A 60-year-old female who has presented to the Emergency Department with breathlessness is referred to you. Her ECG is shown on page 11 (ECG 30.1).

a)    Describe the important features of this ECG.    (40% marks)

b)    List the likely differential diagnoses in this patient.    (20% marks)

ECG 30.1

cor pulmonale and RVH.jpg

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College answer

a)    Describe the important features of this ECG (40% marks)
Sinus tachycardia
Right axis deviation
Peaked P waves
Upright R in avR
R wave in V1,
poor R wave progression (RVH)
b)    List the likely differential diagnoses in this patient. (20% marks)

Massive Pulmonary Embolus

Pulmonary arterial hypertension (various aetiologies, including underlying connective tissue disorders, porto-pulmonary hypertension, primary pulmonary hypertension)

Conditions causing cor pulmonale (including COPD, Interstitial lung disease, OSA/obesity hypoventilation syndrome)


Judging by the differentials, this was an ECG demonstrating some sort of acute or chronic right heart strain. The image comes from Chapter 7 of Clinical Electrocardiography: A Simplified Approach by Goldberger et al (2017). The interpretation for this figure is:

"A tall R wave (as part of an Rs complex) with an inverted T wave caused by right ventricular overload is seen in leads V1 to V5 (also in II, III, and aVF) from a patient with right ventricular hypertrophy (RVH) that was multifactorial. Marked right axis deviation is also present because the R wave in lead III is much taller than the R wave in lead II. In fact, the RVH is so severe that the R wave progression pattern is actually reversed (rS in V6). The negative but prominent P wave in V1 is probably due to right atrial overload, with slightly peaked P waves in leads II, III, and aVF."

The differentials for RV hypertrophy are broad:

  • Due to pulmonary hypertension
    • Acute PE
    • Chronic thromboembolic pulmonary hypertension
    • Chronic hypoxic lung disease, eg. pulmonary fibrosis or connective tissue disease
    • Pulmonectomy
    • Connective tissue disease
    • Secondary pulmonary hypertension, eg. due to mitral valve disease or diastolic heart failure
  • Due to structural cardiac disease
    • Atrial septal defect
    • Ventricular septal defect
    • Eisenmenger syndrome
    • Stenosis of the pulmonic valve or pulmonary artery
    • Anomalous pulmonary venous return
    • RV hypertrophy due to hyperthyroidism



Goldberger, Ary L., Zachary D. Goldberger, and Alexei Shvilkin. "Chapter 7 - Atrial and Ventricular Enlargement"; in:  Clinical Electrocardiography: A Simplified Approach E-Book: A Simplified Approach. Elsevier Health Sciences, 2017.