Transcript Ventricular Hypertrophy in Pediatric EKG

Ventricular Hypertrophy
in Pediatric EKG
Marc Francis
R4 FRCPC Emergency
Year 1 PEM Fellow
Objectives
I do not want to:
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•
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Make you memorize
pages of numbers
Make you memorize
tables
Make you never
want to see another
pediatric EKG
Make you fall asleep
I do want to:
• Give you a bedside
approach to rapidly
looking for LVH and
RVH
Ventricular Hypertrophy
• RVH and LVH can be markers of significant
disease states
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Congenital Heart disease
Shunts
Pulmonary HTN
Renal Failure
• Hypertrophy produces abnormalities on EKG
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QRS axis
QRS voltages
R/S ratio
T axis
The Problem
• Damn kids keep growing!!!
– They start life with dominance of the RV
– By 6-8 weeks they have corrected to a LV
dominated system
– The normal intervals and wave amplitudes
change as they age
– They finally fall in line and become “big
people” only when they are 16 years old
Solutions
Option 1:
Memorize a ton of charts and tables of normal
values
Option 2:
Keep these in your palm pilot to reference every
5-10 minutes until step one has occurred
Option 3:
Ignore any and all EKGs done in the Peds ED
The “Alternative” Solution
Step 1:
Remember a few simple screening
parameters that will allow you to rapidly
assess an EKG to look for RVH and LVH
in pediatric patients
Step 2:
Let the cardiologist remember all the
numbers and charts
RVH
CRITERIA FOR RVH
1) RAD for the patient's age
2) Increased rightward and anterior QRS voltages
a) R in V1, V2, or aVR greater than the upper limits of
normal for the patient's age
b) S in I and V6 greater than the upper limits of normal
for the patient's age
*Note: Assumes QRS is not widened for age indicating abnormal
conduction delay
3) Abnormal R/S ratio in favor of the RV
a) R/S ratio in V1 and V2 greater than the upper limits
of normal for age
b) R/S ratio in V6 less than 1 after one month of age
1) RAD for patient age
Lead I = 0°
Lead II = +60°
Lead AVF = +90°
Lead III = +120°
Lead AVL = -30°
Lead AVR = -150°
Mean and Ranges of Normal
QRS Axes by Age
Age
1 wk-1 mo
1-3 mo
3 mo-3 yr
Older than 3 yr
Adult
Mean (Range)
+110° (+30 to +180)
+70° (+10 to +125)
+60° (+10 to +110)
+60° (+20 to +120)
+50° (-30 to +105)
2) Increased rightward and
anterior QRS voltages
• R in V1, V2, or aVR
greater than the
upper limits of normal
for the patient's age
• S in I and V6 greater
than the upper limits
of normal for the
patient's age
R and S Voltages: Mean (and Upper Limits of
Normal) According to Lead and Age
Age
0-1 mo
1-6 mo
6 mo-1yr
1-3yr
3-8yr
8-12yr
12-16yr
Young Adults
R voltage in V1
S voltage in V6
15 (25)
11 (20)
10 (20)
9 (18)
7 (18)
6 (16)
5 (16)
3 (14)
4 (12)
2 (7)
2 (6)
2 (6)
1 (5)
1 (4)
1 (5)
1 (13)
*Voltages are measured in millimeters, when 1 mV = 10 mm paper
3) Abnormal R/S ratio in favor of
the RV
• R/S ratio in V1 and
V2 greater than the
upper limits of normal
for age
• R/S ratio in V6 less
than 1 after one
month of age
R/S Ratio: Mean and Upper and Lower
Limits of Normal According to Age V1
Age
LLN
Lead VI
Mean
0-1mo
1-6mo
6mo-1yr
1-3yr
3-8yr
8-12yr
12-16yr
Adults
0.5
0.3
0.3
0.5
0.1
0.15
0.1
0.0
1.5
1.5
1.2
0.8
0.65
0.5
0.3
0.3
ULN
19
S=0
6
2
2
1
1
1
*LLN = lower limits of normal; ULN = upper limits of normal
From Guntheroth WB: Pediatric Electrocardiography. Philadelphia, WB
Saunders, 1965
Screening criteria for RVH
1) RAD greater than +120° in any child
over 1 month is highly suggestive of RVH
2) Upright T in V1
• In patients > 3 days and < 6yr old
• Provided that the T is upright in the left precordial
leads (V5, V6)
3) Q wave in V1 always suggests RVH
4) S wave > R wave in Lead V6
LVH
CRITERIA FOR LVH
1) LAD for the patient's age
2) QRS voltages in favor of the LV
a) R in I, II, III, aVL, aVF, V5, or V6 greater than
the upper limits of normal for age
b) S in V1 or V2 greater than the upper limits of
normal for age
3) Abnormal R/S ratio in favor of the LV
– R/S ratio in V1 and V2 less than the lower
limits of normal for the patient's age
1) LAD for patient age
Lead I = 0°
30°
Lead II = +60°
Lead AVF = +90°
Lead III = +120°
Lead AVL = Lead AVR = -150°
Mean and Ranges of Normal
QRS Axes by Age
Age
1 wk-1 mo
1-3 mo
3 mo-3 yr
Older than 3 yr
Adult
Mean (Range)
+110° (+30 to +180)
+70° (+10 to +125)
+60° (+10 to +110)
+60° (+20 to +120)
+50° (-30 to +105)
2) QRS voltages in favor of the LV
•
R in I, II, III, aVL,
aVF, V5, or V6
greater than the
upper limits of
normal for age
•
S in V1 or V2
greater than the
upper limits of
normal for age
R Voltages: Mean (Upper Limits of
Normal) According to Lead and Age
R voltage
Age
Lead I
Lead II
Lead III
0-1mo
1-6mo
6mo-1yr
1-3yr
3-8yr
8-12yr
12-16yr
Young Adults
4(8)
7(13)
8(16)
8(16)
7(15)
7(15)
6(13)
6(13)
6(14)
13(24)
13(27)
13(23)
13(22)
14(24)
14(24)
9(25)
8(16)
9(20)
9(20)
9(20)
9(20)
9(24)
9(24)
6(22)
*Voltages are measured in millimeters, when 1 mV = 10 mm paper
From Park MK, Guntheroth WG: How to Read Pediatric ECGs,
3rd ed. St. Louis, Mosby, 1992.
S Voltages: Mean (Upper Limits of
Normal) According to Lead and Age
S voltage
Age
Lead VI
0-1mo
1-6mo
6mo-1yr
1-3yr
3-8yr
8-12yr
12-16yr
Young Adults
*Voltages
10(20)
7(18)
8(16)
13(27)
14(30)
16(26)
15(24)
10(23)
Lead V2
20(35)
16(30)
17(30)
21(34)
23(38)
23(38)
23(48)
14(36)
are measured in millimeters, when 1 mV = 10 mm paper
From Park MK, Guntheroth WG: How to Read Pediatric ECGs,
3rd ed. St. Louis, Mosby, 1992.
3) Abnormal R/S ratio in favor of
the LV
• R/S ratio in V1 and V2 less than the lower
limits of normal for the patient's age
*Note that lead V2 is in ½ normal standardization
R/S Ratio: Mean and Upper and Lower
Limits of Normal According to Age V1
Age
LLN
Lead VI
Mean
0-1mo
1-6mo
6mo-1yr
1-3yr
3-8yr
8-12yr
12-16yr
Adults
0.5
0.3
0.3
0.5
0.1
0.15
0.1
0.0
1.5
1.5
1.2
0.8
0.65
0.5
0.3
0.3
ULN
19
S=0
6
2
2
1
1
1
*LLN = lower limits of normal; ULN = upper limits of normal
From Guntheroth WB: Pediatric Electrocardiography. Philadelphia, WB
Saunders, 1965
Screening Criteria for LVH
1) LAD less than +10° is highly suggestive
of LVH
2) S wave in lead V1 greater than 20mm
3) Q in V6, ≥5 mm suggests LVH
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With LV diastolic overload
In Summary
If under 1 month all bets are off!!!
Step 1
– Look at the axis:
• > +120° suggests RVH
• < +10° suggests LVH
Step 2
– Look at lead V1:
• Upright T or Q-wave in V1 suggests RVH
• Large S wave >20mm suggests LVH
In Summary
• Step 3
– Look at lead V6:
• S wave > R wave suggests RVH
• Q wave > 5mm suggests LVH
Case 1
• 1 month old with heart murmur
Case 2
• 8yo with heart murmur
Case 3
• 4yo Female with CP
Case 4
• 2yo M
Case 5
• 8mo Female
Questions???
References
• Park: Pediatric Cardiology for Practitioners, 4th ed., Copyright
© 2002 Mosby, Inc.
• Guntheroth WB: Pediatric Electrocardiography. Philadelphia,
WB Saunders, 1965.
• Park MK, Guntheroth WG: How to Read Pediatric ECGs,
3rd ed. St. Louis, Mosby, 1992.