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
L3
V6
L2
Ventricular depolarization V1 V1
L3
V6
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