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11 Atrial Enlargement
Tips and Tricks
• To diagnose right atrial enlargement, look at the height of P wave (more than
2.5mm).
• To diagnose left atrial enlargement, look at the width of P wave (more than
0.11s).
• If P pulmonale is present, diagnosis is right atrial enlargement.
• If P mitrale is present, diagnosis is left atrial enlargement.
• If P tricuspidale is present, diagnosis is biatrial enlargement.
Self-Assessment Questions
1. Pressure overload leads to hypertrophy of muscular wall of cardiac chamber.
True or false?
2. Biatrial enlargement is seen in Lutembacher’s syndrome. True or false?
3. The height of P wave is more than 2.5mm in P pulmonale. True or false?
4. To diagnose atrial enlargement, focus should be on QRS complex. True or false?
5. Biatrial enlargement is diagnosed by P mitrale. True or false?
6. Right atrial enlargement is characterized by:
a. Increased amplitude of the P wave in lead II b. Prolonged P-R interval c.
Widened QRS complex d. Tall and peaked T waves
7. In biatrial enlargement, the P wave in lead V1 may be:
a. Large and biphasic b. Negative, with an inverted shape c. Positive, with a
tall and peaked appearance d. Absent
8. Right atrial enlargement may be caused by:
a. Pulmonary hypertension b. Left ventricular hypertrophy c. Aortic stenosis d. Mitral regurgitation
9. Left atrial enlargement is characterized by:
a. Increased amplitude of the P wave in lead II b. Prolonged P-R interval c.
Bid P wave d. Tall and peaked T waves
10. To diagnose left atrial enlargement, P wave should be examined in:
a. Lead V5 and V6 b. Lead aVR and aVL c. Lead I and aVL d. Lead
II and V1
11.3 Combined Left andRight Atrial Enlargement
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Case Studies
1. A 23-year-old young lady suffering from breathlessness arrived at the emer-
gency. She had mid-diastolic murmur, opening snap and a loud S1. Her ECG
(lead II) is given below (Fig.11.7). Can you identify the abnormality?
2. Lead V1 of a 12-lead ECG is shown in Fig.11.8. Identify the abnormality and
name two conditions in which you will nd this abnormality.
3. A 50-year-old gentleman came to emergency department with severe breathless-
ness. He has similar attacks in the past for which he ignored treatment. He is a
chronic smoker. His chest X-ray revealed increased bilateral bronchovascular
marking, hyperinated lungs with attened hemidiaphragms. Lead II of a 12-lead
ECG is shown in Fig.11.9. Identify the abnormality and name two conditions in
which you will nd this abnormality.
Lead II
Fig. 11.7 Identify the ECG abnormality
Fig. 11.8 Identify the
ECG abnormality
Fig. 11.9 Identify the
ECG abnormality
Lead II
Lead V1
25 mm/s. 10 mm = 1 mV.
25 mm/s. 10 mm = 1 mV.
25 mm/s. 10 mm = 1 mV.
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11 Atrial Enlargement
Answers
1. True 2. True 3. True 4. False 5. False 6. a 7. a 8. a 9. c 10. d
Case Studies
1. There are bid P waves. The P wave has two peaks and the two peaks are more
than 0.04s apart. This is P mitrale. It is suggestive of left atrial enlargement.
Mid-diastolic murmur with opening snap and loud S1 indicates mitral stenosis.
So it is a case of mitral stenosis. However, this patient should be further investi-
gated and echocardiography should be done to treat her properly. She may need
a mitral valve replacement.
2. There is a biphasic P wave in lead V1 with deep and wide terminal negative
component. The negative component is more than 0.04s in duration and more
than 1mm (0.1mV) in depth. This indicates left atrial enlargement. It is observed
in mitral stenosis and mitral regurgitation.
3. There are tall and peaked P waves. These are called P pulmonale which indicates
right atrial enlargement. History of similar past attacks in presence of smoking
indicates chronic obstructive pulmonary disease. Chest X-ray further conrms
the diagnosis. P pulmonale is also seen in pulmonary hypertension and tricuspid
regurgitation.
Chapter 12
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Ventricular Hypertrophy
Learning Objectives
After studying this chapter, the reader will learn about:
• Left ventricular hypertrophy
• Right ventricular hypertrophy
• Biventricular hypertrophy
Ventricular hypertrophy is caused by pressure or volume overload of ventricles.
Concentric hypertrophy is caused by pressure overload, and eccentric hypertrophy
is caused by volume overload. Changes in the amplitude of the R and S waves are
reected in ECG.
12.1 Pressure (Systolic) Overload
Pressure overload occurs when the heart pumps against an increased resistance, as
in systemic hypertension. Chronic increase in resistance results in concentric hypertrophy, in which the ventricular wall thickens as compared to the ventricular cavity.
In hypertrophy, the cardiac muscle bres increase in size. In ECG, the main changes
are increased voltage of QRS complex, depression of S-T segment and asymmetric
inversion of T wave in the chest leads.
Ltd. 2024
T. K. Koley, Rapid Review of ECG,
https://doi.org/10.1007/978-981-99-9116-7_12
143© The Author(s), under exclusive license to Springer Nature Singapore Pte
144
y
Right
atrium
Right
ventricle
Tr
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12 Ventr icular Hypertrophy
12.2 Volume (Diastolic) Overload
Persistent increased volume, as seen in valvular regurgitation, results in stretching or dilatation of the ventricular chamber. This is known as eccentric hypertrophy in which the ventricular wall thickness remains normal relative to the
increase in the radius of the ventricle. Volume and pressure overload often occur
together.
12.3 Left Ventricular Hypertrophy
Prolonged raised pressure in left ventricle leads to anatomical changes of left ventricle hypertrophy (LVH). The various causes of LVH are enumerated in Box 12.1.
Diagnosis of LVH (Fig.12.1) is important because it indicates the future possibility
of major cardiovascular complications. The ECG criteria for diagnosis of LVH are
quite specic. However, one must always remember that similar ECG changes may
be seen in young persons and athletes as well. Besides this, the ECG criteria are not
icuspid valve
Fig. 12.1 Left ventricular hypertrophy. Note the wall thickness of left ventricle and the small left
ventricular cavity
Left atrium
Mitral valve
Small LV cavity
Left ventricular
concentric hypertroph
Thick LV wall
12.3 Left Ventricular Hypertrophy
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always reliable in presence of bundle branch block, WPW syndrome and previous
myocardial infarction. Hence, all ECG changes should be interpreted in light of the
clinical ndings.
Box 12.1 Some Important Causes of LVH
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Hypertensive heart disease
Congenital heart disease like PDA, coarctation of aorta and tricuspid atresia
Hypertrophic cardiomyopathy
After the neonatal period, the left ventricle becomes hypertrophied as compared to right ventricle. The left ventricular electrical dominance is reected in
ECG by tall R waves in left-sided chest leads and deep S waves in right sided
chest leads. In presence of LVH, there is further dominance of the electrical
forces generated in the left ventricle. This is reected in ECG by increase in the
height of R waves in left- sided chest leads and depth of S waves in right sided
chest leads.
The following are the ECG changes of left ventricular hypertrophy:
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• Abnormalities of QRS complex
• Abnormalities of S-T segment and T wave
• Abnormalities of QRS axis
• Inversion of U wave
• Left atrial enlargement
12.3.1 Abnormalities ofQRS Complex
12.3.1.1 Increased Amplitude ofQRS Complex
The amplitude of the QRS complex is increased in LVH due to increase in left ventricular mass. Since ventricular activation occurs from endocardium to epicardium,
the amplitude of the R and S waves indicates the thickness of the ventricular wall.
The amplitude of the QRS complex is increased in LVH.There is deep S wave in
lead V1 and tall R wave in leads V5 and V6 (Fig.12.2). In an adult above 35years
of age if the sum of R wave in lead V5 and the depth of S wave in lead V1 exceed
35mm, it indicates LVH.Sokolow-Lyon voltage criteria are used for diagnosis of
LVH (Box 12.2) in adults over 35years of age.
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25 mm/s. 10 mm = 1 mV
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12 Ventr icular Hypertrophy
Box 12.2 Sokolow-Lyon Voltage Criteria for LVH
RI+SIII≥2.5mv (25mm)
R in aVL>1.2mv (12mm)
R in aVF>2.0mv (20mm)
S in VI≥2.4mv (24mm)
R in V5 or V6>2.6mv (26mm)
R in V5 or V6+S in VI>3.5mv (35mm)
I II III aVLaVR aVF
V1
Fig. 12.2 Left ventricular hypertrophy. This ECG is recorded from a 64-year-old gentleman suffering from hypertension for last 20years. Note the S-T segment, T wave change in leads V4, V5
and V6. SV1+RV5 is 61mm
12.3.1.2 Increase inVentricular Activation Time
Ventricular activation time is increased in LVH to more than 0.05 s in lead V5 or
lead V6 due to increase in wall thickness.
V2
V3
V5V4 V6
V1
V2
V3
V4
V6
V5
12.3 Left Ventricular Hypertrophy
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12.3.1.3 Counterclockwise Electric Rotation
The counterclockwise electric rotation of heart leads to shifting of transition zone to
lead V3 or even lead V2.
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12.3.2 Abnormalities of S-T Segment andT Wave
The left ventricle is under strain in LVH and it is manifested by S-T segment depression and T wave inversion in leads V5, V6, aVL and lead I.This is termed left ventricular strain (Fig.12.3).
I
25 mm/s. 10 mm = 1 mV
Fig. 12.3 Left ventricular hypertrophy. SV1+RV5 is more than 35mm. There is tall R wave in
lead aVL and left axis deviation. There are S-T segment, T wave changes in leads V5 and V6
II
III
aVR
aVL
aVF
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12 Ventr icular Hypertrophy
12.3.3 Abnormalities ofQRS Axis
Normal QRS axis is seen in early and uncomplicated LVH.However, in long standing LVH, especially that associated with hypertension leads to brosis, which
affects the left anterior fascicle resulting in left anterior hemiblock. This results in
left axis deviation.
12.3.4 Inversion ofU Wave
There is inversion of U wave in left-sided chest leads.
12.3.5 Left Atrial Enlargement
Left atrial enlargement provides contributory evidence of left ventricular hypertrophy. It helps in diagnosis of LVH in presence of left bundle branch block. There may
be wide and notched P wave in lead II and there may be biphasic P wave in lead V1
with a deep negative component.
Romhilt and Estes point score system combines several of the above mentioned
criteria. A score of 4 indicates probable LVH and a score of 5 indicates LVH.All the
diagnostic criteria of Romhilt and Estes point score system are enumerated in Box
12.3. The important diagnostic criteria of LVH are enumerated in Box 12.4.
Box 12.3 Romhilt and Estes Point Score
1. Voltage criteria (any of the following):
• Largest R or S wave in limb leads ≥20mm 3 Points
• S wave in V1 or V2≥30mm
• R wave in V5 or V6≥30mm
2. ST-T abnormalities (left ventricular strain pattern):
• ST-T vector opposite to QRS without digitalis 3 Points
• ST-T vector opposite to QRS with digitalis 1 Point
3. (Left atrial abnormality)
• P terminal force in V1 is 1 mm or more in depth with a duration
≥0.04s 3 Points
4. Left axis deviation (QRS axis of −30° or more) 2 points
5. QRS duration ≥0.09s 1 Point
6. Intrinsicoid deection in V5 or V6 (> 0.05s) 1 Point
V6
a
V6
12.3 Left Ventricular Hypertrophy
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LVH due to diastolic overload (excess blood ow in left ventricle) as happens in
aortic incompetence or mitral incompetence has the following features:
Like in systolic overload, there are tall R waves in leads V5 and V6. They may be
even taller than what is seen in systolic overload.
There are narrow and deep Q waves in leads V5 and V6. These do not indicate
any old myocardial infarction.
The T waves in leads V5 and V6 are taller than the normal T waves in those leads.
Often they are pointed with arrowhead appearance.
The S-T segment in leads V5 and V6 are slightly elevated with concavity upwards
(Fig.12.4).
Box 12.4 Diagnostic Criteria of LVH
Increased amplitude of QRS complex
Increase in VAT in lead V5 or V6
Counterclockwise rotation of heart
S-T, T strain pattern in lead V5 or V6
Left axis deviation
Inversion of U wave
Left atrial enlargement
Romhilt and Estes point of 5 or more
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Fig. 12.4 Diagram showing QRS complex in lead V6in LVH: systolic (a) and diastolic (b) over-
load. In systolic overload, the initial q wave often disappears, whereas in diastolic overload, the
initial q wave becomes prominent. The amplitude of R wave is increased in both. The T wave is
inverted with S-T segment depression in systolic overload but in diastolic overload the S-T segment may be minimally elevated with upward concavity
b
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