ECG diagnosis of chamber enlargement

ECG Criterias for Chamber Enlargement

Left Ventricular Hypertrophy

Pressure overload pattern

Volume overload pattern

• Sokolow-Lyon voltages

• SV1 + R V5,6 > 3.5 mVSensitivity 22%Specificity 100 %

• R aVL > 1.1 mV • R V5,6 > 2.6 mV

• 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 %

• Cornel Voltage criteria

–SV3 + R aVL ≥ 2.8 mV (for men)

–SV3 + R aVL >2.0 mV ( women)–Sensitivity 42%–Specificity 96%

• 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

• 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

• 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

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

SOURCE: Hurst 12/e Kafka, Burggraf, Milliken

90 % of LBBB have LVHA left atrial P-wave abnormality QRS duration > 155 ms

SOURCE : hurst 12/e Gertsch, Theler, Foglia

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

S n 5 2 %

S n 5 2 %

S p 9 6 %

Right Ventricular hypertrophy

R’ > 15 mm in RBBB

Cabrera index > 0.5R in V1/(R v1 + s v1)

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

• 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%)

RVH Morphology

1. Precardial Voltage changes2. ST T changes over RV 3. Delayed onset of intrinsicoid deflection4. normal QRS duration5. RAD

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

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

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%

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

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

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

Atrial Enlargement

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)

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

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

Biatrial Enlargement

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