Figure lii

In right atrial hypertrophy the (initial) right atilal component ci the P wave is
increased in magnitude and In duration. The resultant effect on the P wave is an
increase In the P wave height but not In its duration. a) The resultant P wave In Lead
Ills abnormally tall and Is pointed. b) The resultant P wave in Lead V1 has an
abnormally tall (Initial) positive component.
Normal P wave In ii right and left atrial components.
The P wave In II in right atrial hypertrophy right and left atrial components. The
right atrial cOmponent is increased.
The P wave in II in right atrial hypertrophy is abnormally tall.
Normal P wave in V1 right and left atrial components.
The P wave in V1 in right atrial hypertrophy right and left atrial components. The
right abial component is increased,
The P wave in V1 in right atrial hypertrophy has a tall initial positive component.

The primary electrocardiographic change in Fight atdal hypertrophy is therefore an

Increase In the voltage of the P wave in Lead II and an increase in the voltage of the
initial positive part of the P wave In V1. There Is a good deal of variation in the
omlnant dIretion of right atrial depolarisatlon In the horizontal plane and as a
result of this changes In the P wave height in V1 do not reliably Occur in right atrial
hypertrophy. The diagnosis of -right atrial hypertrophy can therefore only safely be
made from the P waves in the frontal plane leads. Lead II usually shows the changes
best An example Is shown In FIgure 112. The ECO in Figure 112 would be reported
as tollows:Sinus rhythm. The mean frontal plane QRS axis Is +165. There Is right
ventricular hypertrophy, right atrial hypertrophy and clockwise cardiac rotation.
Figure 112 ThereI an degree of right axis deviation (+165) and a dominant A wave in V1.
Them Is thus right ventricular hypertropl. The P waves are tall and pointed in l..ead
It and are In excess of 3mm. There Is thus right atrie.I hypertrophy. Right atriai
hypertrophy very frequently accompanies right ventriculer hypertrophy. The
pronounced clockwise cardiac rotation is part of the light ventrIcular hypertrophy.

Criterion for right atrial hypertrophy

The P wave height Is 3mm or more in Leads ii, III or aVF (Leads III and aVF are
Included because the P wave vector is sometimes directed more closely towards
either of these leads than along Lead II, i.e. the P wave axis is often +75 or more
positive than this).
Associated findIngs
in association with right atrial hypertrophy, the positive part of the P wave in V1 is
often greater than 1.5mm tail. There is usually evidence of right ventricular
hypertrophy. There is often also a prominent atrial repolarisation wave (see pages
166 and 167).
Clinical SIgnificance
As indicated earlier, the electrocardiographic finding of right atrial hypertrophy
strictly speaking only defines the presence of right atrial abnormality. Changes
similar to those in hypertrophy also occur in ischaemla or infarction of the right
atrium although the latter two are rare clinical events. The presence of associated
right ventricular hypertrophy makes it much more likely that the right atriai
hypertrophy pattern on the electrocardiogram does indicate true hypertrophy of the
right atrium. Right atrial hypertrophy occurs in all conditions which give rise to right
ventricular hypertrophy and ih addition it occurs in tricuspid stenosis.
Left Atrlat Hypertrophy
The electrocardiographic changes produced by left atriai hypertrophy are those
changes produced by an increase In the voltage- and duration of the left atrial
depolarisation wave. Since the terminal part of the normal P wave is produced by
left atrial depolarlsation, It follows that the total P wave duration is prolonged in left
atrial hypertrophy.
In addition, the P wave tends to be bifid in Lead ii and biphasic in V1 (Figure 113). In
V1 the area of the (terminal) negative component exceeds the area of the (initial)
positive component. An example of left atrial hypertrophy is shown in Figure 114.

In left atrial hypertrophy the left atrial (terminal) component 04 the P wave is
increased in magnitude and in duration. The resultaz* effect on the P wave is to
frtaease the size of the terminal portion and also to increase the total
Pwaveduration.
a) The resaita,tPwave in Lead II is broadened (more than 0.12 see) and Mid with a
lal second component. b) The resultant P wave in Lead V1 is broadened and
biphaslc. The area of the (terminal) negative component is larger than the area of
the (initial) positive component.
NormaiP wave in II right and left atriaf components.
The Pwavein II in left atrial hypertrophy right and left atrial components. The left
atrial component is increased.
The Pwave in II in left atrial hypertrophy is notched and broad. The second
component may be tall.
Normal P wave nV1 right and left atrial components.
The P wave in V1 In left atrial hypertrophy right and left atriaf components. The
left atrial component is increased,
The P wave in Lead V1 in left atrial hypertrophy has a dominant negative (terminal)
component.

The ECGJn Figure 114 would be reported as follows: Sinus rhythm. The mean
frontal plane QRS axis is +750. Th P waves are broad and bit Id in Lead Iland there
Is a dominant negative mponent to the P wave in V,. The changes are Indicative of
left atrial hypertrophy (strictlyleft atrial abnormality). In other respects the record
is within normal limits.
Figure 114
The rflythm is sinus. P waves are bifid in Lead II. The P wave duration in Lead II is
prolonged at 0.15 sec (best seen in the second Twave in Lead II). The P waves nV1
are clearly biphasic. In this lead there isa small, brief (and rather sharp looking)
initial positive component lollowed by a deeper and very much broader negative
component. The area of the negative component clearly exceeds that of the positive
component.

Criteria for left atrial hypertrophy

1. The P wave is notched and exceeds 0.12 sec in duration in Leads, Ii, aVF or aVL.
2. The P wave In V1 has a dominant negative component (I.e. either It is entirely
negative or alternatively the area of the (terminal) negative component exceeds
that of the (initial) positive component).
(Either criterion suggests the diagnosis. If both are satisfied the diagnosis ismore
likely still).
Features commonly associated with left atrial hypertrophy
Just as right atrial hypertrophy is frequently found in association with right
ventricular hypertrophy, so left atrial hypertrophy Is frequently found in association
with left ventricular hyperirophy. in patients with pure mitral stenosis, left atrial
hypertrophy may occur in association with right ventricular hypertrophy.
Clinical Significance
Left atrial hypertrophy occurs in any condition associated with eli ventricular
hypertrophy and it also occurs in mitral stenosis.ltisfrequentiyfound in association
with systemic hypertension even when there Is no electrocardiographic evidence of
left ventricular hypertrophy in that condition. It may also be found in association
with aoilic stenosis, aortic incompetence. mitral incompetence, hypertrophic
cardiomyopathy and chronic ischaemic heart disease.
As discussed earlier (under the heading of right atrial hypertrophy) the term atrial
hypertrophy is less justifiable than atrial abnormahty. The primary
electrocardiographic interpretation of the presence of broad bilid P waves in Lead Il
or a dominant negative component to the P wave in V is that there is some
abnormality of the left atrium. If it is known that there is mitral stenosis or left
ventricular hypertrophy then true left atrial hypertrophy might well be inferred
(secondary interpretation). The electrocardiogram itself merely provides evidence
of abnormality of the left atrium and cannot distinguish between atriai hypertrophy,
atriat ischaemia and atrial infarction, When electrocardiographic evidence of left
atrial hypertrophy is found in a person with ischae,mic head disease it is likely that
the common explanation is ischaemia or infarction of the atrium.
Bi-atrial Kypertrophy

The diagnosis of bi-atrial hypertrophy is not as difficult as the diagnosis of

bkventricuar hypertrophy since the hypertrophy of each individual atrium affects
predominantly a different part of the P wave whereas hypertrophy of each individual
ventricle affects the same part of the ORS complex. Bi-atrial hypertrophy may
therefore be diagnosed whenever the criteria for both left and right atrial
hypertrophy are fulfilled.
Clinical Significance
Bi-atrial enlargement is found in conditions giving rise to bi-ventricular enlargement.
This includes congenital heart disease, hypertrophic cardiomyopathy and pulmonary
hypertension occurring either with aortic
valve disease or with mitral incompetence. The reservations expressed about the
use of the term atriai hypertrophy with reference to hypertrophy of individual atria
apply equally well with reference to hypertrophy of both atria.
Diagnostic criteria for bi-atrial hypertrophy
1. P waves in the limb leads which are both 3mm or greater in height, and also in
excess of 0.12 sec in duration.
2. The presence of a large biphasic P wave in V1 with an (initial) upright portion of
2mm or more in height, and a (terminal) negative portion at least 1mm deep and
0.04 sec in duration.
3. The presence of a tail peaked P wave 2mm or more in height In V1 in combination
with wide (i.e. more than 0.12 sec in duration) notched P waves in the limb leads or
In the left precordial leads.
(Any one criterion suggests the diagnosis. The more criteria are fulfilled the more
likely the diagnosis becomes).

Atrial Repolarisatlon Wave

It was pointed out (page 5) that electrical recovery of myocardium must occur
following depolarisation of that myocardium before any subsequent repeat
depolarisation Is possible. In the case of the ventricular myocardium. depolarisation
and repolaPlsation are both recognisable from the surface electrocardiogram. The
ORS complex Is, In fact, the surface electrocardIographIc manifestation of
ventricular myocardial depolarlsatlon and the T wave Is the surface
electrocardIographIc manifestation of ventricular myocardlal repolarisation
(thdughit should be noted that ventricular myocardial repoladsatlon is actually
taking place during the S-T segment and, In some Darts of the heart, even before
the QAS complex is completed). The P wave lathe surface electrocardiographIc
manifestation of atrial myocardlai depolarisatlon. The process of repolarisatlon of
the atrial myocardlum does not give rise to a recognisab!e wave on the surface
electrocardiogram (i.e. it has no surface electrocardiographic manifestation) even
though repolarisation must necessarily occur beforeany subsequetd, repeat
depolarisation of the atriai myocardium is possible. The atrial repolarisation wave is
called the atrial T wave or Ta wave. It is normally a shallow, smooth negative
wave which, since ft occurs at the same time as the much larger ORS complex, is
normailytotally obscured by the latter. It becomes apparent on the surface
electrocardIogram only when it is increased in size. When the Ta wave becomes
prominent it increases both in depth and in duration (Figure 115). it may then be
apparent as a dip in the trace, seen both before and after the QRS complex. It is
easily confused with a depressed S-T segment but recognition that the depression
starts before the ORS complex should prevent this misunderstanding. Its
appearance may be Ukened to a QRS complex standing slightly left of centre in a
shallow saucer.
Atrial depolarisatior, is shown in red (P wave).
(Ta wave)
Atrial repolarisation is shown in blue
The normal atrial electrocardiogram

A prominent Ta wave
Prominent Ta wave which is, as usual, partly obscured by the QRS complex. At first
sight there is S-T segment depression. 1ore careful inspection reveals that the
depression begins before the QRS complex. It therefore cannot be S-T depression. It
is a prominent Ta wave,

Causes of Prominent Atrial Repolarisatlon Waves

By far the commonest cause of an exaggerated Ta wave is sinus achycardia. An
example is sbswn in Figure 116. The EGG of Figure 116 would be reported as
follows:Sinus tachycardiai. Rate 1 65/mm. Prominent atrial repolarisatlon wave
simulating S-T-depression in some leads. Allowing for the heart rate, the record is
within normal limits.
Prominent Ta waves may also occur in right atrial hypertrophy. Gloss inspection of
Figure 112 shows a prominent Ta wave well seen in Leads II and aVF. Prominent Ta
waves also occur in atrial Infarction (see page 199).
Rarely. a normal Ta wave can be seen in cases of complete heart block when the
ORS complex does not obscure the wave.
Figure 116
A 1 2-lead electrocardiogram taken Just after the completion of an exercise test. The
rhythm Is sinus tachycardla and the heart rate is 1 65/mm. There Is apparent S-T
depression in I, II, aVF and V4-V6, but closer Inspection (especially in II where the T
and Ta vectors are usually best seen) reveals that the negativity begins before the
ORS complexes. It is a prominent Ta wave. There is no significant S-T abnormality
and the exercise test Is negative.