Electrocardiographic (ECG) findings
ECG serves as the basic method for detecting markers of right ventricular hypertrophy and overload. Changes in muscle mass directly affect electrical conductivity.
- Electrical axis of the heart (EAH): deviation of the axis to the right (formation of right-axis deviation) or its vertical position is recorded.
- Changes in chest leads (V1–V2): the amplitude of the R wave significantly increases (it becomes dominant), while the amplitude of the S wave, conversely, decreases. Additionally, T wave inversion is observed—it becomes negative.
- Changes in standard leads (II, III): tall, peaked P waves are formed. This sign is called P-pulmonale and indicates pronounced right atrial overload.
In the case of concomitant rhythm disorders (e.g., atrial fibrillation), the P wave on the cardiogram completely disappears. If left atrial overload is present, a notched, broad P wave—P-mitrale—is recorded in leads I and II.
Radiological presentation
During chest radiography (most informative in oblique projections), direct enlargement and dilatation of the right ventricle are clearly visualized. Simultaneously, a specific pattern of changes in the cardiac silhouette and pulmonary vasculature is formed.
- «Mitral configuration» of the heart: flattening of the cardiac «waist» occurs. This is due to the bulging of the second arch (dilated pulmonary trunk) and the third arch (left atrial appendage). At the same time, the dimensions of the left ventricle generally remain within normal limits.
- Pulmonary hypertension: images show dilatation of the main pulmonary trunk and its peripheral branches.
- Pulmonary congestion: vascularization of the upper lung lobes increases, and the lung roots widen. Due to fluid transudation into the interstitium and perivascular edema, the contours of structures lose clarity. In severe cases, pleural effusion is detected, and cardiomegaly is stated when the cardiothoracic ratio (CTR) exceeds 50%.
Echocardiography and invasive diagnostics
Echocardiography (EchoCG) is used as the main confirmatory tool for verifying structural anomalies and assessing myocardial function.
- Two-dimensional mode: allows the physician to directly visualize cavity dilatation, right ventricular hypertrophy, and left atrial dilatation. The method is indispensable for accurate measurement of the mitral orifice area and detection of intracavitary (mostly mural) thrombi.
- M-mode (one-dimensional): reveals a specific sign—concordant motion of the mitral valve leaflets in the diastole phase (leaflets move parallel, in the same forward direction). The shape of their motion curve resembles the letter «П» (U-shape).
- Markers of heart failure: as the pathology progresses, EchoCG records a decrease in ejection fraction (EF) and an increase in ventricular dimensions (end-systolic and end-diastolic).
For a detailed assessment of hemodynamics, cardiac catheterization is used. This invasive study confirms elevated pressure in the pulmonary artery and an increase in left ventricular end-diastolic pressure.
The vector of the electrical axis always deviates towards the «overworked» muscle. The increased mass of the right ventricle «pulls» the EAH to the right (right-axis deviation). In the right chest leads (V1–V2), this manifests as a surge in the R wave—it dominates, and the T wave goes negative (inverts).
Class and exam questions
What P-wave changes are characteristic of atrial overload?
Right atrial overload manifests as P-pulmonale—a tall, peaked P wave in leads II and III. Left atrial overload produces P-mitrale—a broad, notched P wave in leads I and II.
What does the term «mitral configuration» mean on a radiograph?
This is the flattening of the «waist» of the cardiac silhouette. It occurs due to the bulging of the arches of the pulmonary trunk and the left atrial appendage, while the left ventricle is usually not enlarged.
How can blood flow velocity be assessed clinically?
The magnesium sulfate test is used (determination of the circulation time via magnesium). With intravenous administration of a 25% solution, a normal sensation of warmth in the tongue occurs no later than 14 seconds; in heart failure, blood flow slows down, and the time increases.
What does EchoCG show in one-dimensional M-mode?
A specific sign is concordant (unidirectional) motion of the valve leaflets in diastole, in which the motion curve acquires a characteristic U-shaped form.
What else to study on this topic
- Radiological signs of pulmonary hypertension and fluid transudation into the interstitium.
- Echocardiographic markers of heart failure: assessment of dilatation and ejection fraction.
- Conduction disturbances and scar changes on the ECG as background pathology in heart failure.
- Methodology of the magnesium sulfate test to assess circulation time dynamically.
- Invasive diagnostics: cardiac catheterization and pulmonary artery pressure measurement.
- Assessment of the body's functional reserves using exercise stress tests (cycle ergometry).
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