• Cor Pulmonale
• Chronic Obstructive Pulmonary Disease
• ECG and COPD
• Right Axis Deviation
• Clockwise Heart Rotation
• Right Heart Strain
• Multifocal Atrial Tachycardia

Cor Pulmonale

• Cor pulmonale is "pulmonary heart disease"
• It is defined as remodeling of the right heart due to primary lung disease
• The heart is hemodynamically overloaded due to pulmonary hypertension
• Hypertrophy, or dilation of the right ventricle occurs
• Sometimes P pulmonale (right atrial hypertrophy) also develops
  
  
• Chronic Cor Pulmonale
• It is a chronic hemodynamic overload of the right heart
• Right ventricular hypertrophy develops
• Most common causes:
• Chronic Obstructive Pulmonary Disease (COPD)
• Recurrent small pulmonary embolism
  
  
• Acute Cor Pulmonale
• It is an acute hemodynamic overload of the right heart
• Dilation of the right ventricle occurs
• Most common causes:
• Massive pulmonary embolism
• Acute Respiratory Distress Syndrome (ARDS)
• Acute exacerbation of COPD
• Pneumothorax

ECG and COPD

• In advanced COPD and emphysema, ECG changes occur:
• Right axis deviation
• High R wave in lead III
• Due to the low diaphragm position, the heart apex shifts downward and to the right
• Rightward deviation of the P wave
  • Dominant P waves in the lower leads (II, III, aVF) and flat or negative P waves (I, aVL)
  • Due to the low diaphragm position, the heart apex shifts downward and to the right
• Right bundle branch block (RBBB)
• Occurs with right heart overload
• Saddle-shaped PQ depressions and ST segment depressions
• Due to overload and ischemia of the right heart
• Low QRS voltage
  • Emphysema is an electrical insulator, mainly in (V4-V6)
• Transition zone (V5, V6)
• The heart rotates clockwise
• Right ventricle moves forward, and left ventricle moves backward
• SV1 SV2 SV3
• Complete absence of R waves in V1-V3
• Because the heart is rotated clockwise
• Sometimes reduced R wave progression (tiny R wave in V1-V3)
  
  
• If cor pulmonale develops, additional ECG changes occur:
• P pulmonale
• Right ventricular hypertrophy
  
  
• Arrhythmias in COPD
• Multifocal atrial tachycardia (most common arrhythmia in COPD)
• Atrial fibrillation
• Atrial flutter

Clockwise Heart Rotation

Clockwise Heart Rotation

• The main cardiac vector rotates toward the left ventricle
• Clockwise
• Transition zone is in V5-V6
• Sometimes considered a normal variant:
• Delayed transition zone in V5 (Delayed/Late transition zone)

• Most common causes:
• Left ventricular hypertrophy
• Emphysema
• Pulmonary embolism (right ventricular dilation)

Multifocal Atrial Tachycardia

Multifocal Atrial Tachycardia

• At least 3 different P waves
• Heart rate > 100/min.
• Multifocal atrial tachycardia is the most common supraventricular arrhythmia in COPD

Chronic Obstructive Pulmonary Disease

• Right Axis Deviation (90°)
• P Pulmonale
• Clockwise Rotation of the Heart
• Transition Zone in V6
• SV1 SV2 SV3
• Absence of R wave (V1-V3)
• Reduced QRS Voltage in left-sided leads (I, aVL, V5-6)
• Sinus Tachycardia