HYPERTROPHY PATTERNS - Elsevier · HYPERTROPHY PATTERNS Section 07.qxd 8/11/04 8:26 PM Page 147. CASE 68 A 54-year-old lady with bronchiectasis 148 I aVR II aVL III aVF V1 V2 V3 V4

SECTION 7 147

V1 V4

V2 V5

V3 V6

F 40 021

Right atrial abnormality (P-pulmonale)

Left atrial abnormality (P-mitrale)

Biatrial hypertrophyRight ventricular hypertrophy

(RVH)Left ventricular hypertrophy

(LVH) – limb lead criteria Left ventricular hypertrophy

(LVH) – chest lead criteriaBiventricular hypertrophy

HYPERTROPHYPATTERNS

Section 07.qxd 8/11/04 8:26 PM Page 147

A 5

4-y

ear-

old

lady

wit

h b

ronchie

cta

sis

CA

SE

68

148

IaV

R

IIaV

L

IIIaV

FV

3

V2

V1

V4

V5

V6

RH

YT

HM

ST

RIP

: II

25 m

m/ s

ec; 1

cm

/mV

LOC

000

02 –

000

2F

40

021


•P

eake

d (A

-sha

ped

) P w

aves

mor

e th

an 3

mm

in h

eigh

t in

lead

s II,

III,

or a

VF.

•O

ther

fea

ture

s:–

tall

P w

aves

in t

he r

ight

che

st le

ads

(> 1

.5 m

m)

–p

rom

inen

t at

rial r

epol

aris

atio

n (T

a) w

ave.

FEAT

UR

ES

OF

THIS

EC

G

•S

inus

tac

hyca

rdia

, 12

0 b

.p.m

., rig

htw

ard

QR

S a

xis

•D

iagn

ostic

fea

ture

s of

P-p

ulm

onal

e:–

abno

rmal

ly t

all P

wav

es in

II,

III,

and

aV

F (F

ig.

68.1

)–

tall

P w

ave

in le

ad V

3 (F

ig.

68.2

)–

pro

min

ent

Ta w

ave

(Fig

. 68

.2)

•Fe

atur

es o

f ch

roni

c ob

stru

ctiv

e ai

rway

s d

isea

se:

–cl

ockw

ise

elec

tric

al r

otat

ion

(late

tra

nsiti

on)

–p

oste

rior

dis

pla

cem

ent

of t

he Q

RS

axi

s (d

eep

S w

aves

inth

e rig

ht c

hest

lead

s)

CLI

NIC

AL

NO

TE

Her

che

st x

-ray

(Fig

. 68

.3) s

how

s rig

ht a

tria

l enl

arge

men

t an

dfe

atur

es o

f ch

roni

c lu

ng d

isea

se (h

yper

exp

and

ed lu

ngs

with

flatt

ened

dia

phr

agm

s).

Cause

s of

right

atr

ial

abnorm

alit

y

➔R

aise

d r

ight

ven

tric

ular

pre

ssur

e:–

pul

mon

ary

hyp

erte

nsio

n fr

om a

ny c

ause

–co

r p

ulm

onal

e➔

Tric

usp

id v

alve

ste

nosi

s:–

acq

uire

d (e

ndoc

ard

itis

from

i.v.

dru

g us

e)–

cong

enita

l (E

bst

ein’

s an

omal

y)➔

Rig

ht a

tria

l isc

haem

ia o

r in

farc

tion

(unc

omm

on)

Rig

ht

atr

ial

abnorm

alit

y (P

-pulm

onale

)

149SECTION 7

CASE 68

P w

ave

III

Fig

. 68.1

P-p

ulm

onal

e.

Fig

. 68.2

Ta w

ave.

Fig

. 68.3

Che

st x

-ray

sho

win

g rig

htat

rial e

nlar

gem

ent

(A).

V3

tall

P w

aves

Ta w

ave

(QR

S c

utaw

ay)

deep

S w

ave


A 4

3-y

ear-

old

Maori

man w

ith a

dia

stolic

murm

ur

CA

SE

69

150

IaV

R

IIaV

L

IIIaV

FV

3V2V1

V4

V5

V6

RH

YT

HM

ST

RIP

: VI

25 m

m/s

ec; 1

cm

/mV


Left

atr

ial

abnorm

alit

y (P

-mit

rale

)

151SECTION 7

CASE 69

•N

otch

ed (M

-sha

ped

) P w

ave

whi

ch e

xcee

ds

120

ms

(3 s

mal

lsq

uare

s) in

dur

atio

n in

lead

s I,

II, a

VF

or a

VL.

•O

ther

fea

ture

s:–

pro

long

ed d

urat

ion

( > 4

0 m

s/1

smal

l sq

uare

) and

incr

ease

dam

plit

ude

(0.1

mV

) of

the

term

inal

neg

ativ

e co

mp

onen

t to

the

P w

ave

in V

1.–

dur

atio

n b

etw

een

the

two

pea

ks o

f th

e ‘M

’ >

40

ms

(1 s

mal

lsq

uare

).

FEAT

UR

ES

OF

THIS

EC

G

•S

inus

rhy

thm

, 72

b.p

.m.,

vert

ical

QR

S a

xis

•Fe

atur

es o

f P

-mitr

ale:

–b

road

, no

tche

d P

wav

es s

een

in t

he in

ferio

r le

ads

(Fig

. 69

.1)

–m

arke

d n

egat

ive

com

pon

ent

to P

wav

e in

lead

V1

(Fig

. 69

.2)

•Fe

atur

es o

f rig

ht v

entr

icul

ar h

yper

trop

hy:

–d

omin

ant

R w

ave

in le

ad V

1, w

ith S

T d

epre

ssio

n an

d T

wav

ein

vers

ion

(Fig

. 69

.2)

–d

eep

S w

aves

in t

he la

tera

l lea

ds

(Fig

. 69

.3)

CLI

NIC

AL

NO

TE

The

com

bin

atio

n of

left

atr

ial h

yper

trop

hy a

nd r

ight

ven

tric

ular

hyp

ertr

ophy

sug

gest

s m

itral

ste

nosi

s. T

his

pat

ient

had

mitr

alst

enos

is o

n th

e b

asis

of

rheu

mat

ic h

eart

dis

ease

. H

is c

hest

x-

ray

(Fig

. 69

.4) s

how

s ca

rdio

meg

aly,

enl

arge

men

t of

the

pul

mon

ary

outf

low

tra

ct (A

) and

left

atr

ial e

nlar

gem

ent

(B).

Cause

s of

left

atr

ial

abnorm

alit

y

➔Le

ft a

tria

l hyp

ertr

ophy

➔Le

ft a

tria

l dis

tens

ion

➔In

tera

tria

l con

duc

tion

blo

ck➔

Left

atr

ial s

carr

ing

II

notc

hed

P w

aves

Fig

. 69.1

P-m

itral

e.

–ve

dom

inan

t R w

ave

V1

Fig

. 69.2

Lead

V1.

aVL

deep

S w

ave

Fig

. 69.3

Lead

aV

L.

Fig

. 69.4

Che

st x

-ray

.


A 2

4-y

ear-

old

lady

wit

h a

his

tory

of

rheum

ati

c f

eve

r

CA

SE

70

152

IaV

R

IIaV

L

IIIaV

FV

3

V2

V1

V4

V5

V6

II


Bia

tria

l hyp

ert

rophy

•P

wav

es in

the

lim

b le

ads

mor

e th

an 3

mm

in h

eigh

t an

d a

lso

grea

ter

than

120

ms

(3 s

mal

l sq

uare

s) in

dur

atio

n.•

Larg

e b

ipha

sic

P w

aves

in V

1 w

ith a

n in

itial

pos

itive

def

lect

ion

of m

ore

than

2m

m a

nd a

ter

min

al n

egat

ive

por

tion

at le

ast

1 m

m d

eep

and

40

ms

(1 s

mal

l sq

uare

) in

dur

atio

n.•

P w

ave

grea

ter

than

2 m

m in

hei

ght

in V

1 in

com

bin

atio

n w

ithno

tche

d P

wav

es,

grea

ter

than

120

ms

in d

urat

ion

in t

he li

mb

lead

s or

left

pre

cord

ial l

ead

s.

Any

of

thes

e th

ree

crite

ria s

ugge

sts

the

dia

gnos

is o

f b

iatr

ial

hyp

ertr

ophy

.

FEAT

UR

ES

OF

THIS

EC

G

•S

inus

rhy

thm

, 92

b.p

.m.,

vert

ical

QR

S a

xis

•Fe

atur

es o

f b

iatr

ial h

yper

trop

hy:

–P

wav

es in

the

lim

b le

ads

whi

ch a

re b

road

, no

tche

d,

and

tal

l(F

ig.

70.1

)–

larg

e b

ipha

sic

P w

ave

in V

1 (F

ig.

70.2

)–

notc

hed

P w

aves

with

a d

urat

ion

of g

reat

er t

han

120

ms

inth

e le

ft p

reco

rdia

l lea

ds

(Fig

. 70

.3)

•Lo

ng P

R in

terv

al,

grea

ter

than

200

ms

(Fig

. 70

.4)

CLI

NIC

AL

NO

TE

This

lad

y ha

d r

heum

atic

trip

le v

alve

dis

ease

. H

er c

ard

iac

cath

eter

stu

dy

doc

umen

ted

crit

ical

tric

usp

id s

teno

sis,

sev

ere

mitr

al s

teno

sis,

and

sev

ere

aort

ic s

teno

sis.

153SECTION 7

CASE 70

I

notc

h

4 m

m h

igh

P w

ave

Fig

. 70.1

Lead

I.

V1

P

P

QR

S

QR

S

Fig

. 70.2

Larg

e b

ipha

sic

P w

aves

.

V6

notc

h

Fig

. 70.3

Lead

V6.

II

PR

inte

rval

of 2

40 m

s

Fig

. 70.4

Long

PR

inte

rval

.


A 2

5-y

ear-

old

lady

wit

h D

ow

n s

yndro

me

CA

SE

71

154

IaV

R

IIaV

L

IIIaV

F

II

V3

V2

V1

V4

V5

V6


Rig

ht

ventr

icula

r hyp

ert

rophy

(RV

H)

•R

ight

axi

s d

evia

tion

(QR

S a

xis

> +

90°)

•D

omin

ant

R w

ave

in V

1.•

No

evid

ence

of

ante

rola

tera

l myo

card

ial i

nfar

ctio

n or

bun

dle

bra

nch

blo

ck.

•O

ther

fea

ture

s:–

ST

segm

ent

dep

ress

ion

and

T w

ave

inve

rsio

n in

the

rig

htch

est

lead

s (V

1–4)

–d

eep

S w

aves

in t

he la

tera

l lea

ds

(V4–

6, I

and

aV

L).

FEAT

UR

ES

OF

THIS

EC

G

•S

inus

rhy

thm

, 84

b.p

.m.

•Fe

atur

es o

f R

VH

:–

right

axi

s d

evia

tion,

+12

5°(F

ig.

71.1

)–

dom

inan

t R

wav

e in

V1

(Fig

. 71

.2)

–d

eep

S w

aves

in t

he la

tera

l lea

ds

(Fig

. 71

.3)

•Fe

atur

es o

f rig

ht a

tria

l hyp

ertr

ophy

:–

abno

rmal

ly t

all P

wav

es in

the

infe

rior

lead

s an

d V

1(F

igs

71.2

and

71.

4)

CLI

NIC

AL

NO

TE

This

lad

y ha

d a

con

geni

tal v

entr

icul

ar s

epta

l def

ect

with

a la

rge

right

-to-

left

shu

nt (E

isen

men

ger

synd

rom

e).

She

was

dee

ply

cyan

osed

and

die

d s

ever

al d

ays

afte

r th

is E

CG

was

tak

en.

Cause

s of

a d

om

inant

R w

ave

in V

1

➔N

orm

al f

ind

ing

in c

hild

ren

➔R

ight

ven

tric

ular

hyp

ertr

ophy

➔R

ight

bun

dle

bra

nch

blo

ck➔

True

pos

terio

r m

yoca

rdia

l inf

arct

ion

➔Ve

ntric

ular

pre

-exc

itatio

n (W

PW

syn

dro

me)

➔D

uche

nne

mus

cula

r d

ystr

ophy

155SECTION 7

CASE 71

4 m

mI

aVF

12 m

m–7

+10

11 m

m2

mm

4 –

11 =

7 m

m12

– 2

= 1

0 m

m

+12

5º

Fig

. 71.1

Rig

ht a

xis

dev

iatio

n.

dom

inan

t R w

ave

V1

P w

ave

> 1

.5 m

m

Fig

. 71.2

Lead

V1.

I

deep

S w

aves

Fig

. 71.3

Lead

I.

II

P w

ave

> 3

mm

Fig

. 71.4

P-p

ulm

onal

e.


A 2

5-y

ear-

old

male

soccer

pla

yer

wit

h a

n e

jecti

on s

ysto

lic m

urm

ur

CA

SE

72

156

IaV

R

IIaV

L

IIIaV

FV

3

V2

V1

V4

V5

V6

RH

YT

HM

ST

RIP

: II

25 m

m/s

ec; 1

cm

/mV


Left

ventr

icula

r hyp

ert

rophy

(LV

H)

– lim

b l

ead c

rite

ria

•Th

ere

are

a nu

mb

er o

f cr

iteria

for

LV

H b

ased

on

the

volta

ges

of t

he Q

RS

def

lect

ions

(see

crit

eria

list

ed b

elow

). Th

ese

crite

riaha

ve g

ood

sp

ecifi

city

but

poo

r se

nsiti

vity

.•

Oth

er f

eatu

res:

–S

T d

epre

ssio

n an

d T

wav

e in

vers

ion

(LV

str

ain

pat

tern

) in

lead

s w

ith p

rom

inen

t R

wav

es–

coun

terc

lock

wis

e el

ectr

ical

rot

atio

n (e

arly

tra

nsiti

on)

–in

crea

sed

ven

tric

ular

act

ivat

ion

time

–in

vert

ed U

wav

es in

the

left

che

st le

ads

–le

ftw

ard

QR

S a

xis.

FEAT

UR

ES

OF

THIS

EC

G

•S

inus

bra

dyc

ard

ia,

54 b

.p.m

. •

Feat

ures

of

LVH

(Fig

. 72

.1):

–le

ftw

ard

axi

s–

early

ele

ctric

al t

rans

ition

(dom

inan

t R

in V

2)–

tall

R w

aves

in a

VL

and

lead

I–

tall

R w

aves

in t

he le

ft c

hest

lead

s an

d d

eep

S w

ave

in V

1–

wid

esp

read

ST

dep

ress

ion

and

T w

ave

inve

rsio

n

CLI

NIC

AL

NO

TE

Hyp

ertr

ophi

c ob

stru

ctiv

e ca

rdio

myo

pat

hy (H

OC

M) w

asd

iagn

osed

at

echo

card

iogr

aphy

.

157SECTION 7

CASE 72

Volt

age c

rite

ria f

or

LVH

Sok

olow

& L

yon:

1S

V1

+ R

(V5

or V

6) >

35

mm

Cor

nell:

2S

V3

+ R

aVL

> 2

8 m

m in

men

SV

3 +

RaV

L >

20

mm

in w

omen

Fram

ingh

am:3

RaV

L >

11

mm

RV

4–6

> 2

5 m

mS

V1–

3 >

25

mm

S(V

1 or

V2)

+ R

(V5

or V

6) >

35

mm

RI +

SIII

> 2

5 m

mR

omhi

lt &

Est

es:4

Poi

nt s

core

sys

tem

1S

okol

ow M

, Ly

on T

P 1

949

Vent

ricul

ar c

omp

lex

in le

ft v

entr

icul

ar h

yper

trop

hy a

s ob

tain

ed b

yun

ipol

ar p

reco

rdia

l and

lim

b le

ads.

Am

eric

an H

eart

Jou

rnal

37:

161

2C

asal

e P

N e

t al

198

7 Im

pro

ved

sex

-sp

ecifi

c cr

iteria

for

left

ven

tric

ular

hyp

ertr

ophy

for

clin

ical

and

com

put

er in

terp

reta

tion

of e

lect

roca

rdio

gram

s: v

alid

atio

n w

ith a

utop

sy f

ind

ings

. C

ircul

atio

n75

(3):

565–

572

3Le

vy D

et

al 1

990

Det

erm

inan

ts o

f se

nsiti

vity

and

sp

ecifi

city

of

elec

troc

ard

iogr

aphi

c cr

iteria

for

left

ven

tric

ular

hyp

ertr

ophy

. C

ircul

atio

n 81

: 81

5–82

0 4R

omhi

lt D

W,

Est

es E

H 1

986

Poi

nt s

core

sys

tem

for

the

EC

G d

iagn

osis

of

left

ven

tric

ular

hyp

ertr

ophy

. A

mer

ican

Hea

rt J

ourn

al 7

5: 7

52–7

58

tall

R w

aves

ST

dep

ress

ion

T w

ave

inve

rsio

n

I

Fig

. 72.1

Lead

I.


A 7

0-y

ear-

old

man w

ith l

ongst

andin

g h

ypert

ensi

on

CA

SE

73

158

aVR

I IIaV

L

IIIaV

FV

3V

6

V2

V5

V1

V4

RH

YT

HM

ST

RIP

: II

25 m

m/s

ec; 1

cm

/mV


Left

ventr

icula

r hyp

ert

rophy

(LV

H)

– chest

lead c

rite

ria

•Th

ere

are

a nu

mb

er o

f cr

iteria

for

LV

H b

ased

on

the

volta

ges

of t

he Q

RS

def

lect

ions

(see

p.

157)

.•

Oth

er f

eatu

res:

–S

T d

epre

ssio

n an

d T

wav

e in

vers

ion

(LV

str

ain

pat

tern

) in

lead

s w

ith p

rom

inen

t R

wav

es–

coun

terc

lock

wis

e el

ectr

ical

rot

atio

n (e

arly

tra

nsiti

on)

–in

crea

sed

ven

tric

ular

act

ivat

ion

time

–in

vert

ed U

wav

es in

the

left

che

st le

ads

–le

ftw

ard

QR

S a

xis

–as

soci

ated

left

atr

ial a

bno

rmal

ity.

FEAT

UR

ES

OF

THIS

EC

G

•S

inus

rhy

thm

, 54

b.p

.m.

•Fr

eque

nt v

entr

icul

ar p

rem

atur

e b

eats

(VP

Bs)

•Fe

atur

es o

f LV

H:

–le

ftw

ard

axi

s (−

30°)

–vo

ltage

crit

eria

for

LV

H in

the

che

st le

ads,

SV

1 +

RV

6 >

35

mm

(Fig

. 73

.1)

–R

aVL

> 1

1 m

m–

asso

ciat

ed le

ft a

tria

l ab

norm

ality

(Fig

. 73

.2)

–w

ides

pre

ad S

T d

epre

ssio

n an

d T

wav

e in

vers

ion

(Fig

. 73

.1)

Cause

s of

left

ventr

icula

r hyp

ert

rophy

➔S

ysto

lic o

verlo

ad:

–sy

stem

ic h

yper

tens

ion

–ao

rtic

ste

nosi

s–

coar

ctat

ion

of t

he a

orta

–hy

per

trop

hic

card

iom

yop

athy

➔D

iast

olic

ove

rload

:–

mitr

al in

com

pet

ence

–ao

rtic

inco

mp

eten

ce

159SECTION 7

CASE 73

V1

V6

17 m

m

42 m

m ST

dep

ress

ion

and

T w

ave

inve

rsio

n

Fig

. 73.1

Volta

ge c

riter

ia f

or L

VH

.

V1

broa

d, n

otch

ed p

wav

e in

lead

IIV

PB

term

inal

–ve

p w

ave

in V

1

Fig

. 73.2

Left

atr

ial a

bno

rmal

ity.


A 1

7-y

ear-

old

wom

an w

ith a

loud p

ansy

stolic

murm

ur

CA

SE

74

160

aVR

I IIaV

L

IIIaV

F

II

V3

V3

V2

V5

V1

V4


Biv

entr

icula

r hyp

ert

rophy

•Vo

ltage

crit

eria

for

LV

H in

the

che

st le

ads

com

bin

ed w

ith r

ight

axis

dev

iatio

n an

d p

rom

inen

t R

wav

es in

the

rig

ht p

reco

rdia

lle

ads.

•H

igh

volta

ge b

ipha

sic

RS

com

ple

xes

in t

he m

id-p

reco

rdia

lle

ads

(mos

t co

mm

on in

VS

D).

•E

vid

ence

of

asso

ciat

ed le

ft a

tria

l enl

arge

men

t.

FEAT

UR

ES

OF

THIS

EC

G

•S

inus

tac

hyca

rdia

, 13

0 b

.p.m

. •

Feat

ures

of

RV

H:

–rig

ht a

xis

dev

iatio

n (+

100°

)–

dom

inan

t R

wav

e in

V1

(rS

R′)

–S

T se

gmen

t d

epre

ssio

n an

d T

wav

e in

vers

ion

in t

he r

ight

ches

t le

ads

(Fig

. 74

.1)

•Fe

atur

es o

f LV

H:

–ta

ll R

wav

es in

the

left

che

st le

ads

(RV

5 35

mm

)–

pro

min

ent

nega

tive

com

pon

ent

to P

wav

e in

V1

sugg

estin

gas

soci

ated

left

atr

ial a

bno

rmal

ity (F

ig.

74.2

)•

Hig

h vo

ltage

bip

hasi

c R

S c

omp

lexe

s in

the

mid

-pre

cord

ial

lead

s (F

ig.

74.1

)

CLI

NIC

AL

NO

TE

This

you

ng w

oman

had

a s

mal

l to

mod

erat

e si

zed

VS

D.

161SECTION 7

CASE 74

ST

dep

ress

ion

inve

rted

T w

ave

V3

high

vol

tage

bip

hasi

c Q

RS

Fig

. 74.1

Lead

V3.

Fig

. 74.2

Lead

V1.

V1

dom

inan

t R w

ave

nega

tive

Pw

ave


Documents

HYPERTROPHY PATTERNS - Elsevier · HYPERTROPHY PATTERNS Section 07.qxd 8/11/04 8:26 PM Page 147. CASE 68 A 54-year-old lady with bronchiectasis 148 I aVR II aVL III aVF V1 V2 V3 V4