ECG Review

Tell Me A Story

By Ken Grauer, MD, Professor, Department of Community Health and Family Medicine, University of Florida. Dr. Grauer is the sole proprietor of KG-EKG Press, and publisher of an ECG pocket brain book. Dr. Grauer reports no financial relationship to this field of study.

Figure. 12-lead ECG obtained from a middle-aged heavy smoker.

Clinical Scenario: The ECG in the Figure was obtained from a middle-aged woman with shortness of breath. She is a long-time heavy smoker. How would you interpret her 12-lead ECG?

Interpretation/Answer: The story told by this ECG is that of significant pulmonary disease. The rhythm is sinus tachycardia at a rate of about 110/minute. There is definite RAD (right axis deviation), as the QRS complex in lead I is predominantly negative. There is ECG evidence of bilateral atrial abnormality—tall peaked P waves in the inferior leads consistent with RAA (right atrial abnormality); and a very deep, negative component to the P wave in lead V1 consistent with LAA (left atrial abnormality). There is an r prime addition to the end of the small QRS complex in lead V1. Finally, deep terminal S waves persist across the precordial leads, such that transition never occurs.

The ECG diagnosis of RVH (right ventricular hypertrophy) is often difficult to make. This is because there is no single finding that establishes this diagnosis with certainty. Instead, a combination of findings in the right clinical setting suggests the presence of RVH. This is the case here, in which this middle-aged, long-term smoker manifests RAD, RAA, an r prime pattern in lead V1, and persistent deep, S waves across the precordium. The marked degree of RAD and the very tall and peaked P waves in the inferior leads suggests significant RVH and/or pulmonary hypertension. In view of this patient's shortness of breath occurring in the setting of tachycardia and RVH on ECG, consideration should be given to the possibility that an acute event (ie, pulmonary embolism) may have precipitated her symptoms.