Skip to Main Content

++

A-1

++

NARRATIVE INTERPRETATION

++
++

Image not available.

++
Abnormalities
++

P-wave voltage greater than 2.5 mm, leads II, III, aVF. Limb-lead voltage less than 5 mm. R-wave voltage V1–V3 less than 3 mm.

++
Synthesis
++

Sinus rhythm. Low voltage limb leads. Right atrial abnormality. Poor R-wave progression.

++

TEST ANSWERS

++

1, 59, 66, 67.

++

Comment: Low voltage (the total amplitude of the R and S waves is less than 5 mm in any limb lead) is present in this tracing. Low voltage may be seen in patients with pericardial effusion, myxedema, amyloidosis, profound obesity, chronic obstructive pulmonary disease, and extensive loss of functioning myocardial tissue as might occur after multiple myocardial infarctions. Poor R-wave progression is identified when R waves are present in the anterior precordial leads, but R-wave magnitude is less than 3.0 mm in lead V3. Causes include anterior wall myocardial infarction, left ventricular hypertrophy, right ventricular hypertrophy, left anterior fascicular block, chronic obstructive pulmonary disease (COPD), or normal variants. In this case, the most likely cause of both low voltage and poor R-wave progression is COPD. The tall peaked P waves represent right atrial enlargement secondary to elevated right heart pressures.

++

FURTHER READING

+
Kilcoyne  MM, Davis  AL, Ferrer  MI: A dynamic electrocardiographic concept useful in the diagnosis of cor pulmonale. Circulation 42:903–924, 1970.  [PubMed: 4249377]
+
Selvester  RH, Rubin  HB: New criteria for the electrocardiographic diagnosis of emphysema and cor pulmonale. Am Heart J 69:437–447, 1965.  [PubMed: 14270092]
+
Zema  MJ, Kligfield P: ECG poor R-wave progression. Arch Intern Med[Archives of Internal Medicine Full Text] 142:1145–1148, 1982.  [PubMed: 6212033]

++
Clinical History
++

A 79-year-old man with chronic dyspnea. He is a heavy smoker

++

Image not available.

++

A-2

++

NARRATIVE INTERPRETATION

++
++

Image not available.

++
Abnormalities
++

APC. VPC. Axis leftward of −30 degrees. R wave V1–V3 less than 3 mm. R wave lead aVL + S wave lead V3 greater than 28 mm in a male. R wave in lead aVL greater than 11 mm. R wave lead I + S wave lead III greater than 25 mm. ST depression, leads I, V6. T-wave inversion, leads I, aVL, V6. T-wave biphasic lead V5.

++
Synthesis
++

Sinus rhythm. VPC. APC. Left-axis deviation. Left anterior fascicular block. LVH. Poor R-wave progression. ST-T-wave abnormalities associated with ventricular hypertrophy.

++

TEST ANSWERS

++

1, 10, 26, 64, 66, 72, 78, 103, (106).

++

Comment: Even though “classic” precordial voltage criteria are absent, the gender-specific Cornell criteria call for a diagnosis of LVH. In addition, multiple limb lead criteria for LVH are present. Remember that ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.