ECG

changes in

CHRONIC OBSTRUTIVE PULMONARY DISEASES

Synonyms: Emphysema, Chronic bronchitis, Chronic Obstructive Lung Disease (COLD), Chronic Obstructive Airway Disease (COAD), 

Smoker’s Lung

DR.PRITHVIRAJ METHERESIDENT IN PULMONARY MEDICINE

DEFINITION• COPD is a lung disease characterized by airflow limitation

(FEV1/FVC ratio of less than 70%) that is not fully reversible (FEV1 increase of 200 ml and 12% improvement above baseline FEV1 following administration of either inhaled corticosteroids or bronchodilators). COPD comprises of 2 predominant conditions – Chronic bronchitis and Emphysema.

• Chronic Bronchitis is defined as a productive cough for 3 months in each of 2 successive years in a patient whom other causes of chronic sputum has been excluded.

• Emphysema is defined as the presence of enlargement of airspaces distal to the terminal bronchioles or acinus with destruction of their walls without obvious fibrosis.

Mechanism of ECG changes in COPD

• COPD is associated with increased airway resistance, alveolar and pulmonary capillary destruction, air trapping, chronic hypoxemia and increased work of breathing. In an attempt to improve oxygenation of the blood, pulmonary vessels adjacent to underventilated alveoli tend to constrict (hypoxic reflex pulmonary vasoconstriction), increasing both pulmonary vascular resistance and the work of right heart i.e. COPD imposes chronic strain on the right side of heart resulting in cor pulmonale.

COPD and Heart

• Elongation and vertical orientation of the heart: Hyperexpanded lungs impose external compression of heart and lowering of diaphragms

• Clockwise rotation of heart in the transverse plane: Due to its fixed attachment to the great vessels

• Reduced amplitude of the QRS complexes: Due to dampening effect resulting from increased air between the heart and recording electrodes

• ECG findings of right atrial and right ventricular enlargement are seen with COPD

(The long-term effects of hypoxic pulmonary vasoconstriction upon the right side of the heart, causing pulmonary hypertension and subsequent right atrial and right ventricular hypertrophy)

ECG changes Underlying causeP pulmonale (Tall, peaked P-wave ≥ 2.5 mm height in inferior leads II, III and aVF)

ECG changes Underlying cause

P pulmonale (Tall, peaked P-wave ≥ 2.5 mm height in inferior leads II, III and aVF)

Right atrial abnormality

Increased R wave voltage in leads V1, V2 Right ventricular enlargement

Right axis deviation usually between +90° and +180

Right ventricular dilation

Low voltage QRS complex (<5 mm height) in limb leads

Increased distance between the recording electrode and heart

Poor R wave progression Leftward or clockwise rotation of the heart

Chou’s ECG criteria for COPD

P-pulmonaleP wave axis ≥ +80°QRS amplitude less than 5 mm in all limb leadsQRS axis > +90°QRS amplitude less than 5 mm in V5, V6S1-S2-S3 pattern with R/S <1  in lead I, II, IIIAtrial arrhythmias (especially Multifocal Atrial Tachycardia 

or MAT)• COPD is likely to be present if one P and one QRS

criterion present

Multifocal Atrial Tachycardia or MAT

• MAT is defined electrocardio-graphically as an atrial tachycardia with an overall rate greater than 100 beats per minute and distinct P waves of at least three different morphologies. Both PR and R-R intervals are variable.

Schamroth’s Sign Criteria for COPD

Isoelectric P wave in lead IVery small QRS complex of less than 1.5 mm total deflection

T wave of less than 0.5 mm in lead I

The ECG below is from a 58 years-old man with a recent diagnosis of COPD. ECHOcardiogram showed neither right atrial nor right ventricular dilatation. P wave axis is +80 degrees (P wave verticalization). The P wave is negative in lead aVL. Low voltage and incomplete right bundle branch block are also seen.

The compact ECG above belongs to a 66 years-old woman with COPD. ECHOcardiogram showed neither right atrial nor right ventricular dilatation. Left ventricular systolic function was normal. P wave axis is +68 degrees. The P wave is negative in lead aVL. (P wave verticalization). Exaggerated T wave is seen in lead II

The ECG below is from a 82 years-old man with COPD. The rhythm is multifocal atrial tachycardia (MAT) but seems like atrial fibrillation at first glance. However, one P wave per RR interval confirms the absence of atrial fibrillation.

The ECG below belongs to a 79 years-old man with COPD, chronic systemic arterial hypertension and abdominal aortic aneurysm. P wave axis is +90 degrees (P wave verticalization). The P wave is flat in Lead I (Lead I sign). The P wave is also negative in lead aVL (P wave verticalization). Two atrial premature contractions (APCs) are also seen

The ECG below is from an old man with COPD. P wave verticalization with negative P waves in lead aVL is seen. The rhythm is multifocal atrial tachycardia (P waves with at least 3 different shapes in precordial leads).

The below ECG is from a 74 years-old man with COPD. ECHOcardiogram showed right atrial and right ventricular dilatation. P wave verticalization with negative P waves in lead aVL is seen. Incomplete right bundle branch block is also seen.

The below ECG is from a patient with COPD and multifocal atrial tachycardia. P wave verticalization with negative P waves in lead aVL is seen.

The below ECG is from a 51 years-old man with COPD. ECHOcardiography showed neither right atrial nor right ventricular dilatation. The P wave in lead I is almost flat. Lead aVL shows negative P wave (P wave verticalization). Atrial premature contractions are not rare in patients with COPD. The ECG also shows low voltage in limb leads.

The below ECG is from a 85 years-old woman with COPD, left ventricular systolic dysfunction, and mild pericardial effusion. She has never undergone diagnostic coronary angiography. ECHOcardiography showed dilation of all cardiac chambers and segmentary left ventricular wall motion abnormality. The ECG also shows low voltage in almost all leads

The ECG below is from an old man with COPD. P wave verticalization and low voltage in limb leads are seen.

This ECG is typical for a COPD patient

• The next ECG is from a 48 years-old man with COPD. Coronary angiography revealed coronary artery ectasia with significant coronary slow flow.

• Leads V1 and V2 show QS complexes which are not related to coronary artery disease in this patient.

• Precordial leads show narrow QRS complexes (the widest being 90 milliseconds).

• P wave axis is about +82 degrees. Lead I barely shows a P wave. • Lead aVL shows negative P wave (P wave verticalization). • Right atrial abnormality is also seen. • Limb leads show low voltage.

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