A 65-Year-Old Man With a Cough and Worsening Dyspnea

Joshua M. Kosowsky, MD


April 09, 2020

The disease is not generally diagnosed on the basis of ECG findings; however, the signs and symptoms of cardiac and pulmonary disease may overlap substantially, and ancillary testing can be useful in establishing the diagnosis.[1] In fact, it may not be unusual for ECG to be the first diagnostic test performed in patients with long-standing COPD, if patients present with shortness of breath as part of a general work-up for a possible cardiac etiology for the symptoms. Knowledge of the usual ECG manifestations of COPD enables the clinician to recognize uncharacteristic abnormalities, which often represent the effects of superimposed illnesses or drug toxicity.[2]

A tachycardic rhythm is common in individuals who are experiencing exacerbations of their COPD as a compensatory mechanism for hypoxia or poor right ventricular function (in the setting of cor pulmonale). Sinus tachycardia is the most common form reported in the literature, but other supraventricular arrhythmias, such as atrial tachycardia (unifocal or multifocal), atrial fibrillation, and atrial flutter, can also be present.[3,4]

P pulmonale (ie, a P-wave amplitude > 2.5 mm) is frequently reported but is a relatively insensitive predictor of right atrial enlargement.[5] In patients with COPD, the amplitude of the P wave is in fact dynamic, and it tends to be more prominent during acute exacerbation than at other times.[6]

A vertical or rightward axis is another manifestation of pulmonary hypertension.[7] Similarly, complete or incomplete RBBB, right ventricular hypertrophy, or both commonly occur in patients with cor pulmonale.

Low voltage, particularly in the limb leads, is another ECG characteristic of patients with COPD. This finding is classically attributed to increased impedance through a hyperinflated chest; however, low voltage is not directly correlated with hyperinflation, and it is neither sensitive nor specific for COPD.[8]


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