ECG of Cardiac Enlargement

Harvi Puspa Wardani, dr, SpJP

Fakultas Kedokteran Unisba
2018
 ATRIAL
ENLARGEMENT
RAE LAE
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
≥ 1.5 mm in area
• P Pulmonal
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
• P Mitral
Left Atrial Enlargement - LAE
Left Atrial Enlargement - 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
Biatrial Enlargement - BAE
VENTRICULAR
HYPERTROPHY
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
 Deep persistent S wave ( S wave in lead V5
or V6 ≥ 7 mm)
Right Ventricular Hypertrophy - RVH
Left Ventricular Hypertrophy - LVH
 Left Ventricular Hypertrophy - LVH

• Voltage criteria (Sokolow Lyon)

S(V1) + R(V5/6) ≥ 35 mm
R(aVL) ≥ 35 mm
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 > 7 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
ECG of Myocardial Ischemic and
Infarction
Harvi Puspa Wardani, dr, SpJP
Fakultas Kedokteran Unisba
2018
 Normal ECG

There should be no Q wave or only a small q

less than 0.04 seconds in width in I, II, V2 to
V6
 Normal ECG

In leads I, II, and V2 to V6 the T wave must be upright

 ST SEGMENTT
• The onset of the ST-T wave is the junction
or J point, and it is normally at or near the
isoelectric baseline of the ECG
• The level of the ST segment generally is
measured at the J point or, in some
applications such as exercise testing, 40
or 80 milliseconds after the J point.
 UPPER LIMITS OF NORMAL
J POINT ELEVATION
• Lead V2 and V3
– Men < 40 yo : 0.25 mV
– Men ≥ 40 yo : 0.2 mV
– Women : 0.15 mV

• Other leads : 0.1 mV

 J POINT

The junction between the termination of the QRS complex

and the beginning of the ST segment.
 Ischemia – (Injury) – Infarction
• The electrocardiographic consequences of the
mismatch are ischemia, injury, and infarction (a
myocardial dead zone).
• In the context of the mismatch :
– T wave abnormalities indicate myocardial ischemia,
– ST segment abnormalities indicate myocardial injury,
and
– Q wave abnormalities indicate myocardial infarction
Ischemia – (Injury) – Infarction
 ECG changes
• T wave inversion –
Ischemia
• ST deviation:
– Elevation – Injury
(trans-mural)
- Depression –
Ischemia (Sub-
endocardial).
- Reciprocal changes Infarct Injury Ischemia
• QRS:
Infarct
– decreased R
- Q wave
ISCHEMIC
 Ischemia

The mechanism of formation of abnormal T waves

 Ischemia
• A significant inverted T wave with
symmetrical shape is typical of ischemia
• T inversion ≥ 0.1 mV in two contiguous
leads
Ischemia
 Ischemia
• Ischemia during exercise : ST segment
depression
• Usually indicative of subendocardial ischemia

Baseline
Quantity or depth
of ST-segment
depression
J-point .08 seconds
Ischemia
 Ischemia
Pericardial
LVH type ISCHEMIA
LBBB
RBBB

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

Ischemia
 Ischemia

Common causes of ST segment depression

• Ischemia
• “Strain”
• Digitalis effect
• Hypokalemia / Hypomagnesemia
• Rate-related changes
• Any combination of the above
INFARCTION
Evolution of ST segment
elevation
 HYPERACUTE T
• ‘Hyperacute’ T-waves are seen in the early
stages of ST-elevation MI (STEMI) and
often precede the appearance of ST
elevation and Q waves.
• Criteria
– Extremity leads: ≥ 0,5 mV
– Precordial leads: ≥ 1,5 mV
Measure ST elevation
ACUTE ST-SEGMENT ELEVATION MI
 Infarction
ST elevation is not unique • You should be aware
to MIs and therefore is not that ST elevation can be
confirming evidence. Basic
seen in leads V1 and V2
requirements of ST
changes for diagnosis are: normally. However, if
elevation of at least 1 mm there is also elevation in
in two or more adjoining V3 the cause is unlikely
leads for inferior infarctions to be physiological.
(II, III, and aVF), and at
least 2 mm in two or more
precordial leads for anterior
infarction.
Ischemia
 MYOCARDIAL INFARCTION
• Pathological Q wave
– Duration > 0.04 sec
– Voltage > 25% R wave
– If a Q wave appears in only a single lead  is
not diagnostic of infarction
PATHOLOGICAL Q WAVE
ACUTE NON ST-SEGMENT
ELEVATION MI
Measure ST depression

Baseline
Quantity or depth
of ST-segment
depression

J-point .08 seconds

 ST – T changes
• Ischemia
– T inverted
– ST depression

• Infarction
– ST elevation (acute  Injury)
– ST elevation + T inverted (recent)
– Q wave – pathologic (old)
Coronary Artery
Lateral Infarction
 Lateral Infarction
• I, aVL, V5, V6
Limb Leads Augmented Leads Precordial Leads
 Lateral Infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Left circumflex coronary artery

Extensive Anterior Infarction
Inferior Infarction
 Inferior Infarction

Limb Leads Augmented Leads Precordial Leads

 Inferior Infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Right coronary artery

Inferior Infarction
Anterior Infarction
 Anterior Infarction
• V1 – V4 (Septal – Anterior)
Limb Leads Augmented Leads Precordial Leads
 Anterior Infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Left coronary artery

Left anterior descending artery
Anterior Infarction
Septal Infarction
Right Ventricle Infarction
Posterior Infarction
Thank You