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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2818_Библиотеки_им_академика_М_И_Перельмана
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Tips and Tricks
• If you come across an ECG with big QRS amplitudes in chest leads, think of
LVH.However, it can be seen in healthy persons also.
• To diagnose LVH calculate SV1+ RV5. If it is more than 35, think about the
possibility of LVH.
12 Ventr icular Hypertrophy
12.4 Right Ventricular Hypertrophy
The ECG features for diagnosis of right ventricular hypertrophy (RVH) are specic but lack sensitivity. Conditions like hyperinated lungs, young age, bundle
branch block and body build often make the diagnosis of RVH difcult. The diagnosis is further difcult in young children, as there are prominent R waves in
right-sided chest leads due to physiological dominance of right ventricle over
the left.
Right ventricular hypertrophy (RVH) is seen in various conditions including pul-
monary stenosis, tetralogy of Fallot, cor pulmonale, mitral stenosis, tricuspid
incompetence and idiopathic pulmonary hypertension. Prolonged raised pressure in
right ventricle leads to anatomical changes of right ventricular hypertrophy
(Fig. 12.5). Because of strong vectors generated in the dominant left ventricle,
severe RVH must be present to dominate and manifest on the ECG.As a result, it is
difcult to diagnose minor degrees of right ventricular hypertrophy.
The lead V1 is close to the right ventricular mass, hence, it is the most sensitive
lead to record the changes of RVH.In normal condition, prominent S wave and a
small r wave are recorded in lead V1. The dominant left ventricular vector neutralizes the right ventricular vector. As it is directed away from the positive pole of lead
V1, a prominent S wave is recorded. In RVH, the right ventricular vector becomes
strong and it neutralizes the left ventricular vector. It is directed towards the positive pole of lead V1, hence, a tall R wave is recorded instead of a deep S wave.
Therefore, a tall R wave, a small s wave or a change in R:S ratio are seen in lead V1.
RVH should not be diagnosed only on the basis of ECG changes seen in lead
V1. It is important to look for as many features as possible in ECG to arrive at a
correct diagnosis. The ECG features should always be interpreted in light of the
clinical features. More the ECG features, better is the chance of correct diagnosis.
Right ventricular hypertrophy is characterized by the following ECG
abnormalities:
• Abnormalities of QRS complex
• Abnormalities of S-T segment and T wave
• Abnormality of QRS axis
• Right atrial enlargement
Right ventricular
concentric
hypertrophy
Reduced
RV
Thick
T
valve
e
12.4 Right Ventricular Hypertrophy
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Right
atrium
atrium
Mitral valv
ricuspid
Left
cavity
Left
ventricle
RV wall
Fig. 12.5 Right ventricular hypertrophy. Note the thickness of right ventricular wall and decrease
in cavity size. This is concentric hypertrophy
12.4.1 Abnormalities ofQRS Complex
12.4.1.1 Dominance ofR Wave inRight-Sided Chest Leads
The R wave in lead V1 becomes prominent in comparison to S wave in RVH.There
is gradual, progressive increase in height of R wave and diminution of S wave,
which is expressed as R:S ratio (Fig.12.6). If the ratio exceeds 1, then RVH is diagnosed. The amplitude of R wave is more than 5 mm in lead V1. The S waves are
prominent in V5 and V6. It is important to remember that there are several other
causes of tall R wave in lead V1 including posterior wall myocardial infarction,
persistent juvenile pattern, RBBB, dextrocardia and WPW syndrome.
152
V1
V2
V3
V4
V5
V6
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12 Ventr icular Hypertrophy
I
Fig. 12.6 Right ventricular hypertrophy. R:S ratio is more than 1in lead V1. There is right axis
deviation with clockwise rotation
II
III
aVR
aVL
aVF
12.4.1.2 In Lead V1 There Is Increase inVAT (> 0.02s)
12.4.1.3 Clockwise Electric Rotation
Clockwise rotation is reected by the shifting of transition zone to lead V5 or V6.
All the chest leads may show prominent R waves only.
12.4.1.4 Right Bundle Branch Block
Complete or incomplete RBBB is often associated with RVH.
12.4.2 Abnormalities ofS-T Segment andT Wave
Strain pattern in right-sided chest leads is often seen in RVH.The S-T segment is
slightly depressed with inversion of T waves in lead V1–V4.
12.5 Biventricular Hypertrophy
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12.4.3 Abnormalities ofQRS Axis
QRS axis is deviated to right in RVH.The QRS axis lies between +110° and +180°.
Sometimes it is the only feature of RVH.
12.4.4 Right Atrial Enlargement
ECG features of right atrial enlargement are often associated with RVH. The P
waves become tall and pointed in lead II.The diagnostic criteria of RVH are enumerated in Box 12.5.
Box 12.5 Diagnostic criteria of RVH
R:S ratio greater than 1in lead V1
Increase in VAT in lead V1 or V2
Clockwise rotation of heart
Right axis deviation
S-T, T strain pattern in leads V1–V4
Right atrial enlargement
Tips and Tricks
• To diagnose RVH, look at lead V1 and calculate the R:S ratio. If it is more than
1 and the height of R wave is more than 5mm, think about the possibility of RVH.
12.5 Biventricular Hypertrophy
Hypertrophy of both the ventricles is not an uncommon condition. It is frequently
observed in Eisenmenger’s syndrome. The various other conditions are enumerated
in Box 12.6.
Box 12.6 Causes of Biventricular Hypertrophy
Dilated cardiomyopathy
Congenital heart disease: Eisenmenger’s syndrome
Multiple valvular lesions
It is not always easy to diagnose biventricular hypertrophy in ECG. The ECG
features of LVH may be masked by the development of RVH. The ECG may
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12 Ventr icular Hypertrophy
actually become normal. However, one must look for the following features diagnostic of biventricular hypertrophy:
• Right axis deviation with ECG features of LVH
• Clockwise rotation, i.e. transition zone in lead V5 or V6 with ECG features of LVH
• ECG features of LVH along with tall R wave in lead V1 especially if R:S ratio is
greater than 1 indicate biventricular hypertrophy
• Katz-Wachtel phenomenon: Large biphasic complexes in lead V2 or V3
• P mitrale with R:S ratio greater than 1in lead V1 or right QRS axis deviation
• Tall R waves in left-sided chest leads with disproportionately small S waves in
lead V1 or inverted T wave in right precordial leads
Self-Assessment Questions
1. Left ventricular hypertrophy is seen in mitral stenosis. True or false?
2. Romhilt Estes point score is used for diagnosis of LVH.True or false?
3. VAT is increased in RVH in lead V1 or V2. True or false?
4. Katz-Wachtel phenomenon is seen in biventricular hypertrophy. True or false?
5. Clockwise electric rotation is seen in LVH.True or false?
6. Features of RVH are all except:
a. Right axis deviation (>90°) b. Tall R waves in left-sided chest leads; deep
Swaves in right-sided chest leads c. RV strain pattern d. May see incomplete RBBB pattern or qR pattern in V1
7. All of the following are features of LVH except:
a. Increased QRS amplitude b. Delayed intrinsicoid deection in lead V1 c.
Left ventricular strain pattern d. Biphasic P wave in lead V1 with prominent
negative component
8. ECG features of LVH with right axis deviation indicate:
a. Biventricular hypertrophy b. LVH c. RVH d. Biatrial hypertrophy
9. A 25-year-old lady is suffering from mitral stenosis for last 10years. She
has not taken any treatment for mitral stenosis. What is not expected in
her ECG?
a. P pulmonale b. P mitrale c. SV1 +RV5 more than 35 mm d. Tall R
waves in lead V1.
10. Which ECG lead is most commonly used to assess right ventricular hyper-
trophy (RVH)?
a. Lead I b. Lead aVR c. Lead V1 d. Lead V6
Case Studies
1. Examine the 12-lead ECG (Fig.12.7) and answer the following questions:
a. What is your diagnosis?
b. Name three important points in favour of your diagnosis.
c. Name two conditions where you will get such an abnormality.
25 mm/s. 10 mm = 1 mV
V6
12.5 Biventricular Hypertrophy
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I
II
aVR
aVL
V1
V2
V4
V5
III
Fig. 12.7 Identify the ECG
aVF
V3
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V3
V2
V1
V6
V5
V4
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12 Ventr icular Hypertrophy
2. A 75-year-old gentleman presented with history of breathlessness and dizziness.
On examination, an ejection systolic murmur was audible in aortic area. Examine
the 12-lead ECG (Fig.12.8) and answer the following questions:
a. What is your diagnosis?
b. Name two important points in favour of your diagnosis.
c. Name one condition where you will get such an abnormality.
3. Examine the 12-lead ECG (Fig.12.9) and answer the following questions:
a. What is your diagnosis?
b. Name two important points in favour of your diagnosis.
4. A patient suffering from pulmonary stenosis came to the OPD. His ECG was
mixed up with that of another patient. Do you think the given ECG (Fig.12.10)
belongs to this patient? If yes, give two points in favour of your conclusion.
I
25 mm/s. 10 mm = 1 mV
Fig. 12.8 Identify the ECG
II
III
aVR
aVL
aVF
V2
V3
V1
V4
V5
V6
25 mm/s. 10 mm = 1 mV
V3
V4
V5
V6
V1
25 mm/s. 10 mm = 1 mV
V2
12.5 Biventricular Hypertrophy
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I
II
Fig. 12.9 Identify the ECG
I
II
III
III
aVR
aVR
aVL
aVL
aVF
aVF
Fig. 12.10 Identify the ECG
158
25 mm/s. 10 mm = 1 mV
V4
V5
V6
V3
V1
V2
V1
V2
V3
V4
V5
V6
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12 Ventr icular Hypertrophy
5. A 50-year-old patient was suffering from hypertension for 12years. He used to
take his medicines irregularly. Examine his 12-lead ECG (Fig.12.11) and make
your diagnosis. Give three points in favour of your diagnosis.
6. A 65-year-old lady suffering from off and on breathlessness presents for evalua-
tion. She had mild dyspnoea. There was no cyanosis. There was bilateral wheeze
and a loud second heart sound in pulmonary area. Examine the 12-lead ECG
(Fig.12.12). Make your diagnosis. Give three points in favour of your diagnosis
and name two conditions where you get similar changes in ECG.
I
II
Fig. 12.11 Identify the ECG
I
II
III
.
III
aVR
aVR
aVL
aVL
aVF
aVF
Fig. 12.12 Identify the ECG
12.5 Biventricular Hypertrophy
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Answers
1. False 2. True 3. True 4. True 5. False 6. b 7. b 8. a 9. c 10. c
Case Studies
1. a. The diagnosis is RVH.
b. Three diagnostic points are:
i. P pulmonale
ii. qR pattern in lead V1.
iii. S-T, T changes (strain pattern) in lead V1–V5, which is more prominent
in leads V1 and V2.
c. Mitral stenosis and tetralogy of Fallot.
2. a. The diagnosis is LVH.
b. Two diagnostic points are:
i. SV1+RV5 is more than 35mm.
ii. Strain pattern in lead V5 and lead V6.
c. The patient is most likely suffering from aortic stenosis. Ejection systolic
murmur with LVH in ECG points towards aortic stenosis. History of dizziness
and breathlessness indicate severe obstruction and may lead to sudden cardiac
death. He needs urgent further investigation and management. Similar ECG
changes can also be observed in patients suffering from hypertensive heart
disease.
3. a. The diagnosis is RVH.
b. The two diagnostic points are:
i. Tall R wave in lead V1 with R:S ratio more than 1.
ii. P pulmonale (lead II) indicates right atrial enlargement.
4. This ECG most likely belongs to the patient suffering from pulmonary stenosis.
In pulmonary stenosis, right atrial and right ventricular hypertrophy are observed.
The two points in favour of diagnosis are:
a. Tall R wave in lead V1 with S-T, T changes indicate RVH.
b. P pulmonale in lead II indicates right atrial enlargement.
5. The diagnosis is LVH.Three diagnostic points are:
i. SV1+RV5 is more than 35mm.
ii. Strain pattern in lead V5 and lead V6.
iii. Biphasic P wave in lead V1 with wide (>0.04s) and deep (>1mm) terminal negative component.
6. The diagnosis is RVH.The points in favour of diagnosis are:
i. Tall R wave in lead V1 with R:S ratio more than 1.
ii. Strain pattern in leads V1 to V3.
iii. P pulmonale (lead II).
Bilateral wheeze with loud second heart sound indicates obstructive airway
disease with pulmonary hypertension. ECG features of RVH are seen in COPD
with cor pulmonale and idiopathic pulmonary hypertension.
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