E.C.G.

Course – II
Atrial and
Ventricular
enlargement
Dr. Michael Kassirer

”Dept. Internal Medicine ”D

Tel-Aviv Medical center
LA enlargement
LVH
RVH
RVH
RVH
LVH
 Objective
By the end of lesson 2 the
student will:
 Be able to identify right and left atrial
enlargement.
 Know the how to identify ventricular
enlargement.
 Understand the clinical relevance of LVH
criteria, and the differential diagnosis of
 R.A Enlargment
 P wave amplitude > 2.5mm in L2
(Peaked P)
 Secondary QRS changes:
- QR or qR morphology in V1
- QRS voltage < 5mm and V2/V1
ratio > 6
 Sensitivity = 50%, specificity = 90%
 Causes of R.A
Enlargment
 RV failure
 Pulmonary HTN
 Tricuspid valve disease - Tricuspid
regurgitation
 L.A Enlargment
 P wave > 0.12 sec. L2
 Notched P wave (mitral P)
 Negative terminal P in V1 (>0.04sec,
> 1mm)
 Sensitivity = 50%, specificity = 90%
 Causes of L.A
Enlargment
 Mitral valve disease – MS, MR
 Bi-atrial Enlargment
 P wave > 0.12 sec. and amplitude >
2.5mm in L2
 Notched P wave (mitral P)
 P wave initial + (>1.5mm) and
terminal - in V1
 E.C.G Criteria for L.V.H
 Voltage criteria:
Socolov-lyon: S (V2) + R (V5/6) > 35mm
Cornell: S in V3 + R in aVL > 24 mm (M), > 20 (W)
R (aVL) > 11 – 13mm (if Left axis deviation)
R (L1) + S (L3) > 25mm
 QRS duration > 0.08
 Delayed intrinsic deflection in V6 (time > 0.05 sec.)

Secondary changes:
 Left atrial enlargment
 LBBB
 Left axis deviation
 2º ST-T changes (”strain” pattern) – in V5, V6 , I, aVL
 Anti- clockwise rotation
 Causes of L.V.H
 Volume Overload – MR, AR
 Pressure Overload – HTN, AS
 Cardiomyopathy – Ischemic,
Idopathic
 Hypertrophy
 E.C.G Criteria for R.V.H
 V1 - R > S and negative T
 V – R < S
6
 R > 6mm in V1
 QRS duration > 0.08

Secondary changes:
 Right atrial enlargment (TR)
 RBBB pattern
 Right axis deviation
 2º ST-T changes (”strain” pattern) – in V1,
V2
 clockwise rotation
 Causes of R.V.H
 Volume Overload – TR
 Pressure Overload – Ch . Lung
disease, PPH
 Cardiomyopathy
 2º to LVH / LV failure
 Bi-ventricular
enlargment
 Left atrial enlargment:
+ R/S ratio in V5 or V6 < 1 or
+ S in V5 or V6 > 6 mm, or
+ RAD (>90
degrees).
 criteria for LVH +RVH
 LVH criteria + R.A.D or RA
enlargement
 Ventricular
depolarization

V1
V1 V6

L3
L3 L2
 Ventricular
depolarization

V1 V6

L3 L2
 Ventricular
depolarization

V1
V1 V6

L3 L2
 Ventricular
depolarization

V1
V1 V6

L3 L2
 Ventricular
depolarization

V1
V1 V6

L3
L3 L2
 Ventricular
depolarization

V1
V1 V6

L3
L3 L2
 Ventricular
depolarization

V1
V1 V6

L3
L3 L2
 Ventricular
depolarization

V1
V1
V1 V6

L3
L3 L2
 Ventricular
depolarization

V1
V1
V1 V6

L3
L3 L2
Electrical axis
 Normal Axis:
- 30º - +110

 Right Axis
deviation:
> + 100

 Left Axis
deviation:
< - 30º
Ex. 1 – L.V.H