Cardiac Chambers

Enlargement
M. Rizki Akbar
Department of Cardiology & Vascular Medicine
Faculty of Medicine, Universitas Padjadjaran
BANDUNG
Electrocardiogram
 ATRIAL
ENLARGEMENT
P wave P wave
P wave- normal
 Right Atrial Enlargement - RAE
Criteria
• P wave amplitude in
lead II ≥ 2.5 mm
• Positive component of
biphasic P wave in lead
V1 ≥ 40 ms in area

Not very specific or sensitive

Right Atrial Enlargement - RAE
Right Atrial Enlargement - RAE
 Left Atrial Enlargement - LAE
Criteria
• P wave duration in lead
II ≥ 120 ms
• Notched P wave in
limbs lead with inter
peak duration ≥ 40 ms
• Negative component of
biphasic P in lead V1
≥ 40 ms in area
Sensitivity = 50%; Specificity = 90%
Left Atrial Enlargement - LAE
Left Atrial Enlargement - LAE
RAE LAE
 Biatrial Enlargement - BAE
Criteria
• Features of both RAE and LAE in same ECG
• P wave in lead II >2.5 mm tall and > 120 ms in
duration
• Initial positive component of P wave in V1
>1.5 mm tall and prominent P-terminal force
Atrial Enlargement
 Clinical setting
• LAE
– M shape P wave = P mitral
– Mitral valve disease

• RAE
– = P pulmonale
– Lung disease
VENTRICULAR
HYPERTROPHY
 Ventricular Hypertrophy
• The ECG criteria for diagnosing right or left
ventricular hypertrophy are very insensitive
(i.e., sensitivity ~50%, which means that ~50% of patients with
ventricular hypertrophy cannot be recognized by ECG criteria)

• However, the criteria are very specific

(i.e., specificity >90%, which means if the criteria are met, it is
very likely that ventricular hypertrophy is present).
Right Ventricular Hypertrophy - RVH
 Right Ventricular Hypertrophy - RVH

Any one of the following in lead V1,

 R/S ratio > 1 and negative T wave

 qR pattern
 R > 6 mm, or S < 2mm, or rSR' with R' >10 mm
 Right Ventricular Hypertrophy - RVH
• Better criteria can be derived from the QRS
complex
• QR, Qr, qR, or qRs morphology in lead V1 (in
absence of coronary heart disease)
• QRS voltage in V1 is < 5 mm and V2/V1
voltage ratio is > 6

Sensitivity = 50%; Specificity = 90%

RVH
Right Ventricular Hypertrophy - RVH
 Right Ventricular Hypertrophy

Although there is no widely accepted criteria for

detecting the presence of RVH, any combination of the
following EKG features is suggestive of its presence:

• Right axis deviation

• Right atrial enlargement
• Downsloping ST depressions in V1-V3 (a.k.a. RV strain
pattern)
• Tall R wave in V1
Left Ventricular Hypertrophy - LVH
Left Ventricular Hypertrophy - LVH
• Voltage criteria (Sokolow Lyon)
S(V1) + R(V5/6) ≥ 35 mm
R(aVL) ≥ 35 mm
LVH
Left Ventricular Hypertrophy - LVH
 Biventricular Hypertrophy

• In the presence of LAE any one of the

following suggests this diagnosis:

 R/S ratio in V5 or V6 < 1

 S in V5 or V6 > 6 mm
 RAD (>90 degrees)
 Biventricular Hypertrophy

• Other suggestive ECG findings:

 Criteria for LVH and RVH both met

 LVH criteria met and RAD or RAE present
Exercise
Exercise
Exercise
 ISCHEMIA
INJURY
INFARCTION

M. Rizki Akbar
Department of Cardiology & Vascular Medicine
Faculty of Medicine, Universitas Padjadjaran
BANDUNG
Tissue damage
Ischemia – (Injury) – Infarction
 ECG changes in CHD
• T wave inversion –
Ischemia
• ST deviation:
– Elevation – Injury
(trans-mural)
- Depression – Ischemia
(Sub-endocardial).
- Reciprocal changes
• QRS: Infarct Injury Ischemia
– decreased R
Infarct
- Q wave
ST segment changas
ST segment elevation
Evolution of ST segment elevation
Evolution
 ST-T changes
• T-wave flattening:

• T-wave inversion:

• ST-segment scooping:

•ST-segment depression
ST segment depression

LVH ISCHEMIA
LBBB
RBBB

David Arnall, Ph.D., P.T. (2000)

J point
Measure ST depression

Baseline
Quantity or depth
of ST-segment
depression

J-point .08 seconds

Measure ST elevation
Coronary Artery
 Regions of the Myocardium

Lateral
I, AVL,
V5-V6

Anterior /
Inferior Septal
II, III, aVF V1-V4
PED 596
Regions
 ST – T changes
• Ischemia
– T inverted
– ST depression

• Infarction
– ST elevation (acute  Injury)
– ST elevation + T inverted (recent)
– Q wave – pathologic (old)
Exercise
Exercise
Thank You