RVH in Emphysema
Report:
Sinus rhythm 96/min
Right axis deviation +170o
Right atrial abnormality
Right ventricular hypertrophy
Poor R wave progression
Comment:
The P wave axis is almost +90o and it has the tall peaked look of P pulmonale, with relatively uncommon initial negativity in Lead 1. Even more rarely, it may be completely flat or even entirely negative in Lead 1, sharing that distinction with dextrocardia, reversed arm leads and ectopic atrial rhythms.
The QRS axis is bizarrely right, with negative lead 2, and the emphysema QRS complex is characteristically narrow. In V1 it has a qR morphology, the q said to result from right atrial enlargement displacing the subjacent (to V1) right ventricle15.
The precordial R wave progression â or, rather, lack thereof â is due to emphysema, RVH and the marked frontal axis deviation; old anterior MI is a possibility, but an unlikely one in this setting.
The cor pulmonale is rarely so pronounced in ECGs. When it is, like here, it implies severe, advanced lung disease.
Below is another trace, taken a week earlier (Fig 9a). The voltages are lower, but the basic configuration is the same; P axis is still close to +90o. The computer reported LAA because of increased PTF in V1; this is almost certainly RAA in disguise.
9a. 10. 72 year old man admitted after (until now) unexplained syncope and fall
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