Diagnostic criteria

  Amplitude (height) of the P wave in lead 2 is > 2.5mm (0.25mV). ( > 3mm is abnormal in infants up to 6 months of age ). P wave is pointed with a single crest.

  Additional criteria:
- Amplitude (height) of the first half of P wave in lead C1 or lead C2 is > 1.5 mm (0.15mV).
- Rightward shift of the P wave vector.

  The P wave time (width) is generally normal (<120ms).



Among congenital heart diseases, EXAGGERATED right atrial abnormality is seen in

  Ebstein's anomaly

  Total anomalous pulmonary venous return

  Severe pulmonary stenosis

  Tricuspid atresia



Although NOT EXAGGERATED atrial septal defect (ASD) may also show right atrial abnormality.



About the definition

  Previously P pulmonale , P congenitale , right atrial dilatation , right atrial hypertrophy , atrial overload were used.

  However, the above mentioned ECG findings can be observed not only in patients with atrial muscular hypertrophy but also in patients with increases in atrial pressure, ventricular diastolic dysfunction or intaatrial conduction disturbances.

  Therefore it is suggested that use of the term right atrial abnormalitywill reflect these changes better.



References

  Circulation 2009,119:e251-e261.

  American Journal of Emergency Medicine 2008;26:221-228.




ECG 1. The tall and pointed P waves show right atrial abnormality.

Click here for a more detailed ECG




ECG 2. Right atrial abnormality is seen in a patient with chronic obstructive pulmonary disease (COPD).

Click here for a more detailed ECG




ECG 3. The ECG above belongs to a 6 years old child. Because of critical pulmonary stenosis in the neonatal period, he had
undergone first pulmonary balloon valvuloplasty and then pulmonary valvulotomy. Recently, the echocardiography revealed
severe tricuspid regurgitation and moderate pulmonary regurgitation. Right atrial abnormality is so obvious that the amplitude
of the P wave in lead II is above than that of the following QRS complex. In severe pulmonary stenosis, also a higher than
expected R wave amplitude in lead C1 is usually observed.

Pediatric Cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.

Click here for a more detailed ECG




ECG 4. The ECG above belongs to a 9 years-old boy who had been operated for severe pulmonary valve stenosis in the past.
His recent echocardiography showed a dilated right atrium.
Fourth degree (severe) tricuspid regurgitation and third degree pulmonary regurgitation was observed by Doppler ECHO.
The P waves in lead II are so large that they have the same amplitude with the following QRS complexes .

Pediatric Cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.

Click here for a more detailed ECG




ECG 5. The ECG above belongs to a 30 years-old man with kyphoscoliosis and pectus excavatum.
He has a large (1.4 cm wide) unoperated subaortic VSD.
Color-Doppler ECHOcardiography did not show clear-cut shunt flow suggesting equalization of ventricular pressures.
ECHOcardiography also showed hypokinesia of some left ventricular (LV) segments (mild LV systolic dysfunction).
The patient had clubbing of the fingers.
This ECG shows several signs of right ventricular hypertrophy: R/S ratio in C5 and C6 is <1,
S1S2S3 pattern, right atrial abnormality, S in C5 is >0.7mV (>7mm).
The amplitude of the P wave in lead II is >2.5mm denoting right atrial abnormality.

Click here for a more detailed ECG




ECG 6. The ECG above belongs to a 62 years-old obese woman with chronic bronchitis.
She is a chronic smoker.
Right atrial abnormality, P wave verticalization and low voltage are seen.

Click here for a more detailed ECG