2. chapter Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chamber Enlargement 12 Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

3. Chapter 12 Objectives Identify, by criteria, evidence of right and left atrial enlargement Identify evidence of right and left ventricular hypertrophy and strain Describe the clinical implications of atrial and ventricular enlargement 124

4. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Right Atrial Enlargement 125

5. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Causes of RAE Congenital heart disease Tricuspid or pulmonary valve disease Pulmonary hypertension

6. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Clinical Problems Not an acute problem Seen with RVH Can also be seen with large pulmonary embolism

7. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Left Atrial Enlargement 126

8. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Left Atrial Enlargement Left atrial dilation Volume overload or pressure Causes Hypertension Pulmonary edema Mitral or aortic valve stenosis Left ventricular hypertrophy AMI

9. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Left Atrial Enlargement Clinical implications Keep in mind the causes Can be useful in predicting hemodynamic problems

10. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Right Ventricular Hypertrophy Caused by increased pressure in the right ventricle Large forces go away from the lateral leads and toward the right side 126

11. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ RVH ECG Clues RAE Narrow QRS RAD R wave height in V1 is ≥7mm or R>S Asymmetric downsloping of ST segment in inferior leads

12. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ RVH

13. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ RVH Clinical Concerns No specific treatment Consider the causes for pathology Can mimic posterior hemiblock: both have right axis deviation

14. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Left Ventricular Hypertrophy LVH-increased pressure or volume Found in mitral and aortic stenosis, cardiomyopathy, hypertension, IHD Experts disagree on ECG accuracy Nonetheless, the criteria are proven 127

15. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ LVH ECG Criteria LAE, plus any voltage criteria, is diagnostic QRS is narrow or slightly widened with “strain” Axis can be normal > –15 may be LVH

16. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ LVH Voltage Criteria “Rule of 35” Measure the deepest S wave of V1 or V2 in mm (small squares) Measure the tallest R wave in Lead V5 or V6 Add these two together 26 17 43 127

17. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ LVH Voltage Criteria If they add up to more than 35 mm, and the patient is over 35 years old, then voltage criteria for LVH is met Then look for “strain”

18. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ LVH Voltage Criteria R wave in aVL is >11 mm

19. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Strain Pattern Increases sensitivity of voltage criteria Downsloping ST segment, best seen in V5 or V6

20. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Practice Cases Chamber Enlargement

21. Page, 12-Lead ECG for Acute and Critical Care Providers © 2006 by Pearson Education, Inc. Upper Saddle River, NJ 128

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