EKG of the Week

A 57 y/o female with long history of COPD, continues to smoke. Her son states she has been more “loopy” for a few days. He describes that the doorbell rang and she went to answer the closet door instead of the front door.

Q1. What does the EKG demonstrate?

A1. P Pulmonale (The patient's pCO2 was 110)

Right-atrial enlargement (RAE) produces an abnormally prominent initial part of the P wave. The smooth, rounded contour of the P wave is changed by RAE, which gives the wave a peaked appearance. In leads such as II, the P waves of RAE have an A-like appearance (termed P pulmonale). RAE increases the maximal amplitude of the P wave to >0.20 mV in leads II and aVF.

(Wagner, Chamber Enlargement. In Marriott's Practical Electrocardiography, Ch. 4)

The classic descriptions of P pulmonale (peaked P waves in leads II, III, and aVF), low QRS voltage, clockwise rotation, and poor R wave progression in the precordial leads are interesting correlates of COPD but are both insensitive and nonspecific. The presence of electrocardiogram (ECG) criteria for RVH suggests established cor pulmonale. These findings, however, can be easily obscured on the ECG by other processes, and the absence of criteria for RVH cannot be relied on to rule out cor pulmonale.

(Swadron, Chronic Obstructive Pulmonary Disease. In Rosen’s Emergency Medicine, 8th ed. Ch. 74)