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ECG Lectures Part 2 Hypertrophies and Enlargements Selim Krim, MD Assistant Professor Texas Tech University Health Sciences Center. Step wise approach to ECG. Measurements Rhythm Analysis Conduction Analysis Waveform Description (Atrial and ventricular enlargements). - PowerPoint PPT Presentation
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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
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
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
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
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
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