ECG LecturesECG LecturesPart 2Part 2

Hypertrophies and EnlargementsHypertrophies and Enlargements

Selim Krim, MDSelim Krim, MDAssistant ProfessorAssistant Professor

Texas Tech University Health Sciences CenterTexas Tech University Health Sciences Center

Step wise approach to ECGStep wise approach to ECG

Measurements

Rhythm Analysis

Conduction Analysis

Waveform Description (Atrial and ventricular enlargements)

Right Atrial enlargementRight Atrial enlargement

Left Atrial EnlargementLeft Atrial Enlargement

Bi-Atrial EnlargementBi-Atrial Enlargement

Atrial Enlargement

P wave amplitude P wave amplitude >2.5 mm>2.5 mm in II and/or in II and/or >1.5 mm>1.5 mm in V1 in V1 (these criteria are not very specific or sensitive) (these criteria are not very specific or sensitive)

Better criteria can be derived from the QRS complex; Better criteria can be derived from the QRS complex; these QRS changes are due to both the high incidence these QRS changes are due to both the high incidence of RVH when RAE is present, and the RV displacement of RVH when RAE is present, and the RV displacement by an enlarged right atrium.  by an enlarged right atrium.  QR, Qr, qRQR, Qr, qR, or , or qRsqRs morphology in lead V1 (in absence of coronary heart morphology in lead V1 (in absence of coronary heart disease) disease)

Right Atrial Enlargement

Righ Atrial Enlargement

Right Atrial Enlargement

P wave duration P wave duration >> 0.12s in frontal plane (usually lead II) 0.12s in frontal plane (usually lead II)  Notched P wave in limb leads with the inter-peak  Notched P wave in limb leads with the inter-peak duration duration >> 0.04s 0.04s

Terminal P negativity in lead V1 (i.e., "P-terminal force") Terminal P negativity in lead V1 (i.e., "P-terminal force") duration duration >>0.04s, depth 0.04s, depth >>1 mm. 1 mm.

Sensitivity = 50%; Specificity = 90% Sensitivity = 50%; Specificity = 90%

Left Atrial Enlargement

Left Atrial Enlargement

Left Atrial Enlargement

Features of both RAE and LAE in same ECG Features of both RAE and LAE in same ECG

P wave in lead II >2.5 mm tall P wave in lead II >2.5 mm tall andand >>0.12s in duration 0.12s in duration

Initial positive component of P wave in V1 >1.5 mm tall Initial positive component of P wave in V1 >1.5 mm tall andand prominent P-terminal force prominent P-terminal force

Bi-Atrial Enlargement

Ventricular EnlargementsVentricular Enlargements

Left Ventricular HypertrophyLeft Ventricular Hypertrophy

Right Ventricular HypertrophyRight Ventricular Hypertrophy

General ECG Features of LVH

>> QRS amplitude (voltage criteria; i.e., tall R-waves in LV QRS amplitude (voltage criteria; i.e., tall R-waves in LV leads, deep S-waves in RV leads) leads, deep S-waves in RV leads)

Delayed intrinsicoid deflection in V6 (i.e., time from QRS Delayed intrinsicoid deflection in V6 (i.e., time from QRS onset to peak R is onset to peak R is >>0.05 sec) 0.05 sec)

Widened QRS/T angle (i.e., Widened QRS/T angle (i.e., left ventricular strain pattern, left ventricular strain pattern, or ST-T oriented opposite to QRS direction) or ST-T oriented opposite to QRS direction)

Leftward shift in frontal plane QRS axis Leftward shift in frontal plane QRS axis

Evidence for left atrial enlargement (LAE)Evidence for left atrial enlargement (LAE)

ESTES Criteria for LVH ("diagnostic", >5 points; "probable", 4 points)

ECG CriteriaECG Criteria Points Points

Voltage Criteria (any of)Voltage Criteria (any of): :

R or S in limb leads R or S in limb leads >>20 mm 20 mm

S in V1 or V2 S in V1 or V2 >> 30 mm 30 mm

R in V5 or V6 R in V5 or V6 >>30 mm30 mm

3 points3 points

ST-T AbnormalitiesST-T Abnormalities::Without digitalisWithout digitalisWith digitalis With digitalis

3 points3 points

1 point1 point

Left Atrial Enlargement in V1 Left Atrial Enlargement in V1 3 points3 points

Left axis deviation Left axis deviation 2 points2 points

QRS duration 0.09 sec QRS duration 0.09 sec 1 point1 point

Delayed intrinsicoid deflection in V5 or V6 (Delayed intrinsicoid deflection in V5 or V6 (>0.05 >0.05 sec)sec)

1 point1 point

LVH Based on Estes Criteria

LVH Based on Estes Criteria

CORNELLCORNELL Voltage Criteria for LVH (sensitivity = 22%, Voltage Criteria for LVH (sensitivity = 22%, specificity = 95%)  S in V3 + R in aVL > 24 mm (men) specificity = 95%)  S in V3 + R in aVL > 24 mm (men)

S in V3 + R in aVL > 20 mm (women) S in V3 + R in aVL > 20 mm (women)

Cornell product of [(SV3+RaVL)xQRS duration] >2440 Cornell product of [(SV3+RaVL)xQRS duration] >2440 ms.ms.

Cornell Criteria

LVH By Cornell Product (QRS=134ms)

LVH By Cornell Product (QRS=80ms)

Sokolow-Lyon voltage criteriaSokolow-Lyon voltage criteria

SV1+RV5 or RV6SV1+RV5 or RV6≥≥ 3.5 mV or 35 mm 3.5 mV or 35 mm

Sokolow-Lyon voltage criteriaSokolow-Lyon voltage criteria

Sokolow-Lyon voltage criteriaSokolow-Lyon voltage criteria

Right Ventricular hypertrophy (RVH)Right Ventricular hypertrophy (RVH)

GeneralGeneral ECG features include:   ECG features include:  

Right axis deviation (>90 degrees) Right axis deviation (>90 degrees)

Tall R-waves in RV leads; deep S-waves in LV leads Tall R-waves in RV leads; deep S-waves in LV leads

Slight increase in QRS duration Slight increase in QRS duration

ST-T changes directed opposite to QRS direction (i.e., wide QRS/T ST-T changes directed opposite to QRS direction (i.e., wide QRS/T angle) angle)

May see incomplete RBBB pattern or qR pattern in V1 May see incomplete RBBB pattern or qR pattern in V1

Evidence of right atrial enlargement (RAE) Evidence of right atrial enlargement (RAE)

RVHRVH

  SpecificSpecific ECG features):  Any one or more of the following (if QRS ECG features):  Any one or more of the following (if QRS duration <0.12 sec): duration <0.12 sec):

  Right axis deviation (>90 degrees) in presence of disease capable of Right axis deviation (>90 degrees) in presence of disease capable of causing RVH causing RVH

R in aVR R in aVR >> 5 mm, or 5 mm, or

R in aVR > Q in aVR R in aVR > Q in aVR

Any one of the following in lead V1:  R/S ratio > 1 Any one of the following in lead V1:  R/S ratio > 1 andand negative T wave negative T wave

qR pattern qR pattern

R > 6 mm, R > 6 mm, oror S < 2mm, S < 2mm, oror rSR' with R' >10 mm rSR' with R' >10 mm

RVHRVH

RVHRVH

Let’s practice!Let’s practice!

ECG 1

ECG 2

ECG 3

ECG 4

ECG 5

Questions ?Questions ?

Thank youThank you