In a 68‑year‑old man with COPD, obstructive sleep apnea, obesity and pulmonary hypertension, which ECG finding is most likely: absent P waves, left axis deviation, premature ventricular contractions, right‑ventricular hypertrophy, or ST‑segment elevation in leads V1‑V3?

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Right Ventricular Hypertrophy

In this 68-year-old man with COPD, obstructive sleep apnea, obesity, and documented pulmonary hypertension (mean PAP 35 mmHg), the ECG will most likely show right ventricular hypertrophy.

Clinical Reasoning

This patient has multiple risk factors converging to produce right ventricular pressure overload:

  • Documented pulmonary hypertension with mean PAP of 35 mmHg on cardiac catheterization, which directly causes RV strain 1
  • COPD contributing to chronic hypoxic pulmonary vasoconstriction 1
  • Obstructive sleep apnea causing intermittent hypoxemia and pulmonary vascular remodeling 1
  • Physical examination findings including accentuated S2 (loud P2 component), which is a classic sign of pulmonary hypertension 1

Why Right Ventricular Hypertrophy is Most Likely

Epidemiologic Support

  • Right ventricular hypertrophy is present in approximately 87% of patients with idiopathic pulmonary arterial hypertension 1
  • Right axis deviation (≥100°) occurs in about 79% of patients with IPAH 1
  • In severe COPD specifically, RVH occurs in 29% of patients compared to only 4% in mild-moderate disease 2

ECG Manifestations Expected

The American College of Cardiology states that right ventricular overload causes a shift of the QRS vector to the right and anteriorly, with the following specific findings 1:

  • Right axis deviation (≥90°), which is required for diagnosis in nearly all cases 1
  • Tall R waves in V1 as part of Rs, R, or Qr complexes 1
  • Increased R/S ratio in V1 (≥1), reflecting anterior forces of the hypertrophied right ventricle 1
  • Deep S waves in V5-V6 with R/S <1, indicating rightward shift of electrical forces 1
  • ST segment depression and T wave inversion in right precordial leads (V1-V3), representing the pressure-overload pattern 1

COPD-Specific Considerations

In patients with COPD, the American College of Cardiology notes several confounding factors 1:

  • Low voltage in limb leads due to hyperinflation (present in 24% of severe COPD) 2
  • Persistent S waves in all precordial leads 1
  • Rightward, superior, or indeterminate frontal-plane QRS axis 1
  • However, RVH should still be diagnosed when R-wave amplitude in V1 is relatively increased 1

Why Other Options Are Less Likely

Absent P Waves

  • This finding suggests atrial fibrillation 1
  • While supraventricular tachyarrhythmias occur in 16% of severe COPD patients 2, there is no clinical indication of irregular rhythm (heart rate documented as "regular" at 62/min)
  • Not the primary ECG manifestation of pulmonary hypertension 1

Left Axis Deviation

  • Left axis deviation occurs in only 16% of severe COPD patients 2
  • The American College of Cardiology states that left axis deviation may be associated with LVH, not right heart disease 3
  • This patient's clinical picture points to right-sided pathology, not left ventricular disease 1

Premature Ventricular Contractions

  • While PACs occur in 19% of severe COPD 2, PVCs are not a characteristic finding of pulmonary hypertension 1
  • No mention of irregular rhythm or palpitations in the clinical presentation

ST Segment Elevation in V1-V3

  • This pattern suggests acute anterior myocardial infarction or Brugada syndrome 1
  • The patient has chronic, progressive symptoms over six months—not an acute coronary syndrome presentation
  • ST segment depression (not elevation) with T-wave inversion in V1-V3 is the expected finding in RVH pressure-overload pattern 1

Diagnostic Performance

The sensitivity of ECG for detecting RVH in pulmonary hypertension varies by etiology 1:

  • Highest accuracy in congenital heart disease
  • Intermediate accuracy in acquired heart disease and primary pulmonary hypertension (73% sensitivity, 70% specificity for right axis deviation when mean PAP ≈50 mmHg) 1
  • Lowest accuracy in chronic pulmonary disease 1

Despite lower sensitivity in COPD, this patient's mean PAP of 35 mmHg combined with multiple risk factors makes RVH the most probable ECG finding 1, 4.

Important Caveats

  • Up to 13% of patients with severe PAH may have a completely normal ECG despite elevated pressures 1
  • A normal ECG cannot rule out pulmonary hypertension 1
  • The American College of Cardiology recommends using multiple ECG criteria simultaneously rather than relying on a single finding 1
  • Clinical context is essential for adequate interpretation, as many ECG findings can occur as normal variants 1

References

1
Guideline

Electrocardiographic Signs of Right Ventricular Overload

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Research

Electrocardiographic abnormalities in patients with severe versus mild or moderate chronic obstructive pulmonary disease followed in an academic outpatient pulmonary clinic.

Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 2011

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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