The P wave – atrial depolarization
Smooth contour
Monophasic in lead II
Biphasic in V1
P waves should be upright in leads I and II, inverted in aVR
Duration - < 120 ms
Amplitude ( < 2.5 mm in the limb leads, < 1.5 mm in the precordial leads)
Atrial abnormalities are most easily seen in the inferior leads (II, III and aVF) and lead V1, as the P waves
are most prominent in these leads.
P mitrale (bifid P waves), seen with left atrial enlargement.
P pulmonale (peaked P waves), seen with right atrial enlargement.
P wave inversion, seen with ectopic atrial and junctional rhythms.
Variable P wave morphology, seen in multifocal atrial rhythms.
The presence of broad, notched (bifid) P waves in lead II is a sign of left atrial enlargement, classically
due to mitral stenosis.
The presence of tall, peaked P waves in lead II is a sign of right atrial enlargement, usually due to
pulmonary hypertension (e.g. cor pulmonale from chronic respiratory disease).
P-wave inversion in the inferior leads indicates a non-sinus origin of the P waves. When the PR interval is
< 120 ms, the origin is in the AV junction (e.g. accelerated junctional rhythm)
When the PR interval is ≥ 120 ms, the origin is within the atria (e.g. ectopic atrial rhythm)
The presence of multiple P wave morphologies indicates multiple ectopic pacemakers within the atria
and/or AV junction. If ≥ 3 different P wave morphologies are seen, then multifocal atrial rhythm is
diagnosed
If ≥ 3 different P wave morphologies are seen and the rate is ≥ 100, then multifocal atrial tachycardia
(MAT) is diagnosed
Q Wave - any negative deflection that precedes an R wave
Normal Q wave in V6
The Q wave represents the normal left-to-right depolarisation of the interventricular
septum
Small ‘septal’ Q waves are typically seen in the left-sided leads (I, aVL, V5 and V6)
Small Q waves are normal in most leads
Deeper Q waves (>2 mm) may be seen in leads III and aVR as a normal variant
Under normal circumstances, Q waves are not seen in the right-sided leads (V1-3)
Q waves are considered pathological if:
40 ms (1 mm) wide
2 mm deep
25% of depth of QRS complex
Seen in leads V1-3
Pathological Q waves usually indicate current or prior myocardial infarction.
Differential Diagnosis
Myocardial infarction
Cardiomyopathies — Hypertrophic (HOCM), infiltrative myocardial disease
Rotation of the heart — Extreme clockwise or counter-clockwise rotation
Lead placement errors — e.g. upper limb leads placed on lower limbs
Inferior Q waves (II, III, aVF) with T-wave inversion due to previous MI
The absence of small septal Q waves in leads V5-6 should be considered abnormal.
Absent Q waves in V5-6 is most commonly due to LBBB.
R wave
Dominant R wave in V1
Normal in children and young adults
Right Ventricular Hypertrophy (RVH)
Pulmonary Embolus
Persistence of infantile pattern
Left to right shunt
Right Bundle Branch Block (RBBB)
Posterior Myocardial Infarction (ST elevation in Leads V7, V8, V9)
Wolff-Parkinson-White (WPW) Type A
Incorrect lead placement (e.g. V1 and V3 reversed)
Dextrocardia
Hypertrophic cardiomyopathy
Dystrophy
Myotonic dystrophy
Duchenne Muscular dystrophy
Right Ventricular Hypertrophy (RVH)
Right Bundle Branch Block
Right Bundle Branch Block MoRRoW
Posterior AMI
WPW Type A
Dominant R wave in aVR
Poisoning with sodium-channel blocking drugs (e.g. TCAs)
Dextrocardia
Incorrect lead placement (left/right arm leads reversed)
Commonly elevated in ventricular tachycardia (VT)
This ECG shows all the classic features of dextrocardia:
Positive QRS complexes (with upright P and T waves) in aVR
Negative QRS complexes (with inverted P and T waves) in lead I
Marked right axis deviation
Absent R-wave progression in the chest leads (dominant S waves throughout)
The R wave should be small in lead V1. Throughout the precordial leads (V1-V6), the R wave
becomes larger — to the point that the R wave is larger than the S wave in lead V4. The S wave
then becomes quite small in lead V6; this is called “normal R wave progression.” When the R
wave remains small in leads V3 to V4 — that is, smaller than the S wave — the term “poor R
wave progression” is used.
The most common cause of a dominant R wave in aVR is incorrect limb lead placement, with
reversal of the left and right arm electrodes. This produces a similar pattern to dextrocardia in
the limb leads but with normal R-wave progression in the chest leads.
With LA/RA lead reversal:
Lead I becomes inverted
Leads aVR and aVL switch places
Leads II and III switch places
Poor R wave progression is described with an R wave ≤ 3 mm inV3 and is caused by:
Prior anteroseptal MI
LVH
Inaccurate lead placement
May be a normal variant
Poor R wave progression
Note that absent R wave progression is characteristically seen in dextrocardia (see previous
ECG).
