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1. Left Atrial Abnormality & 1st degree AV Block-KH Frank G.Yanowitz, M.D. The P-wave is notched, wider than 0.12s, and has a prominent negative (posterior) component in V1 - all criter for left atrial abnormality or enlargement (LAE). The PR interval >0.20s. Minor ST-T wave abnormalities are also present. 2. 2. Left Atrial Abnormality & 1st Degree AV Block: Leads II and V1-KH Frank G.Yanowitz, M.D. 3 3. Left Atrial Enlargement & Nonspecific ST-T Wave Abnormalities-KHFrank G.Yanowitz, M.D. LAE is best seen in V1 with a prominent negative (posterior) component measuring 1mm wide and 1mm deep. There are also diffuse nonspecific ST-T wave abnormalities which must be correlated with the patient's clinical status. Poor R wave progression in leads V1-V3, another nonspecific finding, is also present. Left Atrial Enlargement: Leads II and V1-KHFrank G.Yanowitz, M.D. 4 4. LVH and Many PVCs-KHFrank G.Yanowitz, M.D. The combination of voltage criteria (SV2 + RV6 >35mm) and ST-T abnormalities in V5-6 are definitive for LVH. There may also be LAE as evidenced by the prominent negative P terminal force in lead V1. Isolated PVCs and a PVC couplet are also present. 5. Severe RVHFrank G. Yanowitz, M.D. Copyright 1998 RVH features include the marked right axis deviation (+150 degrees), qR complex in lead V1, R:S ratio in V6 <1, and right precordial lead ST depression. Left Atrial Enlargement-KHFrank Yanowitz Copyright 1996 Left atrial enlargement is illustrated by increased P wave duration in lead II, top ECG, and by the prominent negative P terminal force in lead V1, bottom tracing. 6. LVH - Best seen in the frontal plane leads!-KH Frank G. Yanowitz, M.D. copyright 1997 7. LVH: Strain pattern + Left Atrial Enlargement-KH Frank G. Yanowitz, M.D. copyright 1997 8. RVH with Right Axis Deviation Frank G. Yanowitz, M.D. copyright 1997 Note the qR pattern in right precordial leads. This suggests right ventricular pressures greater than left ventricular pressures. The persistent S waves in lateral precordial leads and the RAD are other finding in RVH. 9. 9. Right Ventricular Hypertrophy (RVH) & Right Atrial Enlargement (RAE)-KHFrank G.Yanowitz, M.D. In this case of severe pulmonary hypertension, RVH is recognized by the prominent anterior forces (tall R waves in V1-2), right axis deviation (+110 degrees), and "P pulmonale" (i.e., right atrial enlargement). RAE is best seen in the frontal plane leads; the P waves in lead II are >2.5mm in amplitude. Right Axis Deviation & RAE (P Pulmonale): Leads I, II, III- KH 10. 10. Right Atrial Enlargement (RAE) & Right Ventricular Hypertrophy (RVH)-KHFrank G.Yanowitz, M.D. RAE is recognized by the tall (>2.5mm) P waves in leads II, III, aVF. RVH is likely because of right axis deviation (+100 degrees) and the Qr (or rSR') complexes in V1-2. RAE & RVH-KH 11. 11. LVH with "Strain"-KHFrank G. Yanowitz, M.D., copyright 1997 12. 12. LVH & PVCs: Precordial Leads-KH .Frank G.Yanowitz, M.D. 13. 13. LVH: Limb Lead Criteria-KH Frank G.Yanowitz, M.D. In this example of LVH, the precordial leads don't meet the usual voltage criteria or exhibit significant ST segment abnormalities. The frontal plane leads, however, show voltage criteria for LVH and significant ST segment depression in leads with tall R waves. The voltage criteria include 1) R in aVL >11 mm; 2) R in I + S in III >25mm; and 3) (RI+SIII) - (RIII+SI) >17mm (Lewis Index). LVH: Limb Lead Criteria-KH