Pulmonary hypertension electrocardiogram

Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Assistant Editor(s)-in-Chief: Lisa Prior

Background
Elevated pulmonary pressures can lead to right ventricular hypertrophy (RVH) and right atrial enlargement. These pathological changes may sometimes manifest on electrocardiogram.

ECG findings suggestive of RVH in pulmonary hypertension

 * Right axis deviation
 * R/S ratio > 1 in V1
 * R wave > 7mm in V1
 * rSR' complex in V1 with R' > 10mm
 * qR complex in V1
 * Right ventricular strain pattern: ST and T wave inversion in V1-V3 and occasionally in inferior leads (II, III, AVF)
 * Right Bundle Branch block: QRS duration> 0.12 seconds, rSR' in leads V1 & V2, wide slurred S waves in lateral leads (V5, V6, I)

ECG findings suggestive of right atrial enlargment

 * P 'pulomale': P wave amplitude >2.5mm in inferior leads (II, III, AVF) or >1.5mm in V1/V2
 * P wave axis shifted rightward >70°

Use as a prognostic tool
A number of studies have indicated that a qR pattern in V1 and a tall P wave in lead I point towards a worse outcome in patients with pulmonary hypertension However up to 13% of patients with significant pulmonary hypertension were shown to have normal ECG findings indicating lack of senstivity and casting doubt on it's use a prognostic indicator.