Hypertrophy patterns

Section 7 Hypertrophy patterns



Right atrial abnormality (P-pulmonale)

Left atrial abnormality (P-mitrale)

Biatrial hypertrophy

Right ventricular hypertrophy (RVH)

Left ventricular hypertrophy (LVH) – limb lead criteria

Left ventricular hypertrophy (LVH) – chest lead criteria

Biventricular hypertrophy


Case 69 A 54-year-old lady with bronchiectasis



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Right atrial abnormality (P-pulmonale)



• Peaked (A-shaped) P waves more than 3 mm in height in leads II, III, or aVF.

• Other features:
– tall P waves in the right chest leads (> 1.5 mm)

– prominent atrial repolarisation (Ta) wave.


Features of this ECG



• Sinus tachycardia, 120 b.p.m., rightward QRS axis

• Diagnostic features of P-pulmonale:
– abnormally tall P waves in II, III, and aVF (Fig. 69.1)

– tall P wave in lead V3 (Fig. 69.2)

– prominent Ta wave (Fig. 69.2)

• Features of chronic obstructive airways disease:
– clockwise electrical rotation (late transition)

– posterior displacement of the QRS axis (deep S waves in the right chest leads)

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Fig. 69.1 P-pulmonale.


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Fig. 69.2 Ta wave.



Clinical Note


Her chest x-ray (Fig. 69.3) shows right atrial enlargement and features of chronic lung disease (hyperexpanded lungs with flattened diaphragms).


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Fig. 69.3 Chest x-ray showing right atrial enlargement (A).



Causes of right atrial abnormality



→ Raised right ventricular pressure:
– pulmonary hypertension from any cause

– cor pulmonale

→ Tricuspid valve stenosis:
– acquired (endocarditis from i.v. drug use)

– congenital (Ebstein’s anomaly)

→ Right atrial ischaemia or infarction (uncommon)


Case 70 A 43-year-old Maori man with a diastolic murmur



image


Left atrial abnormality (P-mitrale)



• Notched (M-shaped) P wave squares) in duration in leads

• Other features:
– prolonged duration (> 40 ms/1 small square) and increased amplitude (0.1 mV) of the terminal negative component to the P wave in V1.

– duration between the two peaks of the ‘M’ > 40 ms (1 small square).FEATURES OF THIS ECG


Features of this ECG



• Sinus rhythm, 72 b.p.m., vertical QRS axis

• Features of P-mitrale:
– broad, notched P waves seen in the inferior leads (Fig. 70.1)

– marked negative component to P wave in lead V1 (Fig. 70.2)

• Features of right ventricular hypertrophy:
– dominant R wave in lead V1, with ST depression and T wave inversion (Fig. 70.2)

– deep S waves in the lateral leads (Fig. 70.3)

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Fig. 70.1 P-mitrale.


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Fig. 70.2 Lead V1.


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Fig. 70.3 Lead aVL.



Clinical Note


The combination of left atrial hypertrophy and right ventricular hypertrophy suggests mitral stenosis. This patient had mitral stenosis on the basis of rheumatic heart disease. His chest x-ray (Fig. 70.4) shows cardiomegaly, enlargement of the pulmonary outflow tract (A) and left atrial enlargement (B).


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Fig. 70.4 Chest x-ray.



Causes of left atrial abnormality



→ Left atrial hypertrophy

→ Left atrial distension

→ Interatrial conduction block

→ Left atrial scarring


Case 71 A 24-year-old lady with a history of rheumatic fever



image


Biatrial hypertrophy



• P waves in the limb leads more than 3 mm in height and also greater than 120 ms (3 small squares) in duration.

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  4. Ischaemic heart disease

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Aug 29, 2016 | Posted by in CARDIOLOGY | Comments Off on Hypertrophy patterns

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