Pathologic Q Waves

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This is part of: Myocardial Infarction
A pathologic Q wave

Pathologic Q waves are a sign of previous myocardial infarction. They are the result of absence of electrical activity. A myocardial infarction can be thought of as an elecrical 'hole' as scar tissue is electrically dead and therefore results in pathologic Q waves. Pathologic Q waves are not an early sign of myocardial infarction, but generally take several hours to days to develop. Once pathologic Q waves have developed they rarely go away. However, if the myocardial infarction is reperfused early (e.g. as a result of percutaneous coronary intervention) stunned myocardial tissue can recover and pathologic Q waves disappear. In all other situations they usually persist indefinitely.

The precise criteria for pathologic Q waves have been debated. Here we present the latest definition as accepted by the ESC and ACC.[1]

Definition of a pathologic Q wave
Any Q-wave in leads V2–V3 ≥ 0.02 s or QS complex in leads V2 and V3
Q-wave ≥ 0.03 s and > 0.1 mV deep or QS complex in leads I, II, aVL, aVF, or V4–V6 in any two leads of a contiguous lead grouping (I, aVL,V6; V4–V6; II, III, and aVF)
R-wave ≥ 0.04 s in V1–V2 and R/S ≥ 1 with a concordant positive T-wave in the absence of a conduction defect


  • Absence of pathologic Q waves does not exclude a myocardial infarction!
  • Lead III often shows Q waves, which are not pathologic as long as Q waves are absent in leads II and aVF (the contiguous leads)

For those interested: the Minnesota Code Classification System for Electrocardiographic Findings contains a very extensive definition of pathologic Q waves.

The Novacode system further classifies ischemic abnormalities in patients with no known history of myocardial infarction:[2]

  • High risk of ischemic injury/ Q wave MI:
    • Major Q waves: Q >= 50ms or Q >= 40 ms AND R/Q < 4,
  • Moderate risk of ischemc injury / possible Q wave MI:
    • Q >= 30 ms and ST deviation > 0.20 mV (minor Q waves with STT abnormalities)
    • Q >= 40 ms and ST deviation < 0.20mV (moderate Q waves without STT abnormalities)
  • Marginal risk of ischemic injury / possible Q wave MI:
    • Isolated T wave abnormalities
    • Minor Q waves (shallow Q < 30ms) and ST deviation < 0.15 mV
  • Low risk of ischemic injury
    • No significant Q waves or STT abnormalities