El-Sherif Sign

El-Sherif Sign is an rsR’ complex, or its variants (rSr’ or rSR’), in the left anterior precordial leads that is observed in patients with apical ventricular aneurysm. The rsR’ pattern in V6 with prolonged QRS was mentioned in the ’50s by many researchers that tried to relate it with ventricular aneurysms. In 1970 Nabil El-Sherif described this pattern in 18 patients with normal or prolonged QRS duration. 17 of them had left ventricular aneurysm (LVA).

El-Sherif suggested that the rsR’ pattern in the left precordial leads was due to extensive confluent scarring of the left ventricular cone. Fragmentation of the QRS has also been suggested as a marker of LVA and myocardial scar formation in computer models.

Reddy CV et al. tried to estimate the sensitivity, specificity as well as predictive values of fragmented left sided QRS (RSR’ pattern or its variant RSr’, rSR’, or rSr’) without evidence of left bundle branch block. The sensitivity of those patterns was 50% whereas the specificity was 94.6%. The positive predictive value (PPV) of fragmented QRS for LVA was 83.3% and the negative predictive value (NPV) was 79.2%. In postmyocardial infarction population, the PPV of El-Sherif sign for LVA after infarction was 29–53% and the NPV was 95–98%, as they estimated. Besides chronic apical aneurysms in coronary artery disease patients, El-Sherif sign has also been reported and found to be useful in apical aneurysms in hypertrophic cardiomyopathy (HCM) patients.


Image reproduced from Sherif NE. The rsR’ pattern in left surface leads in ventricular aneurysm. Br Heart J 1970;32:440-448.

1. Sherif NE. The rsR` pattern in left surface leads in ventricular aneurysm. Br Heart J 1970;32:440–448.
2. Dubnow, M. H., Burchell, H. B., and Titus, J. L. (I965). Postinfarction ventricular aneurysm. A clinico-morphologic and electrocardiographic study of 8o cases. American Heart Journal, 70, 753.
3. Goldberger, E., and Schwartz, S. P. (1948). ECG patterns of ventricular aneurysm. AmericanJournal of Medicine, 4, 243.
4. Lesh MD, Spear JF, Simon MB. A computer model of electrogram: What causes fractionation? J Electrocardiol 1988;21:S69–S73.
5. Flowers NC, Horan LG, Tolleson WJ, et al. Localization of the site of myocardial scarring in man by high-frequency components. Circulation 1969;40(6):927–934.
6. Reddy CVR, Cheriparambill K, Saul B, et al. Fragmented left sided QRS in absence of bundle branch block: Sign of left ventricular aneurysm. Ann Noninvasive Electrocardiol 2006;11(2):132–8.
7. Aras D, Ozeke O, Cay S, Ozcan F, Konte HC, Topaloglu S. El-Sherif sign and lateral ST segment elevation in hypertrophic cardiomyopathy associated with apical aneurysm. Int. J. Cardiol. 2016 Mar 15;207:80-3.