Wednesday, December 15, 2010

ECG Interpretation Review - #1 (LVH, Strain, Ischemia, LAE, RAE, RVH, LAA, RAA)

QUESTION: Interpret the 12-lead ECG below.
  • Clinically - What do you suspect this patient has?
(ECG reproduced from ECG-2014-ePub - pg 40A)
- Note - Enlarge by clicking on Figures -

INTERPRETATION:  The rhythm is sinus at ~75/minute.  The PR, QRS, and QT intervals are normal.  There is RAD (predominantly negative QRS in lead I; positive in aVF).
  • Chamber Enlargement - The P wave is tall, peaked, and looks "uncomfortable to sit on" in lead II = RAA.  There is a deep negative component to the P wave in lead V1 = LAA. There is obvious voltage for LVH (the S in V2 plus the R in V5>>35).  We also suspect RVH (because of the presence of otherwise unexplained RAD in this patient who has multiple chamber enlargement).
  • Q-R-S-T Changes - are clearly consistent with LV "strain", especially in leads V5, V6 (asymmetric ST-T depression).  The fact that T wave inversion is so diffuse, tends toward being symmetric in leads I, aVL, V3 and V4 with ST coving and J-point depression in V5,V6 - suggests that ischemia may also be present.
CLINICAL IMPRESSION: We would interpret this ECG as showing sinus rhythm with RAD, LAA, RAA, probable RVH, and LVH with "strain" and/or ischemia (which is our way of acknowledging that strain and ischemia may coexist, and ST-T wave changes of one of these may mask the other . . . )Clinically - We strongly suspect a dilated cardiomyopathy given the multi-chamber enlargement.
Note - Many use the terms LAA and LAE/RAA and RAE interchangeably.  We prefer LAA and RAA (left and right atrial Abnormality) in recognition of the fact that an abnormal-looking P wave will not always mean true atrial chamber "Enlargement".
  • For more information on LVH - Check out ECG Blog #73 - 


  1. hello...
    There is ST depression in inferior leads. Is it due to LVH? If yes than any reason why it(the strain pattern) manifests in inferior leads? I ask this question as standard textbooks talk of Strain pattern of LVH in lateral and high lateral leads.
    thank you

  2. Good question. As I state above — ST-T wave changes in the inferior leads may be due to "strain AND/OR ischemia" — albeit there is NO way to know for certain from a single ECG. Availability of prior tracings and serial tracings + close follow-up would be needed to answer this question. The reason we may see LV "strain" in the inferior leads can be explained by the rightward axis. Occasionally, LV "strain" may even be seen in inferior leads with a normal axis — but it is not at all uncommon with an inferior or rightward axis (since LV forces in such cases are directed more toward the inferior leads) — :)