COPD

  Characterized by progressive, largely irreversible airflow obstruction,

      usually with clinical onset in middle-aged or elderly persons with a history of cigarette smoking,

      and which cannot be attributed to another specific disease, such as bronchiectasis or asthma.

  In the past, COPD included
chronic bronchitis and emphysema. However, COPD is preferred now, since

      most COPD patients have evidence of both emphysema (air space destruction) and chronic bronchitis.




Why do ECG abnormalities develope in COPD?

  Decreased conductivity of the hyperinflated lungs.

  Increased anteroposterior chest diameter (increased distance of the chest electrodes to the heart).

  Downward displacement of the diaphragm.

  High placement of the precordial leads relative to the downwardly displaced heart.

  Right ventricular hypertrophy / dilation in response to pulmonary hypertension.

  Vertical heart due to downward displacement of the diaphragm and heart.




ECG abnormalities in COPD

  Low voltage is seen due to

      - decreased conductivity of the hyperinflated lungs.

      - hyperinflated lungs increasing the distance of the heart from the chest electrodes.

 
P wave axis > +60 degrees (P wave verticalization).

      - P wave axis at +90 degrees will result in a
flat P wave in lead I (Lead I sign).

      - P wave verticalization shows negative correlation with the degree of obstructive lung function.

      - A pericardial ligament around the inferior vena cava attaches the right atrium to the diaphragm.

        It has been suggested that downward displacement and progressive flattening of the diaphragm

        will displace the right atrium inferiorly and result in P wave verticalization.

     
P wave verticalization is the best ECG criteria for screening of COPD.

 
Vertical and rightward axis of the QRS complex is seen due to

      - downward displacement of the diaphragm resulting in vertical heart.

 
Narrowing of the QRS complex (exact mechanism unknown)

      - left ventricular disuse atrophy (?).

      - low voltage with emphysema with partial loss of the initial and terminal QRS,

        which becomes indistinguishable from the baseline (?).

 
Poor R wave progression in the chest leads is seen due to

      - downward displacement of diaphragm resulting in vertical heart position.

      - high placement of the precordial leads relative to the downwardly displaced heart.

 
Atrial arrhythmias (multifocal atrial tachycardia, APCs, etc) may be seen

      - especially during decompensation periods of the COPD.

 
QS in right precordial leads (V1 to V3).

 
The Ta wave may be exaggerated if the P wave is tall. This will be especially evident in lead II.



Effect of P wave axis on mortality

  Abnormal P wave axis has been reported to be related to mortality.

  A long-term follow-up (median 13.8 years) of 7,501 individuals from the NHANES III survey has shown that

     
abnormal P wave axis was associated with:

            -
55% increase in all-cause mortality

            -
41% increase in cardiovascular mortality

      (P wave axis between 0 and +75 degrees was accepted as normal).

  This association of P wave axis and mortality was observed even in patients without COPD.




References

  Am J Cardiol 2014;113:372-376.

  Comprehensive Electrocardiology. Peter W. Macfarlane. 2nd ed. Springer-Verlag London 2011.

  Circulation 1959;20:831-841.

  Can J Cardiol 2010;26:e136..

  Indian Heart J 2012;64:40-42.

  J Electrocardiol 2012;45:136-140.

  Am J Cardiol 2012;109:1046-1049.

  Am J Cardiol 2011;107:1090-1092.

  J Electrocardiol 1974;7:35-36.

  Chest 1995;107:697-700.

  Pacing Clin Electrophysiol 2007;30:448-452.

  Spodick DH. Pericardial macro- and microanatomy.

      In: Spodick DH, ed. The Pericardium: A Comprehensive Textbook. New York:Marcel Dekker;1997:7-14.

  Chronic Obstructive Pulmonary Disease. Dennis E. Niewoehner

      In: Goldman's Cecil Medicine. 24th ed. 2012 Elsevier. p537.





ECG 1. The ECG above is from a 58 years-old man with a recent diagnosis of COPD.
ECHOcardiogram showed neither right atrial nor right ventricular dilatation.
P wave axis is +80 degrees (P wave verticalization). The P wave is negative in lead aVL.
Low voltage and incomplete right bundle branch block are also seen.


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ECG 2. The compact ECG above belongs to a 66 years-old woman with COPD.
ECHOcardiogram showed neither right atrial nor right ventricular dilatation. Left ventricular systolic function was normal.
P wave axis is +68 degrees. The P wave is negative in lead aVL. (P wave verticalization).
Exaggerated Ta wave is seen in lead II.






ECG 3. The ECG above belongs to a 79 years-old man with COPD, chronic systemic arterial hypertension and
abdominal aortic aneurysm. P wave axis is +90 degrees (P wave verticalization). The P wave is flat in Lead I (Lead I sign).
The P wave is also negative in lead aVL (P wave verticalization). Two atrial premature contractions (APCs) are also seen.


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ECG 4. The ECG above is from a 82 years-old man with COPD.
The rhythm is multifocal atrial tachycardia (MAT) but seems like atrial fibrillation at first glance.
However, one P wave per RR interval confirms the absence of atrial fibrillation.


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ECG 5. The ECG above is from an old man with COPD.
P wave verticalization with negative P waves in lead aVL is seen.
The rhythm is multifocal atrial tachycardia (P waves with at least 3 different shapes in precordial leads).


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ECG 6. The ECG above is from a 65 years-old man with COPD and coronary artery disease.
He had undergone coronary artery bypass graft operation 8 months ago. He also has chronic systemic arterial hypertension.
P wave axis is between +80 and +90 degrees with negative P waves in lead aVL (P wave verticalization).
Right bundle branch block and left posterior fascicular block are also seen. The QRS axis is about +160 degrees.
The 4th beat from the right end is an APC.


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ECG 7. The above ECG is from a 74 years-old man with COPD.
ECHOcardiogram showed right atrial and right ventricular dilatation.
P wave verticalization with negative P waves in lead aVL is seen.
Incomplete right bundle branch block is also seen.


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ECG 8. The above ECG is from a patient with COPD and multifocal atrial tachycardia.
P wave verticalization with negative P waves in lead aVL is seen.


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ECG 9. The above ECG is from a 51 years-old man with COPD.
ECHOcardiography showed neither right atrial nor right ventricular dilatation.
The P wave in lead I is almost flat.
Lead aVL shows negative P wave (P wave verticalization).
Atrial premature contractions are not rare in patients with COPD.
The ECG also shows low voltage in limb leads.


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ECG 10. The ECG above is from a 48 years-old man with COPD.
Coronary angiography revealed coronary artery ectasia with significant coronary slow flow.
Leads V1 and V2 show QS complexes which are not related to coronary artery disease in this patient.
Precordial leads show narrow QRS complexes (the widest being 90 milliseconds).
P wave axis is about +82 degrees. Lead I barely shows a P wave.
Lead aVL shows negative P wave (P wave verticalization).
Right atrial abnormality is also seen.
Limb leads show low voltage.
The above ECG is typical for a COPD patient.


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ECG 11. The ECG above is from an old man with COPD.
P wave verticalization and low voltage in limb leads are seen.


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ECG 12. The above ECG is from a 85 years-old woman with COPD, left ventricular systolic dysfunction,
and mild pericardial effusion. She has never undergone diagnostic coronary angiography.
The rhythm is atrial fibrillation.
ECHOcardiography showed dilation of all cardiac chambers and segmentary left ventricular wall motion abnormality.
The ECG also shows low voltage in almost all leads.

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