Comprehensive ECG Guide to Chamber Enlargement and Hypertrophy Diagnosis

[Music] [Music] welcome all

to the session on chamber enlargement by the end of the session you will be able to identify right atal abnormality

left atrial abnormality left ventricular hypertrophy and dilatation and right ventricular hypertrophy and dilatation

in the ecg first i would like to tell you the difference between enlargement and

hypertrophy the term enlargement is used when there is volume overload of the ventricle causing eccentric hypertrophy

that is there is dilatation of the chamber of the heart the term hypertrophy is used when there is

pressure overload of the ventricle causing concentric hypertrophy that is there is increase in the thickness of

the myocardial wall so we'll be using these terms throughout the session so first we'll see about right

atrial abnormality so we all know that the impulses originate in the sa node from there the

depolarization spreads to the right atrium and to the left atrium the net vector of this is in this

direction and the normal p wave axis is between plus 30 to plus 75 degrees now let's see what happens in a right

atrial abnormality in right atrial abnormality there is a stronger right atrial vector and a normal left atrial

vector this will cause the p wave axis to shift clockwise and in right atrial

abnormality the p wave axis will be more than plus 75 degrees in left atrial abnormality there is a stronger left

atrial vector this will cause the p wave axis to shift anticlockwise and in left atrial abnormality the p wave axis is

less than plus 30 degree so that is the first difference in radiatal abnormality the p

wave axis will be shifted clockwise more than plus 75 degrees and in left atrial abnormality the p wave axis will be

shifted anti-clockwise that is less than plus 30 degrees so we'll see the morphology of p wave so if you remember

in lead 2 the p wave is having two components the right atl component and the left atrial component

the normal amplitude of p wave in lead 2 is 0.25 milli volt and the duration is less than 0.1 to second

in lead one the p wave is having a biphasic shape the positive component contributed by the right atrium and the

negative component contributed by the left atrium the amplitude of each of this complex is 0.1 millivolt and the

duration is point not for second so now let's see what happens in a right atrial abnormality so in lead to the

initial component which is contributed by the right atrium will be more will be increased in amplitude and

the latter component contributed by the left atrium will remain the same so what happens in lead to in righteous

abnormality the amplitude of the p wave increases it will be more than 0.25 millivolt whereas the duration remains

the same less than 0.12 second now let's see in v1 in v1 the right atrium the positive

component of the biphasic wave is contributed by the right atrium so that will be increased in amplitude the

negative component will remain the same so in v1 in right in rightetal abnormality you will see

a tall positive deflection and a small negative deflection the duration will remain the

same so to summarize in ritual abnormality we will see tall p wave in both limb and

right precordial leads a positive deflection of p wave is seen in lead v 1 or v 2 more than 0.15 milli

volt there is no increase in the total duration of p wave and the p wave axis in the frontal plane is more than plus

75 degrees ecg 1 we will see lead 2 and one we see p wave in lead two and v one

because p wave axis is in the direction of lead two and v one being the ripe recorded elite so here if you see the

lead two and v one what are we seeing here we have a very tall p wave of amplitude more than four millimeter

and in v1 if you see there is a biphasic p wave with the positive deflection more than 0.1 millivolt so this is an ecg

suggestive of right atrial abnormality there are many other changes in this ecg but right now we'll

concentrate on lead 2 and v1 now let's move on to left atrial abnormality left atrial abnormality unlike right atrial

abnormality it causes interatrial conduction disturbance in which the duration of the middle and the

terminal component of the p wave is prolonged oving to delayed left atrial activation

so we already discussed about the p wave axis there is an anti clockwise shift in the p wave axis and the p wave axis will

be less than plus 30 degrees let's see the morphology of p wave in left atrial abnormality so the initial

component in lead 2 which is contributed by the right atrium remains the same whereas the one contributed by the left

atrium is now prolonged so how do we how do we see it in the ecg we see a notched p wave in

lead 2 with amplitude remaining the same but the

duration more than 0.12 second and in between these two hums there should be at least one small square

in lead v1 the positive deflection contributed by the right atrium remains the same whereas the negative deflection

is now deeper and broader increases in both amplitude and duration the amplitude will be more than 0.1 milli

volt and the duration will be more than 0.04 second in left atrial abnormality so the p wave

is notched with the duration of 0.12 second or more this is called as p mitral in lead 2 and the two hums are

separated by at least one small block there is a leftward shift in the p wave axis in the frontal plane to plus 15

degrees or beyond a p terminal force in v lead v 1 equal to or more negative than 0.04 milli volt second so what is p

terminal false it is nothing but the product of the amplitude and duration of the negative component of p wave in v1

so we already told this amplitude and duration both are increased in case of left atrial abnormality so this p

terminal force will be more than point naught for millivolt second in left atrial abnormality this is called as

mores index combine the sensitivity of p terminal force in v1 more than 0.04 millivolt second and p wave duration

more than 100 millisecond is much more in diagnosing left atrial abnormality so

let's see this ecg lead 2 and v1 we can see here so what do you see here what do you see here

in lead 2 the p wave is looking bifid or notched and if you see carefully

between the two hums there is one small square one small square between two hums and in

v1 what are you seeing there is a positive component and a negative component which is

increased in duration prolonged more than 40 millisecond so if you calculate the p terminal force it will come more

than 0.04 milli volt second so satisfying the morris index so this is an ecg suggestive of left atrial

abnormality so what happens in a biatrial enlargement in case of a biatrial

enlargement both these findings both the findings of left atrial abnormality and right atrial

abnormality will be present that is there will be a large diphasic p wave in v one with an initial positive component

more than one point five millimeter and the terminal negative component more than one millimeter in amplitude and

more than 0.04 second in duration or both or if there is a tall peaked p wave in

right precordial lead and a wide notched p wave in the limb lead or left precordial lead like v5 v6 that is also

suggestive of left biatrial enlargement it is called as p tricuspidal or there will be an increase in both

amplitude and duration of p wave in limb bleeds so a combination of findings of right atrial abnormality and left atrial

abnormality are seen in ecg if there is a biatrial enlargement so let's see this ecg let's concentrate

on lead v1 so what do you see there in lead v1

there is a positive deflection which is well more than one millimeter in amplitude and a negative deflection of

duration more than 40 milliseconds so there are findings of suggestive of both right atrium and left atrial abnormality

so this ecg is suggestive of biatrial enlargement

so how will you identify atrial enlargement in presence of atrial fibrillation in atrial fibrillation you

will not see a p wave instead you will see something called as fibrillatory waves which are seen as baseline

disturbances so you will see something called as fibrillatory waves and not p waves so how will you identify a trail

enlargement so you see the fibrillatory waves if there are coarse fibrillatory waves that means the fibrillatory waves

with amplitude more than one millimeter it is suggestive of an atrial enlargement even in presence of atrial

fibrillation so to summarize in right atrial enlargement the

amplitude of the p wave is more in lead 2 and the positive deflection will be of more amplitude in v 1. in left atrial

enlargement there is a notched p wave in with increased duration in v2 and

normal positive deflection under broader and deeper negative deflection p wave in v1 a combination of these findings are

seen in biatrial enlargement so now let's move on to left ventricular hypertrophy and

dilatation so we already told the impulses originate from the cyanoatrial node they

spread to the av node and from there right ventricle is depolarized then left

ventricle is depolarized the net vector of this will be in the direction in this direction of lead 2 and the normal qrs

axis is between minus 30 degree to plus 90 degree minus 30 degree to plus 90 degree so

what happens in left ventricular enlargement in left ventricular enlargement there is a

stronger left ventricular vector which shift the p qrs axis anti-clockwise

or leftward and the left axis deviation will be there of more than minus 30 degrees in left ventricular enlargement

so the ecg the sensitivity of ecg to diagnose left ventricular hypertrophy is limited so many criteria are being

proposed to diagnose left ventricular hypertrophy in ecg most of these criteria rely on increased qrs voltage

that is because when the left ventricular is hypertrophic that means the thickness of the left ventricular

myocardium is more so the amplitude of the qrs complex will also be more so let's see in the frontal

plane i am concentrating two leads v1 and v6 v1 being the right precordial lead and

v6 being the left precordial layer so this is the normal ecg in a v1 lead v1 so here we can see a

small r wave and a deep s wave this r is contributed to the by the right ventricle and s is contributed by the

left ventricle in left ventricular hypertrophy this s will be depend the s which call which is contributed by the

left ventricle will be deepened and you get a small r d ps in v1 this if there is a small r d pass like this in v1 it

is suggestive of left ventricular hypertrophy what happens in v6 in normally v6 will have a because it is a

left precordial lead so the v6 will have a tall r wave contributed by the left ventricle and a small s wave which is

contributed by the right ventricle so in left ventricular hypertrophy there is an increase in the amplitude of this r wave

contributed by the left ventricle so there are some pointers

for left ventricular hypertrophy in the ecg one i already told you increase to qrs voltage

the second one is a left atrial abnormality during diastole when the mitral valve is open the left ventricle

and left atrium behaves like a common chamber and any pressure or volume differences in the left ventricle is

reflected to the left atrium also so the presence of an associated left atrial abnormality is a pointer for left

ventricular hypertrophy and ventricular activation time is the time taken for the impulse to travel

through the myocardium to reach the recording electrode in case of a left ventricular hypertrophy since the

thickness of the myocardium is more this ventricular activation time which is measured from the beginning of the qrs

complex to the peak of the r wave it is prolonged usually it be less than 0.05 second here it will be prolonged to more

than 0.05 second the intrinsic oil deflection is the point from which this

impulse reaches the recording electrode and so because the ventricular activation time is prolonged the

intrinsic intrinsicoid reflection is also delayed it is evidently seen in the left recording leads that is v5 and v6

if the amplitude of r and v6 is more than or equal to the r in v5 that is also suggestive of left ventricular

hypertrophy because in left ventricular hypertrophy there is some abnormality in

depolarization especially in a concentric hypertrophy it is associated with abnormalities in repolarization

abnormalities in sdt segments the two most commonly used polarization criteria for diagnosis of lvhr qrs t

angle more than 100 degree and the t wave which is upright in v2 and more negative than 0.1 milli volt in v6 so in

addition to the findings which we mentioned above if you see abnormalities in sdt segment and t wave

that is also suggestive of left ventricular hypertrophy the reciprocal changes are also present in the right

precordial needs with sd elevation and a tall tv there are a few criteria which are used commonly in clinical practice

to diagnose left ventricular hypertrophy in the ecg the most commonly used oneness zoklo leon index

so it says that the amplitude of r in v5 or v6 plus the amplitude of s in v1 if it is more than

or equal to 35 millimeter it is suggestive of left ventricular hypertrophy if the amplitude of r

wave in avl is more than 11 millimeter that is also suggestive of left ventricular hypertrophy then another

commonly used criteria is kernel voltage criteria so it says that

the sum of the amplitude of r in avl with s in v3 if it is more than 28 millimeter in men or 20 millimeter in

women it is suggestive of left ventricular hypertrophy corner product is the kernel voltage multiplied by qrs

duration in milliseconds and if it is more than or equal to 2440 milliseconds it is also suggestive of left

ventricular hypertrophy then we have rom hilt and esters criteria they assign points to certain parameters like three

points are given if there is evidence of left atrial abnormality or any increase in the voltage of qrs complex as

evidenced by an r or s in limb lead more than or equal to 20 millimeter s in v1 or v2 more than or equal to 30

millimeter rn v5 or v6 more than or equal to 30 millimeter or any stt abnormalities without digoxin

two points are given if there is a left axis deviation of more than minus 30 degrees and one point is given if

there's a slight widening of qrs complex more than 0.09 seconds and intrinsic deflection in v5 v6 more than or equal

to 0.05 second and st segment or t abnormalities with digoxin so intrinsic oil deflection i hope you

understood it is calculated from the beginning of the qrs complex to the peak of the rv the duration of that if it is

more than 0.05 second we say that there is a prolonged ventricular activation time or delay in intrinsic coil

deflection so if the total score is more than or equal to five points then it is diagnostic of lvh in the ecg a score of

four points is suggestive of probable lbh other ecg changes which are seen in lvhr are total qrs voltage that is the

sum of the amplitude of all the qrs voltage in the ecg more than 175 millimeter presence of an incomplete

left bundle branch block attenuation of a small initial q in the left oriented leads abnormal large q in the inferior

leads a small equifacing rs complex in avf or a u wave amplitude which is increased in right leads or inverted in

left leads these are also pointers to left ventricular hypertrophy so we have seen like all the criteria we have

discussed so far uses the amplitude of the qrs voltage to diagnose lvh but there are some condition in which there

will be left ventricular hypertrophy without increased voltage in the qrs complex like obesity peripheral edema

anasaka lung diseases like emphysema patients with large breast biventricular hypertrophy pericardial

effusion pleural effusion etc so in all these condition you will get a

ecg without increased voltage but the patient will be having left ventricular

hypertrophy there are some conditions in which there is increased qrs voltage not resulting from

lvh like adolescent boys patients with anemia patients who underwent left mastectomy or thin individuals so these

conditions have to be kept in mind whenever you are reading the ecg of any patient so this

is ecg number four so what are we seeing here let's concentrate on the v1 to v6 chest

leads so let's apply so closely on index here so we'll calculate the amplitude of s in v1 it is coming around 20

millimeter and we are calculating the amplitude of r in v6 it is coming 25 so the sum of these

two is more than 35 millimeter so satisfying the zokula leon index let's see the avl the

amplitude of r in avl it is more than 11 millimeter so that is also suggestive of left ventricular hypertrophy if you

apply the corneal voltage criteria we can see that r in avl plus s in v3 so r itself here is 15 s is coming around

25 15 plus 25 it is well more than 28 millimeter so according to kernel voltage criteria also this is suggestive

of left ventricular hypertrophy if you apply the rom hilt and estes criteria there is

evidence of left left ventricular hypertrophy as evidenced by increased qrs voltage

yes well beyond 30 millimeter in the leads so yes that is giving three points and there are stt abnormalities that is

also giving three points so the score is well beyond five so according to rom hilt and estes criteria also this ecg

is having left ventricular hypertrophy now let's see right ventricular hypertrophy and dilatation

so in right ventricular hypertrophy there is a stronger right ventricular vector

which shifts the net qrs axis rightward or clockwise and there's a right axis deviation of more than or

equal to 90 degree but here you have to understand that normally itself left ventricular muscle mass is much more

than the right ventricle so unless the right ventricle is severely hypertrophic this kind of axis deviation will not be

there in the ecg so in the frontal plane in right ventricular hypertrophy there will be a tall r wave and a small s wave

because i already told you the initial r is contributed by the right ventricle so in comparison i have given the left

ventricular hypertrophy ecg also so in right ventricular hypertrophy you get a tall r small s but as a left ventricular

hypertrophy you get a small r d ps in lead v1 in lead v6 in right ventricular hypertrophy are getting an r wave which

is contributed by the left ventricle and a deeper s wave which is contributed by the

right ventricle whereas in left ventricular hypertrophy you are getting a tall r wave in

v6 so the pointers for right ventricular hypertrophy in the ecg are right axis

deviation of more than or equal to 90 degree qr complex or a small q tall r in v1 or

an r wave of amplitude more than 7 millimeter in v1 or an rs ratio of more than or equal to 1 in v1 similar to left

ventricular hypertrophy in right ventricular hypertrophy also because the right ventricular muscle masses

increased there is a delayed onset of intrinsic coil deflection in v1 more than 0.03 second

we will see a small r dps complex in the left oriented leads and an equifacing rs complex in the mid

precordial leads in adults sometimes we see an s1 s2 s3 pattern that is a deep s seen in lead 1

2 3 which is also suggestive of right ventricular hypertrophy presence of right atrial abnormality or right bundle

branch block may also be seen similar to left ventricular hypertrophy we can see st segment and t wave changes

in the form of st depression and t inversion in right precordial leads like v1 and v2

three types of right ventricular hypertrophy are identified type a it is the typical rvh pattern with anterior

and rightward displacement of the main qrs vector type b is the one in which we will see

an incomplete bundle branch block and type c there is posterior and rightward

displacement of the main qrs axis it is seen predominantly in patients with chronic lung disease like emphysema in

that the lead v1 may look normal but we will see a deep s wave in the left precordial leads with right axis

deviation so i like to mention about the ecg in chronic pulmonary disease in chronic pulmonary disease like emphysema

there is over inflation of the lung which will push diaphragm downward so the heart is now aligned vertically

p qrs t wave access everything is shifted rightward and inferiorly towards lead avf since lead

1 is perpendicular to lead avf lead 1 will show very small deflection this is called as lead 1 sign in copd in

addition there will be poor r wave progression in the ecg also so this is ecg number five so what are

we seeing here so in v1 we are seeing a tall r and small s the r is definitely more than

seven millimeter in amplitude the rs ratio is definitely more than one and there are we can see the stt changes

also can you see the sdt changes in v1 v2 v3 so that is also suggestive of right

ventricular hypertrophy this looks like a type a right ventricular hypertrophy pattern

so let's see this acg in this in v1 we are seeing a q r pattern a small q tall r and there is

in v 2 and v 3 we can see a right bundle branch block pattern also so this may be type b

right ventricular hypertrophy here if you see here we have a ecg suggestion of a right atrial

abnormality also in combined ventricular hypertrophy a combination of these findings are seen combination of left

ventricular and right ventricular hypertrophy findings will be seen there is increased voltage of qrs complex

especially over the transition zones that is need v3 and v4 we will see a tall or deepest

or there will be left ventricular hypertrophy with right axis deviation or right atrial

abnormality or a left atrial enlargement with an rs ratio in v5 v6 less than or equal to 1 or s in v5 v6 more than or

equal to 7 millimeter or a right axis deviation of more than plus 90 degrees or if there is a voltage discordance

between limb and precordial leads if you see tall r in right and left precordial leads tall are in left precordial right

precordial leads and large equifacie qrs in the mid precordial leads then this is called as cat natural phenomenon that is

also suggestive of combined ventricular hypertrophy so i'll show you an ecg here we are seeing tall r in

right precordial that is p1 tall r is seen in left precordially that is v6 and in the mid precordial need we

have kind of an equifacing rs complex so this is called as cat bachelor phenomenon and this is indicative of

combined ventricular hypertrophy in heart failure you will see a combination of these findings there may

be finding suggestive of left ventricular enlargement right ventricular enlargement left atrial

abnormality right atrial abnormality any combination is possible in addition we will see arrhythmias like

atrial fibrillation premature ventricular complex atrial ectopics so those kind of arrhythmias may be

present in addition the patient may have complete left bundle branch block or right bundle branch block in the ecg

when these findings are present we suspect heart failure we have to do an echo to confirm systolic or diastolic

dysfunction of the heart these are my references thank you