1. Ventricular Hypertrophy in Pediatric EKG Marc Francis R4 FRCPC Emergency Year 1 PEM Fellow

2. Objectives I do not want to: Make you memorize pages of numbers Make you memorize tables Make you never want to see another pediatric EKG Make you fall asleep I do want to: Give you a bedside approach to rapidly looking for LVH and RVH

3. Ventricular Hypertrophy RVH and LVH can be markers of significant disease states Congenital Heart disease Shunts Pulmonary HTN Renal Failure Hypertrophy produces abnormalities on EKG QRS axis QRS voltages R/S ratio T axis

4. The Problem Damn kids keep growing!!! –They start life with dominance of the RV –By 6-8 weeks they have corrected to a LV dominated system –The normal intervals and wave amplitudes change as they age –They finally fall in line and become “big people” only when they are 16 years old

5. Solutions Option 1: Memorize a ton of charts and tables of normal values Option 2: Keep these in your palm pilot to reference every 5-10 minutes until step one has occurred Option 3: Ignore any and all EKGs done in the Peds ED

6. The “Alternative” Solution Step 1: Remember a few simple screening parameters that will allow you to rapidly assess an EKG to look for RVH and LVH in pediatric patients Step 2: Let the cardiologist remember all the numbers and charts

7. RVH

8. CRITERIA FOR RVH 1) RAD for the patient's age 2) Increased rightward and anterior QRS voltages a) R in V1, V2, or aVR greater than the upper limits of normal for the patient's age b) S in I and V6 greater than the upper limits of normal for the patient's age * Note: Assumes QRS is not widened for age indicating abnormal conduction delay 3) Abnormal R/S ratio in favor of the RV a) R/S ratio in V1 and V2 greater than the upper limits of normal for age b) R/S ratio in V6 less than 1 after one month of age

9. 1) RAD for patient age Lead I = 0°Lead AVL = -30° Lead II = +60° Lead AVR = -150° Lead AVF = +90° Lead III = +120°

10. Mean and Ranges of Normal QRS Axes by Age AgeMean (Range) 1 wk-1 mo+110° (+30 to +180) 1-3 mo+70° (+10 to +125) 3 mo-3 yr+60° (+10 to +110) Older than 3 yr+60° (+20 to +120) Adult+50° (-30 to +105)

11. 2) Increased rightward and anterior QRS voltages R in V1, V2, or aVR greater than the upper limits of normal for the patient's age S in I and V6 greater than the upper limits of normal for the patient's age

12. R and S Voltages: Mean (and Upper Limits of Normal) According to Lead and Age AgeR voltage in V1S voltage in V6 0-1 mo15 (25)4 (12) 1-6 mo11 (20) 2 (7) 6 mo-1yr 10 (20)2 (6) 1-3yr9 (18)2 (6) 3-8yr7 (18)1 (5) 8-12yr6 (16)1 (4) 12-16yr5 (16)1 (5) Young Adults3 (14)1 (13) * Voltages are measured in millimeters, when 1 mV = 10 mm paper

13. 3) Abnormal R/S ratio in favor of the RV R/S ratio in V1 and V2 greater than the upper limits of normal for age R/S ratio in V6 less than 1 after one month of age

14. R/S Ratio: Mean and Upper and Lower Limits of Normal According to Age V1 Lead VI AgeLLNMeanULN 0-1mo0.51.519 1-6mo0.31.5S=0 6mo-1yr0.31.26 1-3yr0.50.82 3-8yr0.10.652 8-12yr0.150.51 12-16yr0.10.31 Adults0.00.31 *LLN = lower limits of normal; ULN = upper limits of normal From Guntheroth WB: Pediatric Electrocardiography. Philadelphia, WB Saunders, 1965

15. Screening criteria for RVH 1)RAD greater than +120° in any child over 1 month is highly suggestive of RVH 2)Upright T in V1 In patients > 3 days and < 6yr old Provided that the T is upright in the left precordial leads (V5, V6) 3)Q wave in V1 always suggests RVH 4) S wave > R wave in Lead V6

16. LVH

17. CRITERIA FOR LVH 1)LAD for the patient's age 2)QRS voltages in favor of the LV a)R in I, II, III, aVL, aVF, V5, or V6 greater than the upper limits of normal for age b)S in V1 or V2 greater than the upper limits of normal for age 3) Abnormal R/S ratio in favor of the LV –R/S ratio in V1 and V2 less than the lower limits of normal for the patient's age

18. 1) LAD for patient age Lead I = 0°Lead AVL = -30° Lead II = +60° Lead AVR = -150° Lead AVF = +90° Lead III = +120°

19. Mean and Ranges of Normal QRS Axes by Age AgeMean (Range) 1 wk-1 mo+110° (+30 to +180) 1-3 mo+70° (+10 to +125) 3 mo-3 yr+60° (+10 to +110) Older than 3 yr+60° (+20 to +120) Adult+50° (-30 to +105)

20. 2) QRS voltages in favor of the LV R in I, II, III, aVL, aVF, V5, or V6 greater than the upper limits of normal for age S in V1 or V2 greater than the upper limits of normal for age

21. R Voltages: Mean (Upper Limits of Normal) According to Lead and Age R voltage AgeLead ILead IILead III 0-1mo4(8)6(14)8(16) 1-6mo7(13)13(24)9(20) 6mo-1yr8(16)13(27)9(20) 1-3yr8(16)13(23)9(20) 3-8yr7(15)13(22)9(20) 8-12yr7(15)14(24)9(24) 12-16yr6(13)14(24)9(24) Young Adults6(13)9(25)6(22) * Voltages are measured in millimeters, when 1 mV = 10 mm paper From Park MK, Guntheroth WG: How to Read Pediatric ECGs, 3rd ed. St. Louis, Mosby, 1992.

22. S Voltages: Mean (Upper Limits of Normal) According to Lead and Age S voltage Age Lead VI Lead V2 0-1mo10(20)20(35) 1-6mo7(18)16(30) 6mo-1yr8(16)17(30) 1-3yr13(27)21(34) 3-8yr14(30)23(38) 8-12yr16(26)23(38) 12-16yr15(24)23(48) Young Adults10(23)14(36) * Voltages are measured in millimeters, when 1 mV = 10 mm paper From Park MK, Guntheroth WG: How to Read Pediatric ECGs, 3rd ed. St. Louis, Mosby, 1992.

23. 3) Abnormal R/S ratio in favor of the LV R/S ratio in V1 and V2 less than the lower limits of normal for the patient's age *Note that lead V2 is in ½ normal standardization

24. R/S Ratio: Mean and Upper and Lower Limits of Normal According to Age V1 Lead VI AgeLLNMeanULN 0-1mo0.51.519 1-6mo0.31.5S=0 6mo-1yr0.31.26 1-3yr0.50.82 3-8yr0.10.652 8-12yr0.150.51 12-16yr0.10.31 Adults0.00.31 *LLN = lower limits of normal; ULN = upper limits of normal From Guntheroth WB: Pediatric Electrocardiography. Philadelphia, WB Saunders, 1965

25. Screening Criteria for LVH 1)LAD less than +10° is highly suggestive of LVH 2)S wave in lead V1 greater than 20mm 3)Q in V6, ≥5 mm suggests LVH With LV diastolic overload

26. In Summary If under 1 month all bets are off!!! Step 1 –Look at the axis: > +120° suggests RVH < +10° suggests LVH Step 2 –Look at lead V1: Upright T or Q-wave in V1 suggests RVH Large S wave >20mm suggests LVH

27. In Summary Step 3 –Look at lead V6: S wave > R wave suggests RVH Q wave > 5mm suggests LVH

28. Case 1 1 month old with heart murmur

29. Case 2 8yo with heart murmur

30. Case 3 4yo Female with CP

31. Case 4 2yo M

32. Case 5 8mo Female

33. Questions???

34. References Park: Pediatric Cardiology for Practitioners, 4th ed., Copyright © 2002 Mosby, Inc. Guntheroth WB: Pediatric Electrocardiography. Philadelphia, WB Saunders, 1965. Park MK, Guntheroth WG: How to Read Pediatric ECGs, 3rd ed. St. Louis, Mosby, 1992.