This document discusses ECG changes seen in patients with chronic obstructive pulmonary disease (COPD). It defines COPD and its two main conditions, chronic bronchitis and emphysema. COPD causes chronic strain on the right side of the heart due to increased pulmonary pressures, leading to ECG findings of right atrial and ventricular enlargement. Common ECG abnormalities in COPD include P pulmonale, right axis deviation, low QRS voltages, and multifocal atrial tachycardia. Several case examples are presented demonstrating some of these classic COPD-related ECG patterns.

1. ECG
changes in
CHRONIC OBSTRUTIVE PULMONARY
DISEASES
Synonyms: Emphysema, Chronic bronchitis, Chronic Obstructive Lung
Disease (COLD), Chronic Obstructive Airway Disease (COAD),
Smoker’s Lung
DR.PRITHVIRAJ METHE
RESIDENT IN PULMONARY MEDICINE

2. DEFINITION
• COPD is a lung disease characterized by airflow limitation
(FEV1/FVC ratio of less than 70%) that is not fully
reversible (FEV1 increase of 200 ml and 12% improvement
above baseline FEV1 following administration of either
inhaled corticosteroids or bronchodilators). COPD
comprises of 2 predominant conditions – Chronic
bronchitis and Emphysema.
• Chronic Bronchitis is defined as a productive cough for 3
months in each of 2 successive years in a patient whom
other causes of chronic sputum has been excluded.
• Emphysema is defined as the presence of enlargement of
airspaces distal to the terminal bronchioles or acinus with
destruction of their walls without obvious fibrosis.

3. Mechanism of ECG changes in COPD
• COPD is associated with increased airway
resistance, alveolar and pulmonary capillary
destruction, air trapping, chronic hypoxemia and
increased work of breathing. In an attempt to
improve oxygenation of the blood, pulmonary
vessels adjacent to underventilated alveoli tend
to constrict (hypoxic reflex pulmonary
vasoconstriction), increasing both pulmonary
vascular resistance and the work of right heart
i.e. COPD imposes chronic strain on the right
side of heart resulting in cor pulmonale.

4. COPD and Heart
• Elongation and vertical orientation of the
heart: Hyperexpanded lungs impose external
compression of heart and lowering of diaphragms
• Clockwise rotation of heart in the transverse
plane: Due to its fixed attachment to the great
vessels
• Reduced amplitude of the QRS complexes: Due
to dampening effect resulting from increased air
between the heart and recording electrodes

5. • ECG findings of right atrial and
right ventricular enlargement are
seen with COPD
(The long-term effects of hypoxic
pulmonary vasoconstriction upon the right
side of the heart, causing pulmonary
hypertension and subsequent right atrial
and right ventricular hypertrophy)

6. ECG changes Underlying cause
P pulmonale
(Tall, peaked
P-wave ≥ 2.5 mm height
in inferior leads II, III and aVF)
ECG changes Underlying cause
P pulmonale (Tall, peaked P-wave ≥ 2.5
mm height in inferior leads II, III and aVF)
Right atrial abnormality
Increased R wave voltage in leads V1, V2 Right ventricular enlargement
Right axis deviation usually between
+90° and +180
Right ventricular dilation
Low voltage QRS complex (<5 mm
height) in limb leads
Increased distance between the
recording electrode and heart
Poor R wave progression Leftward or clockwise rotation of the
heart

8. Chou’s ECG criteria for COPD
P-pulmonale
P wave axis ≥ +80°
QRS amplitude less than 5 mm in all limb leads
QRS axis > +90°
QRS amplitude less than 5 mm in V5, V6
S1-S2-S3 pattern with R/S <1 in lead I, II, III
Atrial arrhythmias (especially Multifocal Atrial
Tachycardia or MAT)
• COPD is likely to be present if one P and one
QRS criterion present

9. Multifocal Atrial Tachycardia or MAT
• MAT is defined electrocardio-graphically as an atrial
tachycardia with an overall rate greater than 100 beats per
minute and distinct P waves of at least three different
morphologies. Both PR and R-R intervals are variable.

10. Schamroth’s Sign Criteria for COPD
Isoelectric P wave in lead I
Very small QRS complex of less than 1.5 mm
total deflection
T wave of less than 0.5 mm in lead I

11. The ECG below is from a 58 years-old man with a recent diagnosis of COPD.
ECHOcardiogram showed neither right atrial nor right ventricular dilatation.
P wave axis is +80 degrees (P wave verticalization). The P wave is negative in lead aVL.
Low voltage and incomplete right bundle branch block are also seen.

12. The compact ECG above belongs to a 66 years-old woman with COPD.
ECHOcardiogram showed neither right atrial nor right ventricular dilatation. Left
ventricular systolic function was normal.
P wave axis is +68 degrees. The P wave is negative in lead aVL. (P wave
verticalization). Exaggerated T wave is seen in lead II

13. The ECG below is from a 82 years-old man with COPD.
The rhythm is multifocal atrial tachycardia (MAT) but seems like atrial fibrillation at
first glance. However, one P wave per RR interval confirms the absence of atrial
fibrillation.

14. The ECG below belongs to a 79 years-old man with COPD, chronic systemic arterial
hypertension and abdominal aortic aneurysm. P wave axis is +90 degrees (P wave
verticalization). The P wave is flat in Lead I (Lead I sign). The P wave is also negative
in lead aVL (P wave verticalization). Two atrial premature contractions (APCs) are
also seen

15. The ECG below is from an old man with COPD.
P wave verticalization with negative P waves in lead aVL is seen.
The rhythm is multifocal atrial tachycardia (P waves with at least 3 different shapes
in precordial leads).

16. The below ECG is from a 74 years-old man with COPD.
ECHOcardiogram showed right atrial and right ventricular dilatation.
P wave verticalization with negative P waves in lead aVL is seen.
Incomplete right bundle branch block is also seen.

17. The below ECG is from a patient with COPD and multifocal atrial
tachycardia. P wave verticalization with negative P waves in lead aVL is
seen.

18. The below ECG is from a 51 years-old man with COPD.
ECHOcardiography showed neither right atrial nor right ventricular dilatation.
The P wave in lead I is almost flat. Lead aVL shows negative P wave (P wave
verticalization). Atrial premature contractions are not rare in patients with COPD.
The ECG also shows low voltage in limb leads.

19. The below ECG is from a 85 years-old woman with COPD, left ventricular systolic
dysfunction, and mild pericardial effusion. She has never undergone diagnostic
coronary angiography.
ECHOcardiography showed dilation of all cardiac chambers and segmentary left
ventricular wall motion abnormality.
The ECG also shows low voltage in almost all leads

20. The ECG below is from an old man with COPD.
P wave verticalization and low voltage in limb leads are seen.

21. This ECG is typical for a COPD patient
• The next ECG is from a 48 years-old man with COPD.
Coronary angiography revealed coronary artery ectasia
with significant coronary slow flow.
• Leads V1 and V2 show QS complexes which are not
related to coronary artery disease in this patient.
• Precordial leads show narrow QRS complexes (the widest
being 90 milliseconds).
• P wave axis is about +82 degrees. Lead I barely shows a P
wave.
• Lead aVL shows negative P wave (P wave verticalization).
• Right atrial abnormality is also seen.
• Limb leads show low voltage.