Which ECG abnormality is most likely in a 68-year-old man with COPD, obstructive sleep apnea, obesity, pulmonary hypertension, accentuated P2 and mild polycythemia?

ECG Findings in Pulmonary Hypertension with COPD

Right ventricular hypertrophy is the most likely ECG abnormality in this patient with documented pulmonary hypertension (mean PAP 35 mmHg), COPD, obesity, and accentuated P2. 1

Clinical Context Supporting RVH

This patient presents with classic features of pulmonary hypertension:

• Confirmed hemodynamic diagnosis: Mean pulmonary artery pressure of 35 mmHg on cardiac catheterization establishes pulmonary hypertension (normal ≤20 mmHg) 1
• Physical examination findings: Accentuated S2 (P2 component) is a cardinal sign of elevated pulmonary artery pressure 1
• Secondary polycythemia: Elevated hematocrit/hemoglobin reflects chronic hypoxemia driving compensatory erythropoiesis 2
• Multiple risk factors: COPD, obstructive sleep apnea, and obesity (BMI 32) all contribute to pulmonary hypertension development 2

Why RVH is Most Likely

ECG abnormalities correlate directly with pulmonary hypertension severity, and this patient has moderate pulmonary hypertension:

• RVH occurs in 87% of patients with idiopathic pulmonary arterial hypertension 3
• Right axis deviation is present in 79% of PAH patients 3
• ECG sensitivity for RVH is 55% with 70% specificity when mean PAP is approximately 50 mmHg 1, 3
• At mean PAP of 35 mmHg, ECG changes are common but not universal 1

The 2015 ESC/ERS guidelines explicitly state that ECG abnormalities are more likely in severe rather than mild PH, and this patient's mean PAP of 35 mmHg represents moderate disease where RVH is the expected finding 1

Specific ECG Patterns Expected

In COPD patients with pulmonary hypertension, look for:

• Right axis deviation (most common, present in 79% of PAH) 3
• Tall R waves in V1 with R/S ratio >1 3, 4
• qR pattern in V1 (highly specific for RVH) 3, 5
• Deep S waves in V5-V6 with R/S <1 3
• RV strain pattern: ST depression and T-wave inversion in right precordial leads (V1-V3) 1, 3
• P pulmonale: Tall P waves ≥2.5 mm in leads II, III, aVF indicating right atrial enlargement 3

Important caveat for COPD patients: The American College of Cardiology emphasizes that in COPD, RVH should only be diagnosed when R-wave amplitude in V1 is relatively increased, as other findings (low voltage, right axis deviation, persistent S waves) may reflect hyperinflation and geometric factors rather than true hypertrophy 3, 6

Why Other Options Are Less Likely

Absence of P waves (atrial fibrillation): While supraventricular arrhythmias occur in advanced pulmonary hypertension with cumulative incidence of 25% after 5 years, this patient has regular heart rate of 62/min, making atrial fibrillation unlikely 1

Left axis deviation: This finding suggests left ventricular pathology, not right-sided disease. The American College of Cardiology states that left axis deviation is more indicative of left ventricular hypertrophy rather than right-sided cardiac pathology 3. This patient's clinical picture points entirely to right heart involvement.

Premature ventricular contractions: The ESC/ERS guidelines note that ventricular arrhythmias are rare in pulmonary hypertension 1. While PACs and supraventricular tachyarrhythmias are more common in severe COPD (19% and 16% respectively), isolated PVCs are not a characteristic finding 6

ST segment elevation in V1-V3: This pattern suggests acute right ventricular infarction or anterior STEMI, neither of which fits this patient's chronic, progressive presentation over six months 1. The patient's symptoms are exertional and gradual, not acute coronary syndrome.

Diagnostic Accuracy Considerations

The diagnostic accuracy of ECG for RVH varies by underlying etiology:

• Highest accuracy: Congenital heart disease 3
• Intermediate accuracy: Acquired heart disease and primary pulmonary hypertension 3
• Lowest accuracy: Chronic pulmonary disease (this patient's category) 3, 6

In severe COPD specifically, ECG findings include:

• Right atrial enlargement in 44% (vs 15% in mild/moderate COPD) 6
• RVH in 29% (vs 4% in mild/moderate COPD) 6
• Right bundle branch block in 29% (vs 11% in mild/moderate COPD) 6
• Low voltage in limb leads in 24% due to hyperinflation 6

Clinical Implications

The presence of RVH on ECG has prognostic significance:

• P-wave amplitude in lead II ≥0.25 mV is associated with 2.8-fold increased risk of death over six years 3
• Each 1 mm increase in P-wave amplitude in lead III confers 4.5-fold higher mortality risk 3
• RVH with R/S >1 in V1 has 100% specificity and positive predictive value for distinguishing pulmonary arterial hypertension from pulmonary hypertension due to left ventricular diastolic dysfunction 4

Critical pitfall: Up to 13% of patients with severe PAH may have a completely normal ECG despite elevated pressures, so a normal ECG cannot rule out pulmonary hypertension 3. However, given this patient's moderate-to-severe disease with mean PAP of 35 mmHg and multiple clinical signs, ECG abnormalities are expected.