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Case #20

You are in youre office and the next patient is here. He is a 59 year old male here becaues his "daughter made him come in for a physical". He has no chief complaint except for a hacking cough in the morning which has been present for a while and does not bother him. He says besides that he "has no medical problems". He also says he cant remember when is the last time he saw a doctor. He does admit to smoking 2 PPD x 20 years. He takes no medications, he has no known drug allergies. On physical exam his BP is 125/80, pulse is 92, and he is breathing at 17. Physical exam is normal except for distant heart sounds, upper airway transmission and some mild end expiratory wheezing in both lung fields. You tell him you want to get a baseline EKG as he says he has never got one before. The EKG is below, what is your read and what is suggested by it?

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This EKG is a an example of COPD Pattern or Pulmonary Disease Pattern. Starting from the beginning it is Sinus Rhythm @ 96. What leads us to the COPD pattern is the findings in the QRS.

First off the Axis is +110 with AVR being the most isolectric deeming the axis in the >90 degress quadrant. The next clue is in the precordial leads. The main forces have moved posterior. Notice there really is no R>S in the entire v1-v6. The final hint is the Voltage of frontal plane leads are all less than 5 mm. So how do all these findings connect?

In COPD the diaphrams are flattened leading to a more vertical position of the heart. This makes the main vector of the QRS, usually pointing Down and to the left, now pointing posterior and to the right. The Vector Basically rotates on a clockwise axis with the heart and posteriorly. That leads to the Right axis deviation. The Voltage findings happen for two reasons. First air is a poor conductor of electricity, and in COPD you have a lot of air trapping and hyperinflation leading to decrease in lead voltage. You also get a decrease in the voltages, especially in the anterior leads due to the now posterior direction of the main vector making them more perpendicular to the leads, and as you can recall, the more perpendicular to a lead, the lesser the deflection in that lead. And finally the posterior vector now leads to the findings in the precordial leads with no real R>S.