Clockwise rotation was associated with higher rates of other mild ECG abnormalities, including axis deviation, ST depression, atrial fibrillation, T wave inversion, and minor Q waves. For both men and women, clockwise rotation increased in prevalence with age and was observed to have a lower prevalence in subjects with a midrange body mass index. In contrast, counterclockwise rotation was associated with lower rates of hypertension, stroke, cardiovascular disease, and death.
In women, clockwise rotation was associated with a higher incidence of cardiovascular risk factors (hypertension, higher cholesterol, higher blood glucose levels), and higher rates of heart failure, cardiovascular disease, and death. In univariate analysis, counterclockwise rotation in men was associated with a higher prevalence of heart failure, cardiovascular disease, coronary heart disease, and total death, whereas counterclockwise rotation was associated with lower rates of cardiovascular disease and total death. A similar ratio was observed in subjects enrolled in NIPPON DATA in 1990. At baseline, 51.7% of subjects (48.4% of women, 56.0% of men) had normal rotation, 41.4% (45.8% of women, 35.8% of men) had counterclockwise rotation, and 6.9% (5.8% of women, 8.2% of men) had clockwise rotation. ECGs were analyzed by two independent observers in cases of disagreement between readers, a panel of epidemiologists and cardiologists determined the final coding. A complete dataset was available for 9067 subjects. Subjects in this analysis were enrolled in 1980, at which time they had a complete history and physical, laboratory evaluation, lifestyle questionnaire, and 12-lead ECG they were then followed until 2004. Individuals with a history of stroke or coronary heart disease were excluded from participation. The NIPPON DATA cohort invited >13,000 individuals in 300 health districts to participate in a longitudinal study. Nakamura and colleagues (2012) used the NIPPON DATA cohort to assess the prognostic value of clockwise and counterclockwise rotation. While long-recognized, the clinical significance if any of clockwise and counterclockwise rotation has not been well defined. “Counterclockwise rotation” refers to a variant in which the transition is “early,” occurring at or before lead V 3, whereas “clockwise rotation” is a variant in which the transition occurs late, at or after lead V 4. In a “normal” electrocardiogram (ECG), the transition of the QRS axis in the precordial leads occurs between leads V 3 and V 4 (i.e., there is a dominant S in V 3 and a dominant R in V 4).
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