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P Cardiale - ECG

P cardiale, P biatriale, Biatrial enlargement (hypertrophy)

Physiological P Wave
Biatrial Hypertrophy
ECG and Biatrial Hypertrophy

Physiological P Wave

Schematic representation of normal P wave depolarization vectors

Impulse (action potential)

originates in the SA node with a frequency of 60/min.

Depolarization wave in the atria

spreads to the right (P1) and left (P2) atria

Summation (P1 + P2) atrial vector

directed from the SA node to the AV node

P wave is depolarization of the atria
Resultant atrial vector

should be imagined in 3D space
the image on the right is in 2D space

Biatrial Hypertrophy

Sometimes the terms used are:

P cardiale, P biatriale

Biatrial enlargement, P cardiale, P biatriale

It is a combination of P mitrale + P pulmonale
Both atria are enlarged

Regardless of the etiology (hypertrophy, dilation, myxoma)
It does not necessarily involve only hypertrophy (as the name might suggest)

Both vectors (P1 and P2) are enlarged

The summation atrial vector is also enlarged

ECG and Biatrial Hypertrophy

Enlarged atria
- Regardless of the etiology (hypertrophy, dilation, myxoma)
- Create an ECG pattern referred to as biatrial hypertrophy
- On the ECG, the pattern appears as P mitrale + P pulmonale

ECG (Lead II) Bifid P wave: P cardiale, P biatriale, Biatrial enlargement

Lead II (Biatrial Hypertrophy)

Amplitude > 2.5mm
Duration > 120ms
P wave may be monophasic/biphasic (M)

ECG (Lead V1) Biphasic P wave: P cardiale, P biatriale, Biatrial enlargement

Lead V1 (Biatrial Hypertrophy)

Biphasic
Amplitude ≥ 1.5mm (of the first wave)
Duration ≥ 1.5mm (of the second wave)

ECG p mitrale (Left Atrial Enlargement)

P Mitrale

Lead II

Biphasic P wave (M)

Distance between the peaks > 40ms

P wave width > 110ms

Lead V1

Terminal negative portion is deep > 1mm
Area of the terminal part > 1 small square
Width of the terminal negative wave > 40ms

On the ECG, P mitrale (left atrial hypertrophy) is observed

Criteria for biatrial hypertrophy are not met

ECG P pulmonale (Right Atrial Enlargement)

P Pulmonale

Lead II

High P wave
Amplitude > 2.5mm

Lead V1

First part of the P wave > 1.5mm (amplitude)
Area of the first part > 1 small square

On the ECG, P pulmonale (right atrial hypertrophy) is observed

Criteria for biatrial hypertrophy are not met

ECG dilatation cardiomyopathy with biatrial enlargement, biatrial hypertrophy, P cardiale, P biatriale,

Biatrial Hypertrophy

Lead V1 (P wave)

Positive amplitude > 1.5mm (P pulmonale)
Negative amplitude > 1mm (P mitrale)
The patient exhibits signs of P mitrale and P pulmonale on the V1 lead

Lead II does not meet the criteria for biatrial hypertrophy (P wave amplitude > 2.5mm, and width > 120ms)

For the diagnosis of biatrial hypertrophy, an ECG image is sufficient from either one lead V1 or II

The patient has dilated cardiomyopathy

Left Ventricular Hypertrophy
- Positive Sokolow index: S (V2) + R (V6) > 35mm
Left Ventricular Overload
- ST depressions (I, II, V5, V6)

ECG biatrial abnormality (enlargement) P pulmonale and P mitrale

Biatrial Hypertrophy

Lead II (P wave)

Amplitude > 2.5mm (P pulmonale)
Width > 120ms (P mitrale)

Lead V1 (P wave)

Positive amplitude > 1.5mm in V2 (P pulmonale)

Sometimes, Lead V2 is assessed instead of V1 (V1 and V2 leads are closely positioned)

Negative amplitude > 1mm (P mitrale)

The patient has biatrial hypertrophy

Meets the criteria for both P mitrale and P pulmonale

Sources

ECG from Basics to Essentials Step by Step
litfl.com
ecgwaves.com
metealpaslan.com
medmastery.com
uptodate.com
ecgpedia.org
wikipedia.org
Strong Medicine
Understanding Pacemakers

P Cardiale - ECG

P cardiale, P biatriale, Biatrial enlargement (hypertrophy)

Physiological P Wave
Biatrial Hypertrophy
ECG and Biatrial Hypertrophy

Physiological P Wave

Impulse (action potential)

originates in the SA node with a frequency of 60/min.

Depolarization wave in the atria

spreads to the right (P1) and left (P2) atria

Summation (P1 + P2) atrial vector

directed from the SA node to the AV node

P wave is depolarization of the atria
Resultant atrial vector

should be imagined in 3D space
the image on the right is in 2D space

Schematic representation of normal P wave depolarization vectors

Biatrial Hypertrophy

Sometimes the terms used are:

P cardiale, P biatriale

It is a combination of P mitrale + P pulmonale
Both atria are enlarged

Regardless of the etiology (hypertrophy, dilation, myxoma)
It does not necessarily involve only hypertrophy (as the name might suggest)

Both vectors (P1 and P2) are enlarged

The summation atrial vector is also enlarged

Biatrial enlargement, P cardiale, P biatriale

ECG and Biatrial Hypertrophy

Enlarged atria
- Regardless of the etiology (hypertrophy, dilation, myxoma)
- Create an ECG pattern referred to as biatrial hypertrophy
- On the ECG, the pattern appears as P mitrale + P pulmonale
Lead II (Biatrial Hypertrophy)

Amplitude > 2.5mm
Duration > 120ms
P wave may be monophasic/biphasic (M)

Lead V1 (Biatrial Hypertrophy)

Biphasic
Amplitude ≥ 1.5mm (of the first wave)
Duration ≥ 1.5mm (of the second wave)

ECG (Lead II) Bifid P wave: P cardiale, P biatriale, Biatrial enlargement

ECG (Lead V1) Biphasic P wave: P cardiale, P biatriale, Biatrial enlargement

ECG p mitrale (Left Atrial Enlargement)

P Mitrale

Lead II

Biphasic P wave (M)

Distance between the peaks > 40ms

P wave width > 110ms

Lead V1

Terminal negative portion is deep > 1mm
Area of the terminal part > 1 small square
Width of the terminal negative wave > 40ms

On the ECG, P mitrale (left atrial hypertrophy) is observed

Criteria for biatrial hypertrophy are not met

ECG P pulmonale (Right Atrial Enlargement)

P Pulmonale

Lead II

High P wave
Amplitude > 2.5mm

Lead V1

First part of the P wave > 1.5mm (amplitude)
Area of the first part > 1 small square

On the ECG, P pulmonale (right atrial hypertrophy) is observed

Criteria for biatrial hypertrophy are not met

ECG dilatation cardiomyopathy with biatrial enlargement, biatrial hypertrophy, P cardiale, P biatriale,

Biatrial Hypertrophy

Lead V1 (P wave)

Positive amplitude > 1.5mm (P pulmonale)
Negative amplitude > 1mm (P mitrale)
The patient exhibits signs of P mitrale and P pulmonale on the V1 lead

Lead II does not meet the criteria for biatrial hypertrophy (P wave amplitude > 2.5mm, and width > 120ms)

For the diagnosis of biatrial hypertrophy, an ECG image is sufficient from either one lead V1 or II

The patient has dilated cardiomyopathy

Left Ventricular Hypertrophy
- Positive Sokolow index: S (V2) + R (V6) > 35mm
Left Ventricular Overload
- ST depressions (I, II, V5, V6)

ECG biatrial abnormality (enlargement) P pulmonale and P mitrale

Biatrial Hypertrophy

Lead II (P wave)

Amplitude > 2.5mm (P pulmonale)
Width > 120ms (P mitrale)

Lead V1 (P wave)

Positive amplitude > 1.5mm in V2 (P pulmonale)

Sometimes, Lead V2 is assessed instead of V1 (V1 and V2 leads are closely positioned)

Negative amplitude > 1mm (P mitrale)

The patient has biatrial hypertrophy

Meets the criteria for both P mitrale and P pulmonale

Sources

ECG from Basics to Essentials Step by Step
litfl.com
ecgwaves.com
metealpaslan.com
medmastery.com
uptodate.com
ecgpedia.org
wikipedia.org
Strong Medicine
Understanding Pacemakers