Fundamental differences between the standard 12-lead electrocardiograph and the modified (Mason--Likar) exercise lead system

A comparison of the standard 12-lead electrocardiograph with the Mason-Likar lead system widely used for exercise stress testing shows that the two are not 'essentially identical' as was originally claimed. Placement of the limb electrodes onto the torso distorts the electrocardiograph causing a rightward shift of the mean QRS axis, a significant reduction in R-wave amplitude in leads I and aVL, and a significant increase in R-wave amplitude in leads II, III and aVF; the R-wave amplitude of the chest leads is also altered. The so-called 'inferior' leads on the exercise electrocardiography are probably modified anterior/inferior leads, since their R-wave amplitudes correlate closely with those of antero-lateral chest leads. The inferior surface of the heart is not represented in isolation on the exercise electrocardiograph, thus explaining the reported inability of the exercise test to predict the location of coronary artery disease and high incidence of false negative tests in patients with ischaemia limited to the inferior cardiac surface.