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

Describe and interpret this ECG


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.

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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) Adult/Paediatric 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


  1. I note these are considered absent R waves in V1-3, but what differentiates this from being called pathological Q waves with ST elevation in leads V1-3, with reciprocal ST depression in leads II, III, aVF? Thank in advance for clarifying!

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