivity, 93%; specificity, 99%) to discriminate VT from Conclusions
supraventricular tachycardia (Pava et al., 2010). RPT can also
discriminate between VT of epicardial and endocardial origin. This In this preliminary study, we defined RPT in clinically healthy
differentiation could be useful in dogs during VT ablation (Santilli dogs of three different thoracic morphotypes. Furthermore, we
et al., 2011); an important consideration in humans when planning identified statistically significant differences between lead V1 and
a VT ablation procedure is deciding when to go to the epicardium other precordial leads, possibly suggesting that by adopting the
(Fernandez-Armenta and Berruezo, 2014). ECG diagnosis of left new precordial system modified by Santilli et al. (2019), RPT can be
epicardial VT is mainly based on the concept that when ventricular used to evaluate LV and RV depolarisation by analysing the left
activation starts at the epicardial level, the initial part of the precordial leads and lead V1, respectively. RPT is easy to acquire and
wavefront progresses slowly through the myocardial wall until it measure, and thus could have clinical utility, especially in dogs
reaches the Purkinje system at the subendocardium, resulting in with congenital and acquired cardiomyopathy, rhythm disorders,
RPT prolongation (Berruezo et al., 2004). Conversely, in the RV, the and conduction disturbances. The intervals reported in the present
combination of RPT and QRS duration is not helpful in identifying study could help to evaluate LV and RV RPT prolongation in dogs of
epicardial ventricular tachycardia, whereas a Q wave or QS in the all morphotypes with these cardiac disorders. Further studies are
leads that best reflect local activation (Q wave in lead I and QS in needed to provide reference ranges based on larger sample sizes
lead V2 for anterior sites, Q wave in leads II, III, and aVF for inferior and to evaluate the clinical applications of RPT in dogs with
locations) suggests that RV depolarisation originates at the structural or arrhythmic heart disease.
epicardium (Bazan et al., 2006). Prolonged RPT, measured as the
maximum value in leads V5 and V6, was significantly associated Conflict of interest
with an increased risk of future heart failure events in a population
of adult humans without clinically apparent cardiovascular disease None of the authors has any other financial or personal
or major ventricular conduction delays (O’Neal et al., 2016). RPT relationship that could inappropriately influence or bias the
could also be used for the prediction of sudden cardiac death. In a content of the paper.
recent study, RPT prolongation was associated with sudden cardiac
arrest risk independent of LV function and mass and other Acknowledgments
electrocardiographic abnormalities, indicating that RPT may be an
indicator of adverse myocardial electrical remodelling (Darouian The authors thank Dr Nicoletta Vitale and Dr Damiano Cavallini
et al., 2017). for their help with the statistical analysis. No grant support was
Several potential mechanisms responsible for delayed impulse received for this work. Preliminary data were presented at the 28th
conduction (and consequently prolonged RPT) and arrhythmo- Annual Congress of the European College of Veterinary Internal
genesis (in particular ventricular arrhythmias) in the context of LV Medicine, Rotterdam, Netherlands, 6–8 September 2018.
hypertrophy have been described. These include myocardial
hypertrophy, interstitial collagen remodelling, abnormalities and
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