Biatrial enlargement in biventricular HCM

P waves in lead II has a duration of 120 msec and amplitude of 0.3 mV, suggesting biatrial
overload. The pattern is that of P mitrale or an M shaped P wave. P wave in V1 has a sharp
upstroke of 0.2 mV indicating right atrial overload and deep and wide negative deflection
indicating left atrial overload. This biatrial overload has occurred because of biventricular
hypertrophic cardiomyopathy which produces diastolic dysfunction of both ventricles and
consequent atrial enlargement. The prominent biphasic deflections in mid precordial leads going
beyond the recording strip is indicative of biventricular hypertrophy. The deep and wide Q wave
in V6 is due to the septal hypertrophy.
Tags: left atrial overload, right atrial overload, septal hypertrophy
How to Look for Hypertrophy
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Contents
[hide]

1 Right Atrial Enlargement

2 Left Atrial Enlargement

3 Left Ventricular Hypertrophy

4 Right Ventricular Hypertrophy

Right Atrial Enlargement

The normal electrical impulse in the heart is initiated in the sinus node. Since the impulse starts
in the right atrium, the initial portion of the P wave is thus produced by the right atrium alone,
the mid portion by both the right and left atria and the terminal portion by the left atrium alone.
Enlargement of the right atrium in adults, most commonly seen in adults as a result of chronic
lung disease and is referred to as P Pulmonale. The result is an increase in the voltage of the
initial and mid forces of the P wave shifting it more rightward producing tall peaked P wives in
leads V1, Lead 3 and aVF of greater than 2.5 mm. Note that right atrial enlargement affects the
initial and mid portion of the P wave and does not increase the ratio of P wave to PR interval.

Left Atrial Enlargement

Enlargement of the left atrium (LAE) which is was historically caused by mitral stenosis and
referred to as P Mitrale is not that common anymore. Other causes of LAE such as Mitral
Regurgitation or Hypertension or much more common today. Since the left atrium as activated

later than the right atrium, LAE is seen in the mid and terminal portion of the P wave without
necessarily affecting the initial portion. Thus to diagnose LAE you must first look in lead II
which may have a secondary peak in the P wave. Probably of more diagnostic value is
observation of the anterior-posterior characteristics of the terminal P vector. The left atrium is
essentially a posterior structure. When enlarged, the mid and terminal P vectors are therefore
oriented posteriorly and are manifested in V1-V2 as a wide negative defection (since most of the
forces are traveling away from V1). Such a terminal negative P vector of 0.04 second duration
(one small box wide) and and 1.0 mm deep (one small box deep), essentially one small square on
the ECG paper) is strong evidence of left atrial enlargement.

Left Ventricular Hypertrophy

Many criteria exist for the diagnosis of Left Ventricular Hypertrophy (LVH) and many have
either false positive of false negatives. Listed below are some examples of criteria

S wave in VI or S wave in V2 + R wave in V5 or R wave in V6 > 35mm

R wave in aVL > 11 mm

R wave in aVF > 20 mm

R wave in Lead I + S wave in Lead III > 25 mm

S wave in V1 > 26 mm

R wave in V5 or R wave in V6 > 26 mm

R wave + S wave in any lead > 35 mm

Right Ventricular Hypertrophy

The most common sign of Right Ventricular Hypertrophy is Right Axis Deviation in the frontal
plane of 90 degrees or more. Below several criteria are listed

V1 R wave > 7

R wave axis > 110 degrees

R/S ratio in V1 > 1

rSR' V1 with R'> 10

QRS < 120 ms (RVH is difficult to diagnose in the presence of a Right Bundle
Branch Block)

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