Ventricular Hypertrophy in Pediatric EKG

Marc FrancisR4 FRCPC EmergencyYear 1 PEM Fellow

Objectives

I do not want to:• Make you memorize

pages of numbers• Make you memorize

tables• Make you never

want to see another pediatric EKG

• Make you fall asleep

I do want to:• Give you a bedside

approach to rapidly looking for LVH and RVH

Ventricular Hypertrophy

• RVH and LVH can be markers of significant disease states

• Congenital Heart disease• Shunts• Pulmonary HTN• Renal Failure

• Hypertrophy produces abnormalities on EKG• QRS axis• QRS voltages• R/S ratio• T axis

The Problem

• Damn kids keep growing!!!– They start life with dominance of the RV– By 6-8 weeks they have corrected to a LV

dominated system– The normal intervals and wave amplitudes

change as they age– They finally fall in line and become “big

people” only when they are 16 years old

Solutions

Option 1:

Memorize a ton of charts and tables of normal values

Option 2:

Keep these in your palm pilot to reference every 5-10 minutes until step one has occurred

Option 3:

Ignore any and all EKGs done in the Peds ED

The “Alternative” Solution

Step 1:

Remember a few simple screening parameters that will allow you to rapidly assess an EKG to look for RVH and LVH in pediatric patients

Step 2:

Let the cardiologist remember all the numbers and charts

RVH

CRITERIA FOR RVH

1) RAD for the patient's age 2) Increased rightward and anterior QRS voltages

a) R in V1, V2, or aVR greater than the upper limits of normal for the patient's age

b) S in I and V6 greater than the upper limits of normal for the patient's age *Note: Assumes QRS is not widened for age indicating abnormal

conduction delay

3) Abnormal R/S ratio in favor of the RVa) R/S ratio in V1 and V2 greater than the upper limits

of normal for ageb) R/S ratio in V6 less than 1 after one month of age

1) RAD for patient age

Lead I = 0° Lead AVL = -30°

Lead II = +60° Lead AVR = -150°

Lead AVF = +90°

Lead III = +120°

Mean and Ranges of Normal QRS Axes by Age

Age Mean (Range)

1 wk-1 mo +110° (+30 to +180)

1-3 mo +70° (+10 to +125)

3 mo-3 yr +60° (+10 to +110)

Older than 3 yr +60° (+20 to +120)

Adult +50° (-30 to +105)

2) Increased rightward and anterior QRS voltages

• R in V1, V2, or aVR greater than the upper limits of normal for the patient's age

• S in I and V6 greater than the upper limits of normal for the patient's age

R and S Voltages: Mean (and Upper Limits of Normal) According to Lead and Age

Age R voltage in V1 S voltage in V6

0-1 mo 15 (25) 4 (12)

1-6 mo 11 (20) 2 (7)

6 mo-1yr 10 (20) 2 (6)

1-3yr 9 (18) 2 (6)

3-8yr 7 (18) 1 (5)

8-12yr 6 (16) 1 (4)

12-16yr 5 (16) 1 (5)

Young Adults 3 (14) 1 (13)

*Voltages are measured in millimeters, when 1 mV = 10 mm paper

3) Abnormal R/S ratio in favor of the RV

• R/S ratio in V1 and V2 greater than the upper limits of normal for age

• R/S ratio in V6 less than 1 after one month of age

R/S Ratio: Mean and Upper and Lower Limits of Normal According to Age V1

Lead VIAge LLN Mean ULN0-1mo 0.5 1.5 191-6mo 0.3 1.5 S=06mo-1yr 0.3 1.2 61-3yr 0.5 0.8 23-8yr 0.1 0.65 28-12yr 0.15 0.5 112-16yr 0.1 0.3 1Adults 0.0 0.3 1*LLN = lower limits of normal; ULN = upper limits of normal

From Guntheroth WB: Pediatric Electrocardiography. Philadelphia, WB Saunders, 1965

Screening criteria for RVH

1) RAD greater than +120° in any child over 1 month is highly suggestive of RVH

2) Upright T in V1 • In patients > 3 days and < 6yr old • Provided that the T is upright in the left precordial

leads (V5, V6)

3) Q wave in V1 always suggests RVH

4) S wave > R wave in Lead V6

LVH

CRITERIA FOR LVH

1) LAD for the patient's age2) QRS voltages in favor of the LV   

a) R in I, II, III, aVL, aVF, V5, or V6 greater than the upper limits of normal for age

b) S in V1 or V2 greater than the upper limits of normal for age

3) Abnormal R/S ratio in favor of the LV– R/S ratio in V1 and V2 less than the lower

limits of normal for the patient's age

1) LAD for patient age

Lead I = 0° Lead AVL = -30°

Lead II = +60° Lead AVR = -150°

Lead AVF = +90°

Lead III = +120°

Mean and Ranges of Normal QRS Axes by Age

Age Mean (Range)

1 wk-1 mo +110° (+30 to +180)

1-3 mo +70° (+10 to +125)

3 mo-3 yr +60° (+10 to +110)

Older than 3 yr +60° (+20 to +120)

Adult +50° (-30 to +105)

2) QRS voltages in favor of the LV

• R in I, II, III, aVL, aVF, V5, or V6 greater than the upper limits of normal for age

• S in V1 or V2 greater than the upper limits of normal for age

R Voltages: Mean (Upper Limits of

Normal) According to Lead and Age R voltage

Age Lead I Lead II Lead III0-1mo 4(8) 6(14) 8(16)1-6mo 7(13) 13(24) 9(20)6mo-1yr 8(16) 13(27) 9(20)1-3yr 8(16) 13(23) 9(20)3-8yr 7(15) 13(22) 9(20)8-12yr 7(15) 14(24) 9(24)12-16yr 6(13) 14(24) 9(24)Young Adults 6(13) 9(25) 6(22)*Voltages are measured in millimeters, when 1 mV = 10 mm paper

From Park MK, Guntheroth WG: How to Read Pediatric ECGs, 3rd ed. St. Louis, Mosby, 1992.

S Voltages: Mean (Upper Limits of

Normal) According to Lead and Age S voltage

Age Lead VI Lead V20-1mo 10(20) 20(35)1-6mo 7(18) 16(30)6mo-1yr 8(16) 17(30)1-3yr 13(27) 21(34)3-8yr 14(30) 23(38)8-12yr 16(26) 23(38)12-16yr 15(24) 23(48)Young Adults 10(23) 14(36)*Voltages are measured in millimeters, when 1 mV = 10 mm paper

From Park MK, Guntheroth WG: How to Read Pediatric ECGs, 3rd ed. St. Louis, Mosby, 1992.

3) Abnormal R/S ratio in favor of the LV

• R/S ratio in V1 and V2 less than the lower limits of normal for the patient's age

*Note that lead V2 is in ½ normal standardization

R/S Ratio: Mean and Upper and Lower Limits of Normal According to Age V1

Lead VIAge LLN Mean ULN0-1mo 0.5 1.5 191-6mo 0.3 1.5 S=06mo-1yr 0.3 1.2 61-3yr 0.5 0.8 23-8yr 0.1 0.65 28-12yr 0.15 0.5 112-16yr 0.1 0.3 1Adults 0.0 0.3 1*LLN = lower limits of normal; ULN = upper limits of normal

From Guntheroth WB: Pediatric Electrocardiography. Philadelphia, WB Saunders, 1965

Screening Criteria for LVH

1) LAD less than +10° is highly suggestive of LVH

2) S wave in lead V1 greater than 20mm

3) Q in V6, ≥5 mm suggests LVH• With LV diastolic overload

In Summary

If under 1 month all bets are off!!!

Step 1– Look at the axis:

• > +120° suggests RVH• < +10° suggests LVH

Step 2– Look at lead V1:

• Upright T or Q-wave in V1 suggests RVH• Large S wave >20mm suggests LVH

In Summary

• Step 3– Look at lead V6:

• S wave > R wave suggests RVH• Q wave > 5mm suggests LVH

Case 1

• 1 month old with heart murmur

Case 2

• 8yo with heart murmur

Case 3

• 4yo Female with CP

Case 4

• 2yo M

Case 5

• 8mo Female

Questions???

References

• Park: Pediatric Cardiology for Practitioners, 4th ed., Copyright © 2002 Mosby, Inc.

• Guntheroth WB: Pediatric Electrocardiography. Philadelphia, WB Saunders, 1965.

• Park MK, Guntheroth WG: How to Read Pediatric ECGs, 3rd ed. St. Louis, Mosby, 1992.