BMJ 2018;361:k1673 doi: 10.1136/bmj.

k1673 (Published 7 June 2018) Page 1 of 2

Endgames

ENDGAMES

SPOT DIAGNOSIS

An epsilon wave on electrocardiogram

Daniel B Petrov consultant cardiologist
Emergency Hospital “Pirogov,” Sofia, Bulgaria

A 39 year old man with no history of heart disease was admitted

with symptoms of palpitations and weakness lasting for several
hours. An electrocardiogram (ECG) showed a wide complex
tachycardia with left bundle branch block morphology,
consistent with sustained ventricular tachycardia of right
ventricular origin. Because of continuing haemodynamic
instability, the patient was cardioverted to sinus rhythm with a
single 200 J shock. The post-cardioversion ECG (fig 1) showed
inverted T-waves in leads V1-V3, with QRS complex duration
of 112 ms, and prolonged S-waves upstroke of 55 ms. Increased
amplitude ECG showed waves with a small spike upward in
lead V3 (fig 2, arrows), which represent characteristic epsilon
waves. The patient reported no family history of sudden cardiac
death or arrhythmias.
Post-electrocardioversion ECG, with repolarisation changes
in leads V1-V3

Increased amplitude ECG showing epsilon waves (arrows)

in lead V3

What disease is the epsilon wave indicative of?

Answer
The epsilon wave is a specific ECG finding for arrhythmogenic
right ventricular cardiomyopathy (ARVC), which is the second
most common cause of unexpected sudden cardiac death in
young people after hypertrophic obstructive cardiomyopathy.

Discussion
Arrhythmogenic right ventricular cardiomyopathy is an inherited
heart muscle disease that predominantly affects the right

Correspondence to D B Petrov dpetrov@techno-link.com

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BMJ 2018;361:k1673 doi: 10.1136/bmj.k1673 (Published 7 June 2018)
ventricle. The prevalence of ARVC has been estimated at
approximately 1 in 5000 in the population.1 In a series of sudden
cardiac deaths in young adults, ARVC was the cause of death
in 2%-5%.2
Other possible causes of ventricular tachycardia in young people
with no previous cardiovascular disease are cardiac
channelopathies (Long QT, Short QT syndromes),
catecholaminergic polymorphic VT, and Brugada syndrome.
The first presenting symptom is sudden onset of ventricular
tachycardia. There is no single diagnostic test for ARVC.
Diagnosis is made using a combination of clinical, ECG, and
radiological features. The 12-lead surface ECG can play a key
role in the diagnosis of ARVC as most subjects with ARVC
have some ECG changes. The most common finding is T-wave
inversion in lead V1-V3, but this is non-specific and can be
considered a normal variant in women and children under 12.
The presence of epsilon waves, however, is considered to be a
major diagnostic criterion in ARVC, but it is very difficult to
identify patients who are likely to have this wave;
electrocardiographic epsilon waves are seen in only 30% of all
cases of ARVC.3 The epsilon wave is a small deflection buried
in the end of the QRS complex and represent a delay in the
depolarisation of the right ventricular free wall.
Patient outcome
Cardiac echocardiogram, coronary angiography with right
ventriculography, and magnetic resonance imaging confirmed
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Page 2 of 2
ENDGAMES
the diagnosis of ARVC. The patient was treated with an
implantable cardioverter defibrillator and discharged on
amiodarone.
Learning points
1. Identification of an epsilon wave on a standard 12-lead
ECG is a simple, inexpensive initial way to assess patients
for ARVC.
2. ARVC is the second most common cause of unexpected
sudden cardiac death in young people, after hypertrophic
obstructive cardiomyopathy.
Competing interests: I have read and understood the BMJ policy on declaration
of interests and declare that I have no competing interests.
Patient consent obtained.
Provenance and peer review: not commissioned; externally peer reviewed.
1 Kiès P, Bootsma M, Bax J, Schalij MJ, van der Wall EE. Arrhythmogenic right ventricular
dysplasia/cardiomyopathy: screening, diagnosis, and treatment. Heart Rhythm
2006;3:225-34. 10.1016/j.hrthm.2005.10.018 16443541
2 Francés RJ. Arrhythmogenic right ventricular dysplasia/cardiomyopathy. A review and
update. Int J Cardiol 2006;110:279-87. 10.1016/j.ijcard.2005.07.004 16099519
3 Gemayel C, Pelliccia A, Thompson PD. Arrhythmogenic right ventricular cardiomyopathy.
J Am Coll Cardiol 2001;38:1773-81. 10.1016/S0735-1097(01)01654-0 11738273
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