• Cor Pulmonale
• Pulmonary Embolism
• ECG and Pulmonary Embolism
• Right Axis Deviation
• Clockwise Heart Rotation

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 occurs
• 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 Pulmonary Embolism

• Pulmonary embolism creates ECG signs that result from
• Hemodynamic overload of the right heart (acute or chronic)
• There is no single specific ECG sign that confirms embolism
• Each sign has certain sensitivity and specificity
• 18% of patients with pulmonary embolism have normal ECG
  
  
• Most common ECG signs in pulmonary embolism:
• Sinus Tachycardia (44% of patients)
• Occurs due to stimulation of the sympathetic nervous system from pain, anxiety, fear
• Right Ventricular Overload (34% of patients)
• Descending ST depressions and negative T waves (V1-V4, II, III, aVF)
• Right Bundle Branch Block (18% of patients)
• Occurs due to right ventricular overload
• S1Q3T3 (20% of patients) is the "classic" sign of pulmonary embolism
• Deep S (I), Q (III), negative T (III)
• Right Axis Deviation (16% of patients)
• Often an extreme right axis deviation between 0 and -90 degrees
• Resembles left axis deviation but is an extreme right deviation
• P pulmonale (9% of patients)
• High P wave > 2.5mm in lead II
• Dominant R in V1
• Indicates acute right ventricular dilation
• Clockwise Rotation of the Heart is a characteristic sign of pulmonary overload
  • Transition Zone is in V5-V6
  • The right ventricle moves forward, while the left ventricle moves backward
• Supraventricular Tachycardia (8% of patients)
  • Atrial Fibrillation
  • Atrial Flutter
  • Focal Atrial Tachycardia
• Non-specific ST and T changes (50% of patients)
• ST elevations or ST depressions

Right Axis Deviation

Right Axis Deviation

• The vector points to the lower right quadrant
• Lead I is negative and aVF is positive
• Lead aVR is negative
• The vector is directed away from lead aVR
  (i.e., somewhere between leads III and aVF)
• R wave in III is greater than in aVF
• The vector is closer to lead III
• The vector axis is +110°

Acute Pulmonary Embolism

• Sinus rhythm (69/min.)
• P pulmonale
• P wave in lead II > 2.5 mm
• Right axis deviation (125°)
• S1Q3T3
• Dominant S in lead I, Q wave in lead III, Negative T in lead III
• Incomplete right Tawar bundle branch block
• qR (V1)
• Deep S (V6)
• Narrow QRS < 0.12s
• Negative T waves (V1, V2)

Acute Pulmonary Embolism

• Right Bundle Branch Block
• Extreme Right Axis Deviation
• Dominant R in aVR
• S1Q3T3
• Negative T waves (V1-V4, III)
• Clockwise Rotation
• Transition Zone (V5)

Acute Pulmonary Embolism

• Sinus Tachycardia (105/min.)
• Negative T waves (V1-V3, III)

Acute Pulmonary Embolism

• Sinus Tachycardia
• Right Bundle Branch Block
• Negative T waves (V1-V3, III, aVF)