Tall upright P wave >2.5mm in II, III, aVF (P-pulmonale)

     or >1.5mm in V1, V2

P wave axis right-shifterd >/= 70 deg

P-Pulmonale can be seen in COPD, pulmonary HTN, PE, congenital heart dx like tetralogy, pulmonic stenosis, tricuspid atresia.

Normal variant in thin patients

Terminal negative P wave in V1 >/= 1mm x 0.04 sec (1x1 box) OR

Notched P wave >/= 0.12 sec in II, III aVF (P-mitrale)

Can be seen in mitral valve dx, aortic valve dx, heart failure, MI, HTN, LVH

Normal P wave axis and morphology

Rate = 60-100 BPM

Regular rhythm = PP interval varies by <0.16 sec or <10%

Normal P wave axis and morphology

Phasic change in PP interval

Variation by >0.16 sec or >10%

Sinus Block

Second degree Type I

Some sinus impulses fail to capture

P wave axis and morphology is normal

Constant PR interval

Shortening PP interval up to a pause (missed beat)

Pause is <2x normal PP

Sinus Block

Second Degree Type II

Constant PP interval followed by a pause (missed beat)

Causes: Hyperkalemia, Sinus node dysfunction, organic heart disease, MI, vagal stim, Drugs (digitalis, quinidine, flecainide, propafenone, procainamide)

Cornell: R in aVL + S in V3 >28mm M/ >20 F

Sokolow-Lyon: S in V1 + R in V5/6 >35mm (>40 y/o)

Others: V1-6 Max R + Max S >45mm;  R in V5 >26; R in V6 >20mm;     R in I + S in II >25mm; R in aVL >12mm (very specific except with LAFB)

Romhilt-Estes: 4 points probable, 5 points definite

    Largest R or S in limb leads >20mm (3 pts); S in V1/2 >30mm or R in V5/6 >30mm (3 pts); ST displaced opposite QRS w/o dig= 3 pts, w/ dig= 1 pt; LAA = 3 pts; LAD = 2 pts; QRS >90msec = 1 pt

AV Block

1st Degree

PR interval >0.20sec

Each P is followed by a narrow QRS

Caused by: Normal variant, athletes, high vagal tone, acute rheumatic fever, myocarditis, Congenital herat dx, Drugs (digitalis, quinidine, procainamide, flecainide, propafenone, amiodarone, sotalol, propranolol, verapamil)

AV Block

2nd Degree, Type I

Progressively longer PR interval and shorter RR interval

Results in non-conducted P wave

RR interval with blocked P wave is < 2x PP interval

AV block

2nd Degree Type II