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By Ken Grauer, MD
Figure. 12-lead ECG obtained from a 49-year-old man with hypertension, a history of alcohol abuse, and progressive dyspnea. What might this echocardiogram show?
Clinical Scenario: The 12-lead ECG shown in the Figure was obtained from a 49-year-old African American man with a history of hypertension, alcohol abuse, and progressively increasing dyspnea. What might his echocardiogram show? How many cardiac chambers are likely to be enlarged?
Interpretation: The rhythm is sinus tachycardia at a rate of about 115 beats/minute. The PR and QRS intervals are normal. The mean QRS axis is rightward, as suggested by the negative QRS complex in lead I. Biatrial enlargement is suggested by the presence of tall, peaked P waves in the inferior leads (right atrial enlargement [RAE]) and by the deep negative component of the P wave in lead V1 (left atrial enlargement [LAE]). QRS voltage is markedly increased in the precordial leads, clearly exceeding the limits that define left ventricular hypertrophy (LVH). In view of the clinical profile of this patient and the history of progressive dyspnea, congestive (dilated) cardiomyopathy with multichamber enlargement is likely. The presence of right axis deviation (RAD) in association with the clinical picture and combined ECG findings of RAE, LAE, and LVH strongly suggest that there is also enlargement of the fourth cardiac chamber (right ventricular hypertrophy [RVH]).