The P wave – atrial depolarization

 Smooth contour
 Monophasic in lead II
 Biphasic in V1
 P waves should be upright in leads I and II, inverted in aVR
 Duration - < 120 ms
 Amplitude ( < 2.5 mm in the limb leads, < 1.5 mm in the precordial leads)

Atrial abnormalities are most easily seen in the inferior leads (II, III and aVF) and lead V1, as the P waves
are most prominent in these leads.

P mitrale (bifid P waves), seen with left atrial enlargement.

P pulmonale (peaked P waves), seen with right atrial enlargement.

P wave inversion, seen with ectopic atrial and junctional rhythms.

Variable P wave morphology, seen in multifocal atrial rhythms.

The presence of broad, notched (bifid) P waves in lead II is a sign of left atrial enlargement, classically
due to mitral stenosis.
The presence of tall, peaked P waves in lead II is a sign of right atrial enlargement, usually due to
pulmonary hypertension (e.g. cor pulmonale from chronic respiratory disease).

P-wave inversion in the inferior leads indicates a non-sinus origin of the P waves. When the PR interval is
< 120 ms, the origin is in the AV junction (e.g. accelerated junctional rhythm)

When the PR interval is ≥ 120 ms, the origin is within the atria (e.g. ectopic atrial rhythm)
The presence of multiple P wave morphologies indicates multiple ectopic pacemakers within the atria
and/or AV junction. If ≥ 3 different P wave morphologies are seen, then multifocal atrial rhythm is
diagnosed

If ≥ 3 different P wave morphologies are seen and the rate is ≥ 100, then multifocal atrial tachycardia
(MAT) is diagnosed

Q Wave - any negative deflection that precedes an R wave

Normal Q wave in V6

 The Q wave represents the normal left-to-right depolarisation of the interventricular

septum
 Small ‘septal’ Q waves are typically seen in the left-sided leads (I, aVL, V5 and V6)
 Small Q waves are normal in most leads
  Deeper Q waves (>2 mm) may be seen in leads III and aVR as a normal variant
 Under normal circumstances, Q waves are not seen in the right-sided leads (V1-3)

Q waves are considered pathological if:

 40 ms (1 mm) wide
 2 mm deep
 25% of depth of QRS complex
 Seen in leads V1-3

Pathological Q waves usually indicate current or prior myocardial infarction.

Differential Diagnosis

 Myocardial infarction
 Cardiomyopathies — Hypertrophic (HOCM), infiltrative myocardial disease
 Rotation of the heart — Extreme clockwise or counter-clockwise rotation
 Lead placement errors — e.g. upper limb leads placed on lower limbs

Inferior Q waves (II, III, aVF) with T-wave inversion due to previous MI

 The absence of small septal Q waves in leads V5-6 should be considered abnormal.
 Absent Q waves in V5-6 is most commonly due to LBBB.
R wave

Dominant R wave in V1

 Normal in children and young adults

 Right Ventricular Hypertrophy (RVH)
 Pulmonary Embolus
 Persistence of infantile pattern
 Left to right shunt
 Right Bundle Branch Block (RBBB)
 Posterior Myocardial Infarction (ST elevation in Leads V7, V8, V9)
 Wolff-Parkinson-White (WPW) Type A
 Incorrect lead placement (e.g. V1 and V3 reversed)
 Dextrocardia
 Hypertrophic cardiomyopathy
 Dystrophy
 Myotonic dystrophy
 Duchenne Muscular dystrophy

Right Ventricular Hypertrophy (RVH)

 Right Bundle Branch Block

Right Bundle Branch Block MoRRoW

 Posterior AMI

WPW Type A
Dominant R wave in aVR

 Poisoning with sodium-channel blocking drugs (e.g. TCAs)

 Dextrocardia
 Incorrect lead placement (left/right arm leads reversed)
 Commonly elevated in ventricular tachycardia (VT)

This ECG shows all the classic features of dextrocardia:

 Positive QRS complexes (with upright P and T waves) in aVR

 Negative QRS complexes (with inverted P and T waves) in lead I
 Marked right axis deviation
 Absent R-wave progression in the chest leads (dominant S waves throughout)

The R wave should be small in lead V1. Throughout the precordial leads (V1-V6), the R wave
becomes larger — to the point that the R wave is larger than the S wave in lead V4. The S wave
then becomes quite small in lead V6; this is called “normal R wave progression.” When the R
wave remains small in leads V3 to V4 — that is, smaller than the S wave — the term “poor R
wave progression” is used.
The most common cause of a dominant R wave in aVR is incorrect limb lead placement, with
reversal of the left and right arm electrodes. This produces a similar pattern to dextrocardia in
the limb leads but with normal R-wave progression in the chest leads.

With LA/RA lead reversal:

Lead I becomes inverted

Leads aVR and aVL switch places

Leads II and III switch places

Poor R wave progression is described with an R wave ≤ 3 mm inV3 and is caused by:

 Prior anteroseptal MI
 LVH
 Inaccurate lead placement
 May be a normal variant
 Poor R wave progression

Note that absent R wave progression is characteristically seen in dextrocardia (see previous
ECG).