ECG diagnosis of chamber enlargement

1. ECG Criterias for
Chamber Enlargement

2. Left Ventricular Hypertrophy

3. Pressure overload pattern

4. Volume overload pattern

6. • Sokolow-Lyon voltages
• SV1 + R V5,6 > 3.5 mV
Sensitivity 22%
Specificity 100 %
• R aVL > 1.1 mV
• R V5,6 > 2.6 mV

7. • Romhilt-Estes point score system
– Any limb lead R wave or S wave > 2.0 mV (3 points)
or SV1 or SV2 ≥ 3.0 mV (3 points)
or RV5 to RV6 ≥ 3.0 mV (3 points)
– ST-T wave abnormality, no digitalis (3 points)
ST-T wave abnormality, digitalis therapy (1 point)
– Left atrial abnormality (3 points)
– Left axis deviation ≥ −30 degrees (2 points)
– QRS duration ≥ 90 msec (1 point)
– Intrinsicoid deflection in V5 or V6 ≥ 50 msec (1 point)
• Probable =4, Definite > = 5
• Sn 35-55 %, Specificity 85-95 %

8. • Cornel Voltage criteria
–SV3 + R aVL ≥ 2.8 mV (for men)
–SV3 + R aVL >2.0 mV ( women)
–Sensitivity 42%
–Specificity 96%

9. • Cornell voltage duration measurement
– QRS duration X Cornell voltage > 2,436 mm-sec
( + 8mm if female )
– QRS duration X sum of voltages in all leads > 1,742
mm-sec
– Sn 51 % and specificity of 95 %
– Accurate in obese

10. • Cornell Regression equation
– Risk of LVH = 1/(1+ e−exp)
– For subjects in sinus rhythm,
– exp = 4.558 − 0.092 (SV3 + RaVL) − 0.306 TV1 −
0.212 QRS − 0.278 PTFV1 − 0.559 (gender)
– PTF is the area under the P terminal force in lead
V1 (in mm-sec)
– gender = 1 for men and 2 for women.
– LVH is diagnosed present if exp < −1.55

11. • LVH : total QRS voltage in all 12 leads > 175
mm
• LVH : R in V6 = > V5
• Gertsch index : S III + max ( R+S) in any
precardial lead > 3.0 mV . valid even if LAFB
• Lewis score: R I + S III > 17 mm

12. More sensitive : LVH in HTN : sum of the QRS voltage of 12 ECG
leads >120 mm

13. 90 % of LBBB have LVH
A left atrial P-wave abnormality
QRS duration > 155 ms
SOURCE: Hurst 12/e Kafka, Burggraf, Milliken

14. SOURCE : hurst 12/e Gertsch, Theler, Foglia

15. RBBB and LVH
• RBBB decreases sensitivity of precardial voltage criteria
• LAA can be useful
• Point score system can be useful 96 % specific

16. Right Ventricular
hypertrophy

17. R’ > 15 mm in RBBB
Cabrera index > 0.5
R in V1/(R v1 + s v1)

19. Sokolow Lyon criteria for RVH:
– R V1 + S V5, V6 > 10.5 mm
– R V1 > 7 mm
– R in aVR > 5mm
– S V1 < 2mm

20. • Butler leggett formula :
RVH : Anterior (R or R’ in v1 or v2) + Right
(deepest S in I or v6) – Posterolateral
( S in V1) => 0.7mV ( Sn 34% and Sp 95%)

21. RVH Morphology
1. Precardial Voltage changes
2. ST T changes over RV
3. Delayed onset of intrinsicoid deflection
4. normal QRS duration
5. RAD

22. CHOU Types of RVH
• Type A: Typical RVH
tall R in V1 , Prominent S in V5, V6
• Type B: Incomplete RBBB pattern( ASD, RHD )
R in V1 >0.5 mV with R/S >1, Normal
QRS in V5, V6
• Type C: Chronic Lung Disease
(rS V1, V2 and RS in V5, V6 precardial
leads)
– ECG changes due to both RVH + anatomical shift
of heart

23. • RAD and Clockwise rotation is very common
in Type A RVH compared to B & C

24. The signs of acute RV overload :
• Change in the ÂQRS (>30° to the right)
• Transient negative T waves
• SI, QIII TIII pattern (McGinn-White pattern) in
the frontal plane and an RS or rS pattern in V6
• Appearance of a complete right bundle-branch
block morphology often with ST-segment
elevation
• S1Q3T3 pattern occurs in only about 10% PE
PPV 23- 69%

25. Chronic Obstructive Pulmonary Disease
• reduced amplitude of the QRS complex
• right axis deviation in the frontal plane
• delayed transition in the precordial leads
• Evidence of true RVH
– (1) RAD > 110 degrees
– (2) deep S waves in the lateral precordial leads
– (3) an S1Q3T3 pattern

26. Biventricular hypertrophy
• Diagnostic voltage criteria for both ventricles
• Delayed intrinsicoid delection over both
ventricles
• Repolarization changes over both
• LVH with RAD of QRS
• LVH with RAE
• Deep S in LVH
• LVH with clock wise rotation of precardial
morphology

27. Biventricular hypertrophy
• LAD with counterclockwise rotation in RVH
• Large equiphasic QRS in midprecardial leads
>6mm( Katz wachtel sign)
• Tall R in Left precardial leads + small s in V1 or
inverted t waves in right precardial leads

28. Atrial Enlargement

31. RAA
• Q waves (especially qR patterns) in the right
precordial leads (100 % specific)
• low-amplitude QRS complexes (<0.6 mV) in
lead V1 with a threefold or greater increase in
lead V2 (90 % specific)
• Severe RAE  prominent terminal negativity
in V1 ( Pseudo LAE pattern )
• Early terminal negativity of P V1 (< 0.03 s)

32. AF – LAE present if f wave > 1mm in V1

33. LAE Criteria Sensitivity specificity
Prolonged P wave duration > 120 msec in lead II 33 88
Prominent notching of P wave, usually most obvious in
lead II, with interval between notches of 0.40 msec (P
mitrale)
15 100
Ratio between the duration of the P wave in lead II and
duration of the PR segment > 1.6 Macruz index
31 64
Increased duration and depth of terminal- negative
portion of P wave in lead V1 (P terminal force) so that
area subtended by it > 0.04 mm-sec Morris index
69 93
Terminal negative deflection in V1 > 0.1 mV 60 93
duration > 0.04 s 83 80
Leftward shift of mean P wave axis to between −30 and
−45 degrees

34. Biatrial Enlargement