ECG in Chronic Obstructive Pulmonary Disease

Common ECG findings in COPD

ECG changes occur in Chronic Obstructive Pulmonary Disease (COPD) due to:

  • The presence of hyperexpanded emphysematous lungs within the chest
  • The long-term effects of hypoxic pulmonary vasoconstriction upon the right side of the heart, causing pulmonary hypertension and subsequent right atrial and right ventricular hypertrophy (i.e. cor pulmonale)

Effects of Emphysema on the Heart
  • Lung hyperexpansion causes external compression of the heart and lowering of the diaphragm, with consequent elongation and vertical orientation of the heart
  • Due to its fixed attachments to the great vessels, the heart undergoes clockwise rotation in the transverse plane, with movement of the right ventricle anteriorly and displacement of the left ventricle posteriorly
  • The presence of increased air between the heart and recording electrodes has a dampening effect, leading to reduced amplitude of the QRS complexes
CXR COPD Vertical Heart 800
Lung hyperexpansion and vertical orientation of the heart

Effects on the pulmonary vasculature
  • Chronic hypoxaemia causes reflex vasoconstriction in the pulmonary arterioles (“hypoxic pulmonary vasoconstriction”), with consequent elevation of pulmonary arterial pressures
  • Destruction of lung tissue with loss of pulmonary capillaries increases the resistance of the pulmonary vascular bed by reducing its effective surface area
  • Over time, this chronic elevation of pulmonary arterial pressures results in compensatory right atrial and right ventricular hypertrophy

Typical ECG Findings in COPD
1. The most typical ECG findings in emphysema are:
  • Rightward shift of the P wave axis with prominent P waves in the inferior leads and flattened or inverted P waves in leads I and aVL
  • Rightward shift of the QRS axis towards +90 degrees (vertical axis) or beyond (right axis deviation)
  • Exaggerated atrial depolarisation causing PR and ST segments that “sag” below the TP baseline
  • Low voltage QRS complexes, especially in the left precordial leads (V4-6)
  • Clockwise rotation of the heart with delayed R/S transition point in the precordial leads +/- persistent S wave in V6. There may be complete absence of R waves in leads V1-3 (the “SV1-SV2-SV3” pattern)
Sagging of the PR and ST segments below the TP baseline

Clockwise rotation of heart and R wave progression changes

2. With development of cor pulmonale, the following additional changes are seen:

3. Other ECG changes that may be seen include:
Multifocal Atrial Tachycardia (MAT)
Mutlifocal atrial tachycardia

Rapid, irregular, narrow-complex rhythm with at least three distinct P-wave morphologies (arrows)

ECG Examples
Example 1
Pulmonary disease pattern COPD ECG

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) with a 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)

Sinus tachycardia may be due to breathlessness, hypoxia or bronchodilator therapy.

Example 2
Pulmonary disease pattern COPD ECG 2

Another good example of the pulmonary disease pattern:

  • Rightward axis (+ 90 degrees)
  • Peaked P waves
  • Low QRS voltages (most obvious in the limb leads)
  • Clockwise rotation (transitional lead = V6)
  • Virtually absent R waves in the right precordial leads (SV1-SV2-SV3 pattern)

Example 3

This ECG shows multifocal atrial tachycardia with additional features of COPD:

  • Rapid, irregular rhythm with multiple P-wave morphologies (best seen in the rhythm strip)
  • Right axis deviation, dominant R wave in V1 and deep S wave in V6 suggest right ventricular hypertrophy due to cor pulmonale


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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

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