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ECG reporting
The atria
LAA
RAA
BAA

The ventricles

ECG recording and coding

LVH
RVH
BVH
Ventricular strain
Low voltage

The Atria

Normal Atria

Atrial
Enlargement

Atrial depolarization begins at the SA node and travels through


the right atrium, across the intra-atrial septum to the left atrium.
The electrocardiographic representation of atrial depolarization is
the P wave.
Right atrial depolarization forms the initial portion of the P wave.
The left atrial depolarization forms the terminal portion of the P
wave.
The normal P wave axis is falls between +45o and +60o.

Left Atrial
Enlargement

Diagnostic Criteria
The terminal portion of the P wave in lead V1 must be one small
box wide by one small box deep or larger to qualify as left atrial
enlargement.
This force can be calculated by multiplying the time in seconds
by the depth in millimeters. If this product is more negative than
-0.04 LAE is present.
A notched P wave in leads I & II with a duration of 0.12 msecs
or more. "P mitrale"
LAE can shift the P wave axis to +15o or less.
Differential Diagnosis
Valvular disease
Mitral stenosis
Mitral regurgitation
Decreased Left Ventricular Compliance
Longstanding hypertension
Obstructive cardiomyopathy
Aortic stenosis
Aortic regurgitation

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Infiltrative heart disease


All of these conditions increase either pressure or volume loading
on the atria leading to enlargement and/or hypertrophy.

Right Atrial
Enlargement

Diagnostic Criteria
The P wave in leads II, II and aVF is peaked with a height greater
than 2.5mm. "P pulmonale"
The P wave axis is +75o or greater.
The positive aspect of the P wave in lead V1 or V2 is >1.5mm in
height.
Differential Diagnosis
Valvular Disease
Tricuspid stenosis
Tricuspid regurgitation
Pulmonary Hypertension
COPD
Pulmonary emboli
Interstitial lung disease
Sleep apnea
Mitral valve disease
Left ventricular systolic dysfunction
Congenital Heart Disease
Ebstein's anomaly

Biatrial
Enlargement

Diagnostic Criteria
Because the P wave is composed of distinct right and left atrial
components, the diagnosis of biatrial enlargement is simply made by
looking for the criteria for both right and left atrial enlargement.
A large biphasic P wave in lead V1 with the initial component
greater than 1.5mm in height and the terminal component at
least 1mm in depth and 0.04 sec in duration.
A P wave amplitude of >2.5mm and duration of >0.12 seconds in
the limb leads. II.

The Ventricles

Normal Ventricles

Depolarization of the ventricles is represented by the QRS


waveform on the surface ECG.
The normal axis of ventricular depolarization is between -30o and
+105o.

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Ventricular Hypertrophy

Left
Ventricular
Hypertrophy

Conditions that increase the load, pressure or volume, on either the left
or right ventricle, cause a compensatory increase in the ventricular
muscle mass. This increase in muscle mass is seen on the surface
electrocardiogram as an increase in QRS voltage.
Diagnostic Criteria (>40 years of age)
Limb Leads (Low sensitivity, high specificity)
R wave lead I + S wave lead III > 25 mm
R wave aVL > 11mm
R wave aVF > 20mm
S wave in aVR > 14mm
Precordial Leads (High sensitivity, low specificity)
R wave V5 or V6 > 26mm
R wave V5 or V6 + S wave in V1 > 35mm
Largest R wave + largest S wave in precordial leads >
45mm
Differential Diagnosis
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Systemic hypertension
Hypertrophic cardiomyopathy
Other criteria
Sokolow + Lyon (Am Heart J, 1949;37:161)
S V1+ R V5 or V6 > 35 mm
Cornell criteria (Circulation, 1987;3: 565-72)
SV3 + R avl > 28 mm in men
SV3 + R avl > 20 mm in women
Framingham criteria (Circulation,1990; 81:815-820)
R avl > 11mm, R V4-6 > 25mm
S V1-3 > 25 mm, S V1 or V2 +
R V5 or V6 > 35 mm, R I + S III > 25 mm
Romhilt + Estes (Am Heart J, 1986:75:752-58)
Point score system

Right
Ventricular
Hypertrophy

Diagnostic Criteria
Right axis deviation of +110o or more
R/S ratio > 1 in lead V1
R wave lead V1 <7mm
S wave lead V1 < 2mm
qR in V1
rSR' V1 with R' >10mm

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Differential Diagnosis
Pulmonary stenosis
Mitral stenosis
Ventricular septal defect
Atrial septal defect
Pulmonary hypertension
COPD
Pulmonary emboli
Sleep apnoea
Interstitial lung disease
Other causes of a large R wave in lead V1 are posterior infarct,
muscular dystrophy, type A Wolff-Parkinson-White syndrome and right
bundle branch block.
Biventricular
Hypertrophy

Diagnostic Criteria
One or more criteria for both left and right ventricular
hypertrophy
LVH in the precordial leads with an axis > +90o

Ventricular Strain Patterns

Low Voltage

ST-T wave changes associated with abnormal repolarisation secondary


to increased ventricular tension have classically referred to as "strain"
pattern.

Left
Ventricular
Strain

Left ventricular hypertrophy is often associated with ST depression and


deep T wave inversion. These changes occur in the left precordial
leads, V5 and V6. In the limb leads the ST-T changes occur opposite the
main QRS forces. Therefore, if the axis is vertical, the ST-T changes are
seen in II, III and aVF. If the axis is horizontal the ST-T changes are
seen in I and aVL.

Right
Ventricular
Strain

Right ventricular hypertrophy can be associated with ST depression and


T wave inversion in the right precordial leads, V1 - V3. Leads II, II and
aVF may also show similar ST - T wave changes.
Diagnostic Criteria
Voltage of entire QRS complex in all limb leads <5mm.
Voltage of entire QRS complex in all precordial leads < 10mm.
Either criteria may be met to qualify as "low voltage".
Differential Diagnosis
An increase in the distance between the heart and the ECG leads,
infiltration of the heart muscle itself and metabolic abnormalities are
all associated with low voltage.

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1. Increased Distance
Pericardial effusion
Obesity
COPD with hyperinflation
Pleural effusion
Constrictive pericarditis
2. Infiltrative Heart Disease
Amyloidosis
Scleroderma
Hemachromatosis
3. Metabolic Abnormality
Myxoedema

References
Chou, Timothy K. Knilans. Electrocardiography in Clinical Practice. 4th Edition. Philadelphia: W.B.
Saunders. 1996.

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