Atrial and Ventricular Atrial and Ventricular Hypertrophy.Hypertrophy.

ECG Features and Common ECG Features and Common Causes.Causes.

Aims and Objectives.Aims and Objectives.

Understand pathophysiology of types of Understand pathophysiology of types of hypertrophy.hypertrophy.

Common patient presentation and Common patient presentation and symptoms.symptoms.

ECG appearances associated with different ECG appearances associated with different types of hypertrophy.types of hypertrophy.

Pitfalls in diagnosis from ECG.Pitfalls in diagnosis from ECG.

Left Atrial Hypertrophy / Left Atrial Hypertrophy / Enlargement.Enlargement.

Thickening of wall.Thickening of wall. Dilatation of chamber Dilatation of chamber

(enlargement).(enlargement). Increased volume.Increased volume. Increased muscle Increased muscle

mass.mass.

Some causes.Some causes.

Mitral and / or aortic valve disease.Mitral and / or aortic valve disease. Left ventricular systolic and diastolic Left ventricular systolic and diastolic

dysfunction.dysfunction. Cardiomyopathy - hypertrophic / dilated.Cardiomyopathy - hypertrophic / dilated. Atrial fibrillation.Atrial fibrillation. Left atrial mass.Left atrial mass. Hypertension.Hypertension.

ECG appearances.ECG appearances.

Appearances cont..Appearances cont..

Common ECG Features of LAH.Common ECG Features of LAH.

Usually seen in late portion of P wave.Usually seen in late portion of P wave. Often biphasic in V1 - larger negative Often biphasic in V1 - larger negative

deflection.deflection.– RA conducts anteriorly (+ initially)RA conducts anteriorly (+ initially)

– Large LA mass conducts posteriorly (-ive Large LA mass conducts posteriorly (-ive component).component).

• Prolonged P wave duration (>0.12 secs).Prolonged P wave duration (>0.12 secs).

• Pronounced notch with peak to peak Pronounced notch with peak to peak >0.04secs.>0.04secs.

Right Atrial Hypertrophy / Right Atrial Hypertrophy / Enlargement.Enlargement.

Some causes.Some causes.

Tricuspid and / or pulmonary valve disease.Tricuspid and / or pulmonary valve disease. Lung disease.Lung disease. Congenital heart disease (ASD, PFO, VSD).Congenital heart disease (ASD, PFO, VSD). RV systolic and diastolic dysfunction.RV systolic and diastolic dysfunction. Mitral stenosis (pressure back-up).Mitral stenosis (pressure back-up).

RAH Appearance.RAH Appearance.

Common ECG Appearance.Common ECG Appearance.

Tall, peaked P wave (>2.5mm).Tall, peaked P wave (>2.5mm). Best seen lead II - often throughout ECG.Best seen lead II - often throughout ECG. Known as P pulmonale.Known as P pulmonale.

Left Ventricular Hypertrophy.Left Ventricular Hypertrophy.

Thickened walls.Thickened walls. Dilated chamber.Dilated chamber. Increased muscle mass or Increased muscle mass or

increased volume.increased volume.

Some causes of LVH.Some causes of LVH.

Aortic valve disease.Aortic valve disease. Coarctation of the aorta.Coarctation of the aorta. Cardiomyopathy - dilated, hypertrophic.Cardiomyopathy - dilated, hypertrophic. Hypertension.Hypertension. Heart Failure - systolic.Heart Failure - systolic.

Left Ventricular Hypertrophy Left Ventricular Hypertrophy Appearance.Appearance.

LVH Appearance.LVH Appearance.

Commonly Used Criteria for LVH.Commonly Used Criteria for LVH.

Scoring System.Scoring System. Suggested if Suggested if >>5 points.5 points. Chou, T. and Knilans, Chou, T. and Knilans,

T.K. (1996). T.K. (1996). Electrocardiography in Electrocardiography in Clinical PractiseClinical Practise. . 4th 4th EdEd. Philadelphia: . Philadelphia: Saunders.Saunders.

ECG Feature:ECG Feature: Amplitude:Amplitude:

– Largest R or S wave in limb leads Largest R or S wave in limb leads >>20mm.20mm.

– S wave leads V1 and V2 S wave leads V1 and V2 >>30mm.30mm.– R waves in leads V5 or V6 R waves in leads V5 or V6 >>30mm. 30mm.

3 POINTS.3 POINTS.

ST-T wave changes typical for LVH. ST-T wave changes typical for LVH. 3 3 POINTS.POINTS.

Left atrial involvement. Left atrial involvement. 3 POINTS.3 POINTS.

Left axis deviation. Left axis deviation. 2 POINTS.2 POINTS.

QRS Duration of >0.09s. QRS Duration of >0.09s. 1 POINT.1 POINT.

Right Ventricular Hypertrophy.Right Ventricular Hypertrophy.

Some causes of RVH.Some causes of RVH.

Pulmonary hypertension (numerous causes Pulmonary hypertension (numerous causes - primary and secondary - also cor - primary and secondary - also cor pulmonale).pulmonale).

Mitral stenosis.Mitral stenosis. Pulmonary valve disease.Pulmonary valve disease. Congenital heart disease (VSD, Ebsteins Congenital heart disease (VSD, Ebsteins

Anomaly). Anomaly). RV systolic dysfunction (e.g. post inferior RV systolic dysfunction (e.g. post inferior

MI).MI).

ECG Appearance Right Ventricular ECG Appearance Right Ventricular Hypertrophy.Hypertrophy.

ECG Criteria for RVH.ECG Criteria for RVH.

Right axis deviation of +110 degrees or Right axis deviation of +110 degrees or more.more.

Dominant R wave in lead V1.Dominant R wave in lead V1. R wave in lead V1 R wave in lead V1 >>7mm.7mm.

Other supporting criteria:Other supporting criteria:– ST segment depression and T inversion V1 - ST segment depression and T inversion V1 -

V4.V4.– Deep S waves V5, V6, I and aVL.Deep S waves V5, V6, I and aVL.

Conclusion.Conclusion.

LAH – ECG appearance and common LAH – ECG appearance and common causes.causes.

RAH – appearance and causes.RAH – appearance and causes. LVH – appearance, certainty of diagnosis, LVH – appearance, certainty of diagnosis,

causes and pitfalls.causes and pitfalls. RVH – appearance, causes and pitfalls.RVH – appearance, causes and pitfalls.