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Demystifying the ECG in theory and practice
HypertrophyDr Frank Owusu-Sekyere
PSG AGSM Pre-conference
6th February 2020
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Why hypertrophy?
• Congenital – hypertrophic cardiomyopathies
• acquired- Remodeling of the heart in chronic HF
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• Increasing SV ----- INCREASED WALL TENSION-----increased oxygen consumption
• Laplace law
• Wall stress = pressure x radius
2 x wall thickness
- the bigger the LV (Radius)or pressure, the greater the wall stress
- In HF, Hypertrophy develops to balance the increased pressure and keeps the wall stress unchanged, same as reducing the diameter of the heart.
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P-WAVE
• Gives atrial dimension
• Height- RIGHT (>3mm)
• Width- LEFT (>2.5 small squares in children or 2 small squares in infants)
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AXIS
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VENTRICLES
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GENERAL PRINCIPLES OF VENTRICULAR HYPERTROPHY
• CHANGES IN QRS AXIS
-directed toward the hypertrophied ventricle
- RAD seen in RVH
-LAD- LVH with volume overload but not pressure overload
-Marked LAD indicates VCD
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CHANGES IN QRS VOLTAGE
• CHANGES IN QRS VOLTAGE
-RVH ----Voltages increases in leads that look at right or a negative in leads that look at LV
LVH- Voltages increase in leads that look at LV and negative for those that look at the right
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CHANGES IN R/S RATIO
• R/S ratio represents the relative electromotive force of opposing ventricles
• In VH, a change may be seen in the R/S ratio without an increase in the absolute voltage
• Increase in right precordial leads-RVH
• Decrease in RT precordial leads –LVH
• Increase in LT leads –LVH
• Decrease in LT leads -RVH
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•Changes in T-axis
•Changes seen in severe ventricular hypertrophy with relative ischemia of the hypertrophied myocardium
•Upright T-wave in V1 RVH
•Q- wave in V1- RVH
•Deep Q-wave (>5mm) as well as Tall T-wave (>15mm) in V5, V6 suggest LVH of volume loading type
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Left Ventricular Hypertrophy
• Increased R voltages in frontal left leads ( I, II, aVL , aVF )
• Tall R in V5, V6 and/or S wave in V1,V2 ,V4R
•Decreased R/S ratio in Right praecordial leads
• Increased R/S ratio in V5,V6
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RVH
• Increased R voltage in aVR, III, Deep S in I
• Increased R in V4R, V1, V2 and S in V5, V6
• Increased R/S in Rt chest leads
•Decreased R/S in V5, V6
•T-wave
•RAD
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Biventricular hypertrophy
• Positive voltage criteria for RVH and LVH, absence of BBB or Preexcitation
• Katz-Wachtel Phenomenon
- Large equiphasic QRS in 2 or more limb leads
- And mid-precordial leads (V2-V5)
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Q-WAVE
• Any negative deflection that precedes an R wave
• L-R depolarisation of the interventricular septum
• Small ‘septal’ Q waves are typically seen in the left-sided leads (I, aVL, V5 and V6)
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AXIS
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Hope its no more a double blind study