ECG Rounds:Dr. Dave Dyck R3

April 3, 2003

Case 1: 2 week infant with tachypnea (RR=60-70),

tachycardia (170) and “dusky” in appearance.

Cardiologists Interpretation: Sinus rhythm. Heart Rate 160. QRS axis 90. PR 130ms. QRS 50ms. QT/QTc

280/450 Right atrial hypertrophy Right ventricular hypertrophy LV strain/ischaemia

Of Note: The T wave changes are the most significant features of this

ECG.

An upright T wave in V1 in a 2 week old infant is abnormal and may signify RV systolic hypertension.

Inverted T waves in V5-6 are evidence of LV strain which may cause reciprocally upright T waves in the right chest leads.

(TGA/VSD/PA)

Case 2: 13m female with failure to thrive and

worsening tachypnea sent to ER by GP HR=125 RR=42 O2sat=94%

ECG:

Cardiologist’s Interpretation: Sinus rhythm. Rate 124. QRS axis +150.

PR 150ms. QRS 60ms. QT/QTc 240/340Bi-atrial hypertrophy, left >rightRight axis deviationRight ventricular hypertrophy

(upright T waves in V1= abnormal)

ECG:

Of Note: This young child was born with a dysmorphic

mitral valve which has resulted in both mitral stenosis and incompetance.

The right sided hypertrophy is a result of pulmonary hypertension caused by her elevated left heart pressures.

Pediatric ECGs Often 13 lead ECGs done (V3R or V4R) for

the evaluation of RVH in children

V1 inverted Ts: 1st day = RAD, large R waves + upright T

waves in right precordial leads (V3R, V1) by 48 hrs: inverted T waves in V1, V3R

Upright Ts > 1 wk pathologic (RVH or strain)

Should never be upright before age 6 and often into adolescence

Axis: Newborn Axis: usually +110 - +180 V1, V3R have R>S wave usually and often

for months/years (up to 8 yrs) Over the years, the QRS axis gradually shifts

leftward and right ventricular forces slowly regress

If it looks like a normal adult ECG early on think LVH

Pediatric Heart Chamber Hypertrophy: Right Atrial Enlargement (RAE):

P wave > 2 mm tall in infants and small children and > 3 mm tall in older children

P waves best seen in inferior (I,II & aVF) and the right chest leads (V3R, V1 & V2)

RAE:

Left Atrial Enlargement: Wide P waves > 2 mm wide (.08s) in infants

and small children and more than 3 mm wide (.12s) in larger children

Best seen in inferolateral leads

LAE:

P wave morphology in AE:

Right Ventricular Hypertrophy: R in V1 >95% of normal + S in V6 deeper than

95% of normal

Age HRbpm

QRSaxis

degrees

PRintervalseconds

QRSintervalseconds

Rin V1mm

Sin V1mm

Rin V6mm

Sin V6mm

1st week 90-160 60-180 0.08-0.15 0.03-0.08 5-26 0-23 0-12 0-10

1-3wks 100-180 45-160 0.08-0.15 0.03-0.08 3-21 0-16 2-16 0-10

1-2 mo 120-180 30-135 0.08-0.15 0.03-0.08 3-18 0-15 5-21 0-10

3-5 mo 105-185 0-135 0.08-0.15 0.03-0.08 3-20 0-15 6-22 0-10

6-11 mo 110-170 0-135 0.07-0.16 0.03-0.08 2-20 0.5-20 6-23 0-7

1-2 yr 90-165 0-110 0.08-0.16 0.03-0.08 2-18 0.5-21 6-23 0-7

3-4 yr 70-140 0-110 0.09-0.17 0.04-0.08 1-18 0.5-21 4-24 0-5

5-7 yr 65-140 0-110 0.09-0.17 0.04-0.08 0.5-14 0.5-24 4-26 0-4

8-11 yr 60-130 -15-110 0.09-0.17 0.04-0.09 0-14 0.5-25 4-25 0-4

12-15 yr 65-130 -15-110 0.09-0.18 0.04-0.09 0-14 0.5-21 4-25 0-4

> 16 yr 50-120 -15-110 0.12-0.20 0.05-0.10 0-14 0.5-23 4-21 0-4

RVH #2 rsR’ in V1 & V2 without a widened QRS duration

as in RBBB (note= 2nd R is larger)

RVH #3 qR in V1 and V2

RVH #4

Pure R in V1 & V2 +/- strain changes

Left Ventricular Hypertrophy (LVH): S in V1 deeper than 95% of normal and R in V6

taller than 95% of normal

Summary: From 5 days to age 6, upright T waves in V1 are

abnormal. RAD (& V3R, V1 R>S) is prominent early and is

normal RVH in kids

1. R in V1>95% of normal and S in V6 deeper than 95% 2. RsR’ in V1(2) without widened QRS 3. qR in V1(2) 4. pure R in V1(2) +/- strain

Ventricular hypertrophy in children is based on comparison to statistical norms