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Pediatrics. 2018 Mar;141(3). pii: e20171970. doi: 10.1542/peds.2017-1970. Epub 2018 Feb 1.

Left Axis Deviation in Children Without Previously Known Heart Disease.

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Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine.
Division of Heart Rhythm Services, Department of Cardiovascular Diseases, and.
Department of Molecular Pharmacology and Experimental Therapeutics and Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota.
Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine,



Left axis deviation (LAD) discovered in children via electrocardiogram (ECG) is uncommon but can be associated with heart disease (HD). The optimal diagnostic approach in a seemingly healthy child with LAD is unclear. We sought to better stratify which patients with LAD but without previously known HD may warrant additional workup.


A retrospective chart review was performed to identify patients ≥1 to <18 years of age with LAD (QRS frontal plane axis 0 to -90) on an ECG between January 2002 and December 2014. Patients with known HD before their initial ECG were excluded.


Overall, 296 patients were identified (n = 181 [61%] male; mean age: 10.8 ± 4.6 years; mean QRS axis: -24 ± 22°). An echocardiogram was performed in 158 (53%) patients, with 24 (15%) having HD. Compared with those with an echocardiogram but without HD (n = 134), patients with HD had a more negative mean QRS axis (-42 vs -27°; P = .002) and were more likely to have a QRS axis ≤-42° (58% vs 26%; P = .003), ECG chamber enlargement or hypertrophy (38% vs 5%; P < .0001), and abnormal cardiac physical examination findings (75% vs 8%; P < .0001).


LAD discovered in isolation in the asymptomatic pediatric patient may not necessitate further cardiovascular investigation. Clinicians should consider obtaining an echocardiogram in patients with LAD and ECG cardiac chamber enlargement or hypertrophy, a QRS axis ≤-42°, and/or the presence of abnormal cardiac physical examination findings.

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Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: Dr Ackerman is a consultant for Audentes Therapeutics, Boston Scientific, Gilead Sciences, Invitae, Medtronic, MyoKardia, and St. Jude Medical. Dr Ackerman and Mayo Clinic have a potential equity and/or royalty relationship with AliveCor, Blue Ox Health, and StemoniX. However, none of these entities have participated in this study in any way; the other authors have indicated they have no potential conflicts of interest to disclose.

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