75-year old smoker presenting with acute dyspnoea and productive cough. Describe the ECG.

TOP 100 ECG QUIZ LITFL 021

Describe and interpret this ECG

ECG ANSWER and INTERPRETATION

This ECG demonstrates many of the features of chronic pulmonary disease:

  • Rightward QRS axis (+90 degrees)
  • Peaked P waves in the inferior leads > 2.5 mm (P pulmonale)
  • Rightward P-wave axis (inverted in aVL)
  • “Clockwise rotation” of the heart with a delayed R/S transition point (transitional lead = V5)
  • Absent R waves in the right precordial leads (SV1-SV2-SV3 pattern)
  • Low voltages in the left-sided leads (I, aVL, V5-6)

Tachycardia may be due to dyspnoea, hypoxia or beta-agonist treatment. This ECG pattern is a common finding in patients with COPD. The inferior axis (+90 degrees) is due to hyperinflation of the lungs causing vertical orientation of the heart.

CXR COPD Vertical Heart 800

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Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

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