Principles of ECG Diagnosis

6
Chamber Enlargement
Dr Ghazi Ahmad Radaideh
MD, FRCP
Rashid Hospital
Dubai - UAE
16/12/2008

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Reading 12-Lead ECG step-by-step

(RAWIHI)
1. Rate, Rhythm and Regularity
2. Determine the QRS Axis
3. Evaluate the Waves (P,QRS,T ),
Intervals (PR,ST,QT)
4. Evaluate for chamber Hypertrophy
5. Look for myocardial Infarction and Ischemia
6. Interpret the ECG
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Objectives

Atrial enlargement Rt & Lt

LVH
RVH
Cardiomyopathy

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Chamber enlargement
It may occur because of either:
an increase in the volume of blood within the
chamber (volume overload or diastolic overload)
or
an increase in the resistance to blood flow out of
it (pressure overload or systolic overload).
The increase in blood volume causes dilation
the increase in resistance causes thickening of the
myocardial wall (hypertrophy).
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RAE & Right Axis Deviation

(P Pulmonale)
Tall and symmetrically
peaked P wave.
Amplitude >2.5 mm in II

(these criteria are not very specific or sensitive)

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(RAE)
To diagnose RAE you can use the following criteria
II

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P > 2.5 mm

or

V1 or V2

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P > 1.5 mm

Left Atrial Enlargement

(LAE)
1. Widened P wave
> 0.12s (usually lead II)
2. Notched P (m-shaped) wave in
limb leads with the inter-peak
duration > 0.04s

Terminal P negativity in lead V1

duration >0.04s, depth >1 mm.
Sensitivity = 50%; Specificity = 90%
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What is the ECG diagnosis?

Lead II : > 0.04 s
(1 box) between
notched peaks

Lead V1: Neg. deflection

> 1 box wide x 1 box deep

LAE
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Bi-Atrial Enlargement (BAE)

Features of both RAE and
LAE in same ECG
P wave in lead II >2.5 mm
tall and >0.12s in duration
Initial positive component
of P wave in V1 >1.5 mm
tall and prominent Pterminal force

Lead II
Normal

RAE
LAE
RAE &
LAE
Norma

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Lead V1

Left Ventricular Hypertrophy

Why is left ventricular hypertrophy characterized by tall QRS
complexes?
The thicker muscle mass increases the distance traveled by the wave of
depolarization as well as the amount of current that flows from hypertrophied
cells (amplitude is therefore increased AND the QRS vector is changed)
Hypertrophid Heart

Normal Heart

V6
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V6

General ECG features of LVH include:

1. Increased QRS amplitude (voltage criteria; i.e., tall
R-waves in LV leads, deep S-waves in RV leads)
2. Delayed intrinsicoid deflection (VAT) in V6 (i.e.,
time from QRS onset to peak R is >0.05 sec)
3. Widened QRS/T angle (i.e., left ventricular strain
pattern)
4. Leftward shift in QRS axis
5. Evidence for (LAE)

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Simple criteria for LVH

To diagnose LVH you can use the following criteria:
R in V5 (or V6) +
S in V1 (or V2) >
35 mm

or
R in aVL > 13 mm

QRS axis between 15 and 30 or greater

AND

left ventricular strain pattern in leads with tallest R

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one of the following

LVH: Limb Lead Criteria

Example 2:

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Right ventricular hypertrophy

Compare the R waves in V1, V2 from a normal ECG and one from a
person with RVH.
R wave is normally small in V1, V2
because the right ventricle does not
have a lot of muscle mass.

in the hypertrophied right ventricle

the R wave is tall in V1,V2.

Normal
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RVH
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Simple criteria for RVH

Right axis deviation (>90 degrees)
Tall R in V1
Other chest lead criteria:

R in V1 + S in V5 (or V6) 10 mm
R/S ratio in V5 or V6 < 1
R in V5 or V6 < 5 mm
S in V5 or V6 > 7 mm

Presence of RAH
RV strain in V1-V3
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Biventricular Hypertrophy

(difficult ECG diagnosis to make)

In the presence of LAE, any one of the

following suggests this diagnosis:
R/S ratio in V5 or V6 < 1
S in V5 or V6 > 6 mm
RAD (>90 degrees)

Other suggestive ECG findings:

LVH pattern + large R in right precordial leads
LVH pattern + right axis deviation
LVH pattern + RAE
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Hypertrophic cardiomyopathy :
(note : giant T wave inversion in
precordial leads)

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