From the Guidelines
A peaked P wave is a significant electrocardiogram (ECG) finding that indicates right atrial enlargement, and its presence is associated with a higher risk of mortality, particularly in patients with pulmonary hypertension, as evidenced by a study that found a P-wave amplitude in lead II of ≥ 0.25 mV to be associated with a 2.8-fold greater risk of death over a 6-year follow-up period 1.
Key Points to Consider
- The most common causes of peaked P waves include chronic pulmonary diseases such as chronic obstructive pulmonary disease (COPD), pulmonary hypertension, pulmonary embolism, and congenital heart defects.
- A tall upright P wave in lead II (greater than 2.5 mm) is characteristic, often with a peaked or pointed appearance that presumably reflects summation of the enhanced right atrial component with the simultaneous left atrial component 1.
- Further evaluation is necessary to determine the underlying cause of a peaked P wave, which may include additional cardiac testing such as echocardiography to assess right heart function and pulmonary artery pressures, chest imaging to evaluate lung pathology, and pulmonary function tests if respiratory disease is suspected.
- Treatment is directed at the underlying condition rather than the ECG finding itself, and prompt identification and management of the underlying cause are crucial to improve morbidity, mortality, and quality of life.
Important Considerations for Management
- The presence of a peaked P wave should prompt a thorough evaluation to determine the underlying cause, including a detailed medical history, physical examination, and diagnostic testing as needed.
- The management of patients with peaked P waves should be individualized based on the underlying cause, and may involve collaboration with specialists such as cardiologists, pulmonologists, and thoracic surgeons.
- The use of echocardiography and other cardiac imaging modalities can help to assess right heart function and pulmonary artery pressures, and guide management decisions.
- The prognosis for patients with peaked P waves is generally poor, particularly in those with underlying pulmonary hypertension, and prompt identification and management of the underlying cause are crucial to improve outcomes 1.
From the Research
Peaked P Wave
- A peaked P wave is often associated with right atrial enlargement or cor pulmonale, which can be a consequence of pulmonary hypertension 2, 3.
- Pulmonary hypertension can be caused by various underlying conditions, including chronic obstructive pulmonary disease (COPD), left-sided heart disease, and chronic thromboembolic pulmonary hypertension (CTEPH) 2, 3, 4.
- Electrocardiography (ECG) is a routine test used to diagnose pulmonary hypertension, and a peaked P wave can be an indicator of right atrial enlargement 2, 3.
- Echocardiography is also a useful tool in diagnosing pulmonary hypertension, providing accurate measurements of pulmonary hemodynamics and right heart function 5, 6.
- The diagnosis of pulmonary hypertension and cor pulmonale can be challenging, and a combination of clinical evaluation, ECG, echocardiography, and right heart catheterization is often necessary for accurate diagnosis and classification 2, 3, 5, 4, 6.