Broad P wave, peaked P wave, double humb p wave

Thanks for your answer, but I disagee. Broad P wave is the hallmark of interatrial block, and peaked Pwave resembles right atrial enlargement

Dear Dr. Marano, how about a pronounced notch in the  late portion of the P wave with a peak-to-peak interval of >0.04 s? Amit

Reference:

Edhouse J, Thakur RK, Khalil JM. ABC of clinical electrocardiography. Conditions affecting the left side of the heart. BMJ. 2002;324 (7348): 1264-7. doi:10.1136/bmj.324.7348.1264

http://www.bmj.com/content/324/7348/1264.1

Hi Amit

It sounds better !  It is enough ?

Thanks for sharing the link to bmj

marco

Hi Marco,

Ok, thanks. I am not sure if it's enough, but it certainly helps to make a diagnosis. Looking forward to hear from other experts!

Amit

Hello Marco,

I'm not an expert, i read in one of our lessons that a sign for left atrial enlargement is a longer P-wave (Dog/cat: >0,04s, large dogs: >0,05s) also a sign is if the P wave is notched.

Source: ECG in dogs and cats, Károly Vörös, Department and Clinic Internal Medicine, Faculty of Veterinary Science, Szent István University, István u. 2., 1078 Budapest, Hungary;

Maybe a prominent negative wave in V1?

Dear Marco

See below an explanation David Chung. It seems quite valid to me. 

ECG – A Pictorial Primer

Author:

David C Chung MD, FRCPC

Right and Left Atrial Abnormalities

(NB:“Atrial abnormality” is a term being used increasingly in place of “atrial enlargement”, “atrial dilatation” or “atrial hypertrophy”.)

Look for signs of atrial abnormalities in leads in which the P wave is most prominent: usually lead II, but also leads III, aVF, and V1.

In sinus rhythm the right atrial depolarization wave (brown) precedes that of the left atrium (blue) and the combined depolarization waves, the P wave, is less than 120 ms wide and less than 2.5 mm high.

In right atrial abnormality, right atrial depolarization lasts longer than normal and its wave extends to the end of left atrial depolarization. Although the amplitude of the right atrial depolarization current remains unchanged, its peak now falls on top of that of the left atrial depolarization wave. As a result, the combined waves of right and left atrial depolarization, the P wave, is taller than normal (taller than 2.5 mm) but its width remains within 120 ms.

In left atrial abnormality left atrial depolarization lasts longer than normal but its amplitude remains unchanged. Therefore, the height of the resultant P wave remains within normal limits but its duration is longer than120 ms. A notch (broken line) near its peak may or may not be present.

A biphasic P wave in V1 is another sign suggesting atrial abnormality. In right atrial abnormality, the initial positive portion of the biphasic P wave is larger than the terminal negative portion.

A biphasic P wave in V1, with its terminal negative deflection more than 40 ms wide and more than 1 mm deep is another ECG sign of left atrial abnormality

Dear Ugo and Christa

Many thanks for your contributions. At the time the best candidate is just the terminal negative deflection of P-wave in V1 (>40 ms, >1 mm). However I want to be sure that this sign doesn't occur during interatrial block.  An experienced cardiologist told me that he has observed some cases where this happens (deep terminal force in V1 AND interatrial block). My opinion is that only Bachmann's bundle block (ie advanced interatrial block) is accompanied by the accentuation of the P terminal force

Prominent negative terminal deflection of the biphasic P wave in lead V1, Slurred (prolonged duration of) a bifid P wave in any lead are important features.

Hi, Dr. Marano

Do you have any paper about interatrial block with Baranchuk about interatrial block? 

I offer in spanish these signals in ECG of  LAE

Autores:

Antonio Bayés de Luna, Andrés R. Pérez-Riera, Adrian Baranchuk, Diego Conde

CURSO SOLAECE/SIAC/2014

Sobrecarga de la aurícula izquierda (SAI): criterios electrocardiográficos

I) Criterios directos

1) Onda P de duración aumentada: ≥110 ms en adultos, ≥120 ms en ancianos y 90 ms en niños. Especificidad: 90% y

sensibilidad: 40% a una edad avanzada.

2) Onda P con muesca y bífida en II, con intervalo entre los ápices ≥40 ms. Voltaje del 2° módulo > que el 1°. Una onda P

bífida es un hallazgo raro con el diámetro de la AI ≥60 mm. La fibrilación auricular está presente en el 70% de los casos.

3) SÂP (eje de P en el plano frontal) desviado hacia la izquierda: entre +40° y -30°;

4) Aumento en la profundidad y la duración del componente negativo final de la onda en V1 (sobrecarga de la AI, índice de

Morris (Morris 1964)); lento y profundo de P en V1 o V1-V2. FTPV1. Fuerza terminal de P en la derivación V1 igual o

más negativa que 0,04 mm/s. Mayor a 0,03 mm/s: producto de la duración del componente negativo final (duración

expresada en segundos); mientras que la profundidad se exrpesa en mm. Valores sobre 0,03 mm por segundo constituyen

un criterio muy sensible para el diagnóstico de SAI.

5) Índice de Macruz (Macruz 1958) > 1,7: Duración de P / Duración de PRs;

6) Deflexión intrínseca de V1 de 30 ms (0,03 s) o mayor. Esta deflexión se mide desde el ápice del componente positivo

inicial hasta el nadir del componente negativo final de la onda P de V1.

7) Fuerza terminal de P (FTP-V1) de más de 0,04 mm/s. Ésta es la parte negativa y terminal de la onda P en la derivación

V1 expresada como la multiplicación de su profundidad en milímetros y la amplitud en segundos (mm/s). La FTP-V1 no

supera una amplitud de 0,04 s y profundidad de 1 mm; es decir 0.04 mm/s.

II) Criterio indirecto

La presencia de fibrilación auricular gruesa: ondas “f” con amplitud igual o mayor a 1 mm en V1 o V1 - V2: en el 75% de los

casos de FA gruesa hay SAI coexistiendo. Hay una relación significativa entre la magnitud de la onda f y la etiología de la

FA. Así, el 88% de los pacientes con FA gruesa presentan cardiopátia valvular como causa subyacente y el 88% de los

pacientes con FA fina presentan coronariopatía.

Now, with this reinforcing estlabishment of the concept  of Bayés Syndrome(Interatrial Block, partial or advanced) by Adrian Baranchuk and his group differentiation ecg criterias to LAE are very difficulty.

Warms regards

Dear Adail,

many thanks for your contribution. Yes, I have more than one paper with Adrian Baranchuk on Interatrial Block (IAB). This is the problem !!

I am finding a lot of IAB, also some Bayes Syndrome, but I am unable to find the  LAE !!

Also P terminal force, the latest sign that has remained for LAE, would seem also related to other conditions (as an example to atrial and ventricular fibrosis !) so this is NOT specific for LAE.

Great trouble !! 

As mentioned in Marriott's book (Clinical Electrocardiography), because the atria are depolarized by contiguous depolarization - like ripples on a pond - (rather than through a highly specialized conduction system, as in the ventricles), ECG abnormalities indicating LA abnormality (i.e. P pulmonale, and/or predominantly negative P deflection in V1) are very non-specific as to cause.

These changes merely show the fact of an abnormality, but cannot distinguish between the causes (ischaemia, infarction, infiltration, enlargement, hypertrophy, etc).

Left atrial enlargement [5]

ECG criteria

 1. P wave duration > 0.12s in frontal plane (usually lead II)                                            

                                                                                   sensitivity 33%; specificity 88%

2. Notched P wave in limb leads with the inter-peak duration > 0.04s                                     

                                                                                 sensitivity 15%; specificity 100%

3. Terminal P negativity in lead V1 (i.e. "P-terminal force") duration >0.04s     

                                                                               sensitivity 83%; specificity 80%

Hi Richard,

many thanks