These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Eugene H Chung, MD, FACC The left atrial index was also higher in the hypertensive group, 2.18 +/- 0.45 versus 1.88 +/- 0.10 cm/m2 (p less than 0.05), and the left atrial-to-aortic root dimension ratio was significantly higher in the hypertensive group, 1.36 +/- 0.20 versus 1.17 +/- 0.07 (p less than 0.01). Learn how your comment data is processed. Assessing the causal role of hypertension on left atrial and left ventricular structure and function: A two-sample Mendelian randomization study. Treatment is not usually necessary as Mitral Valve Prolapse is rarely a serious condition. Wide P wave with prominent negative component. . In addition, in lead V1, the depth of the negative final component is greater than the height of the initial part. The negative deflection of biphasic (diphasic) P-waves is generally <1 mm deep. poss left atrial enlargement Look for other features of arrhythmogenic cardiomyopathy if the preceding J-point is not elevated. 2022 Nov 2;9:1006380. doi: 10.3389/fcvm.2022.1006380. But this change is not associated or caused by anxiet Anxiety isn't a cause of left atrial enlargement. Specific treatment for mitral valve prolapse will be determined by your doctor based on: Your tolerance for specific medications, procedures, or therapies, Expectations for the course of the disease. T wave inversions in contiguous inferior leads or lateral leads warrant investigation in all athletes. Normally taking a b complex vi Left atrial enlargement itself has no symptoms. J Electrocardiol. The normal Pwave measures less than 2.5mm (0.25mV) in height and less than 0.12s in length (3small squares). Clin Cardiol. The overflow capacity of attendees and number of live streaming participants exceeded 220 in total. The negative intrathoracic pressure may cause the left atrium to expand and stretch its walls during each OSA event. 1989 Jun;117(6):1409-10. doi: 10.1016/0002-8703(89)90455-9. Results of the PAMELA Study. This regurgitation may result in a murmur (abnormal sound in the Also known as: Left Atrial Enlargement (LAE), Left atrial hypertrophy (LAH), left atrial abnormality. For example, because of the smaller distance in the thoracic cavity between the sternum and spine, compared to the other directions, less room exists for enlargement of the left atrium along the anteroposterior axis. Ekg says "borderline ecg" and "probable left atrial enlargement." Additional procedures may include: Stress test (also called treadmill or exercise ECG). The Septal Q wave can hint on a possible left sided disease if any. Find more COVID-19 testing locations on Maryland.gov. Hypertension The presence of electrocardiographic signs of left atrial enlargement is one of the criteria for the diagnosis of left ventricular hypertrophy (LVH), this is one of the few signs of LVH detectable on the EKG in patients with right bundle branch block (read left ventricular hypertrophy). 2014 Mar 4;9(3):e90903. P-waves with constant morphology preceding every QRS complex. Normally the flaps are held tightly closed during left ventricular contraction (systole) by the chordae tendineae (small tendon "cords" that connect the flaps to the muscles of the heart). 2015 Aug 7;16(8):18454-73. doi: 10.3390/ijms160818454. Mitral Valve Prolapse may be detected by listening with a stethoscope, revealing a "click" (created by the stretched flaps snapping against each other during contraction) and/or a murmur. 2016 Aug 1;116(2):206-19. doi: 10.1160/TH15-12-0923. Right Atrial Enlargement (RAE) ECG Review | Learn the Heart - Healio Moreover, the P-wavemay be slightly biphasic (diphasic) in lead V1, implying that the terminal part of the P-wave is negative (Figure 1, upper panel). [7] However, if atrial fibrillation is present, a P wave would not be present. ECG criteria for LAE and RAE were assessed by an expert observer blinded to CMR data. This is often (but not always) seen on ordinary ECG tracings and it is explained by the fact that the atria are depolarized sequentially, with the right atrium being depolarized before the left atrium. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Medications. Left atria is one of the chamber of heart out of four chambers its situated above left ventricle it takes oxygenated blood from lungs and forward it to left ventrical so if the left atrial is enlarged it is most commonly in association with diastolic dysfunction, left ventricular hypertrophy, mitral valvular disease, and systemic hypertension. Sinus bradycardia fulfills the criteria for sinus rhythm but the heart rate is slower than 50 beats per minute. borderline/ normal ecg margin-top: 20px; Necessary cookies are absolutely essential for the website to function properly. 2. The ECG has, as one could expect, low sensitivity but high specificity with respect todetecting atrial enlargement. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. Study technics (electrocardiogram, echocardiography, exercise test and Holter]. This category only includes cookies that ensures basic functionalities and security features of the website. measurement results are as follows: qrs 68ms qtqtcb 376-441ms pr 140ms p 102ms rr-pp 726-720ms p-qrs-t 79-66-7? Dr. Jerome Zacks answered. LAE is often a precursor to atrial fibrillation. Echocardiography is the most useful diagnostic test for Mitral Valve Prolapse. PMC #mergeRow-gdpr fieldset label { 2014; 64: 1205-1211. doi: 5. Cookie Notice eCollection 2014. Blood and urine tests may be done to check for conditions that affect heart health. At Another Johns Hopkins Member Hospital: Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov. In addition, the function of the heart and the valves may be assessed. The latter study also showed that the persistent type of AF was associated with LAE, but the number of years that a subject had AF was not. The presence of left axis deviation, right axis deviation, voltage criterion for left atrial enlargement, voltage criterion for right atrial enlargement or voltage criterion for right ventricular hypertrophy in isolation or with other Group 1 changes (e.g., sinus bradycardia, first degree AVB, incomplete right bundle branch block [RBBB], early repolarization, isolated QRS voltage criteria for . Atrial volume index was computed using the biplane area-length method. However, studies that have found LAE to be a predictor for mortality recognize the need for more standardized left atrium measurements than those found in an echo-cardiogram. Atrial Fibrillation/Supraventricular Arrhythmias, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Revascularization for Ischemic Ventricular Dysfunction, ACC.23/WCC Opening Showcase Presidential Address: Edward T. A. Fry, MD, FACC, Personalized Pacing: A New Paradigm for Patients With Diastolic Dysfunction or Heart Failure With Preserved Ejection Fraction, Atrial Fibrillation Ablation for Heart Failure With Preserved Ejection Fraction, Findings From NCDR AFib Ablation Registry, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism. Also known as: Right Atrial Enlargement (RAE), Right atrial hypertrophy (RAH), right atrial abnormality. Mechanism of left atrial enlargement related to ventricular diastolic impairment in hypertension. Int J Mol Sci. The site is secure. Ecg borderline left atrial abnormality Ecg borderline left atrial abnormality Share this page Hi, My sister was having a pain on left side under her arm pit and shoulder since a month. The murmur is caused by some of the blood leaking back into the left atrium. EKG Left Atrial Enlargement l The EKG Guy - www.ekg.md Join the largest ECG community in the world at https://www.facebook.com/TheEKGGuy/Like this video and . My EKG team recomends you the books that we used to create our website. Alternately the left atrial enlargement might have caused the AF. Permanent symptomatic bradycardias are treated with artificial pacemakers. Surawicz B, et al. No patient met ECG criteria for left atrial abnormality. Left atrial enlargement can develop too, resulting in problems with how blood is pumped out to the body. A pathological Q-wave (depth exceeding 25% of the height of proceeding R wave) is abnormal. sharing sensitive information, make sure youre on a federal Please note, we cannot prescribe controlled substances, diet pills, antipsychotics, or other abusable medications. An axis of 57 degrees is not a 'ri Had an ecg that showed borderline abnormal, possible left atrial enlargement. worrisome? To confirm left atrial enlargement, the best investigation would be an ECHO. These ECG changes, including T-wave inversions, can often return to normal with detraining (see below ECGs); outside the context of age <16 years and black ethnicity, T wave inversions beyond V2 should be investigated. Hypertension. Read More Created for people with ongoing healthcare needs but benefits everyone. Left atrial enlargement: Sinus bradycardia fulfills the criteria for sinus rhythm but the heart rate is slower than 50 beats per minute. Before Video chat with a U.S. board-certified doctor 24/7 in less than one minute for common issues such as: colds and coughs, stomach symptoms, bladder infections, rashes, and more. P wave changes with Left Atrial Enlargement ECG Criteria for Left Atrial Enlargement They show how a patient's heart is beating in real-time. Also, LAE is a significant risk factor for developing atrial fibrillation. The early repolarization pattern accompanied by concave ST segment elevation is seen in 25-40% of highly trained athletes; more common among males, black athletes and those with voltage criteria for LVH; usually seen in leads V5 and V6. results read "normal sinus rhythm with sinus arrhythmia. The primary form of Mitral Valve Prolapse is seen frequently in people with Marfan's Syndrome or other inherited connective tissue diseases, but is most often seen in people with no other form of heart disease. Tests used to diagnose left ventricular hypertrophy may include: Lab tests. Barlow's syndrome, balloon mitral valve, or floppy valve syndrome, 1996 Dec;19(12):954-9. doi: 10.1002/clc.4960191211. The EKG is just a guidance to help us . Without seeing the ecg and only given what you wrote, it isn't possible to know whether the ecg is abnormal or not. Weight gain. Note that sinus bradycardia due to ischemia located to the inferior wall of the left ventricle is typically temporary and resolves within 12 weeks (sinus bradycardia due to infarction/ischemia is discussed separately). In association with left ventricular hypertrophy: Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. It is important to note that in patients with ischemic heart disease, wide Pwaves with a left atrium of normal dimensions can be observed, probably due to a delay of the atrial conduction. In order to determine if echocardiographic left atrial enlargement is an early sign of hypertensive heart disease, we evaluated 10 normal and 14 hypertensive patients undergoing routine diagnostic cardiac catheterization for echocardiographic left atrial enlargement. Left atrial enlargement is also referred to as P mitrale, and right atrial enlargement is often referred to as P pulmonale. Chou's Electrocardiography in Clinical Practice: Adult and Pediatric, Sixth Edition, Saunders, Philadelphia, 2008. [2] LAE has been found to be correlated to body size, independent of obesity, meaning that LAE is more common in people with a naturally large body size. The reasons for this are explained below. All patients had normal coronary arteriography, sinus rhythm, normal left ventricular volumes and function, no valvular disease, and no echocardiographic or ECG left ventricular hypertrophy. Dreslinski GR, Frohlich ED, Dunn FG, Messerli FH, Suarez DH, Reisin E. Am J Cardiol. In an asymptomatic athlete, RBBB in isolation with QRS duration <140msec and in the absence of significant repolarization abnormalities does not warrant further investigation. In these cases, it is the morphology of the P wave in lead V1 that allows us to determine if there is a left atrial enlargement associated with interatrial block. Left atrial enlargement (LAE) or left atrial dilation refers to enlargement of the left atrium (LA) of the heart, and is a form of cardiomegaly. Left Atrial Enlargement (LAE) ECG Review | Learn the Heart - Healio Simple guide to reading and reporting an EKG step by step. ECG criteria follows: Regular rhythm with ventricular rate slower than 50 beats per minute. eCollection 2022. All rights reserved. The echo sound waves create an image on the monitor as an ultrasound transducer is passed over the heart. On this Wikipedia the language links are at the top of the page across from the article title. possible left atrial enlargement borderline ecg. Other effects are fibrosis (scarring) of the flap surface, thinning or lengthening of the chordae tendineae, and fibrin deposits on the flaps. To learn more, please visit our. For these, please consult a doctor (virtually or in person). (P wave 2.5 mm in II and aVF). 1995; 25: 1155-1160. doi: 4. Summarizing: The most striking sign of the left atrial enlargement is a wide Pwave, greater than 0.12s or 3small squares, with a predominance of the negative final component in leadV1. Front Cardiovasc Med. Note that left atrial enlargement is not able to be diagnosed in the presence of atrial fibrillation because this rhythm is defined by erratic atrial activity and no visible P wave on the ECG. Connect with a U.S. board-certified doctor by text or video anytime, anywhere. Its not uncommon to discover SB in healthy young individuals who are not well-trained. last week ecg read: AO 1.8 and ECG criteria independent of left atrial indexed diameter z-score C1: P wave duration 110msec C2 . I'm 68 fem ale, normal weight, swim 3hours a week, practice QiGong, read more DrKarenB Family Medicine Physician MD 373 satisfied customers Can you please read this? Please feel free to contact Chris Driver (cdriver@acc.org) or me (chungeug@umich.edu) with any questions. 2017 ecg normal. margin-right: 10px; Conditions affecting the left side of the heart. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. 8600 Rockville Pike Patients with bradycardia due to myocardial ischemia/infarction only demand treatment if cardiac output is compromised or if the bradycardia predisposes to more malign arrhythmias (the algorithm above applies to this situation as well). Related article: Bays syndrome and interatrial blocks. Doctors typically provide answers within 24 hours. P-waves with constant morphology preceding every QRS complex. Educational text answers on HealthTap are not intended for individual diagnosis, treatment or prescription. Top answers from doctors based on your search: Created for people with ongoing healthcare needs but benefits everyone. By accepting all cookies, you agree to our use of cookies to deliver and maintain our services and site, improve the quality of Reddit, personalize Reddit content and advertising, and measure the effectiveness of advertising. Conditions that lead to left atrial enlargement include hypertension, heart valve problems, heart failure and atrial fibrillation 1. Circ Cardiovasc Imaging. These symptoms include weakness, fatigue, and shortness of breath. A test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and can sometimes detect heart muscle damage. References: The duration of the P-wave will exceed 120 milliseconds in lead II. Benign causes of sinus bradycardia (SB) do not require treatment. New York, NY A 29-year-old female asked: Ekg says "borderline ecg" and "probable left atrial enlargement." is this anything of concern? [1] Also, a study found that LAE can occur as a consequence of atrial fibrillation (AF),[3] although another study found that AF by itself does not cause LAE. Heart palpitations. LAFB occurs when the anterior fascicle of the left bundle branch can no longer conduct action potentials. Figure 1. Unconfirmed means a cardiologist hasn't reviewed the EKG yet. Clinical electrocardiography and ECG interpretation, Cardiac electrophysiology: action potential, automaticity and vectors, The ECG leads: electrodes, limb leads, chest (precordial) leads, 12-Lead ECG (EKG), The Cabrera format of the 12-lead ECG & lead aVR instead of aVR, ECG interpretation: Characteristics of the normal ECG (P-wave, QRS complex, ST segment, T-wave), How to interpret the ECG / EKG: A systematic approach, Mechanisms of cardiac arrhythmias: from automaticity to re-entry (reentry), Aberrant ventricular conduction (aberrancy, aberration), Premature ventricular contractions (premature ventricular complex, premature ventricular beats), Premature atrial contraction(premature atrial beat / complex): ECG & clinical implications, Sinus rhythm: physiology, ECG criteria & clinical implications, Sinus arrhythmia (respiratory sinus arrhythmia), Sinus bradycardia: definitions, ECG, causes and management, Chronotropic incompetence (inability to increase heart rate), Sinoatrial arrest & sinoatrial pause (sinus pause / arrest), Sinoatrial block (SA block): ECG criteria, causes and clinical features, Sinus node dysfunction (SND) and sick sinus syndrome (SSS), Sinus tachycardia & Inappropriate sinus tachycardia, Atrial fibrillation: ECG, classification, causes, risk factors & management, Atrial flutter: classification, causes, ECG diagnosis & management, Ectopic atrial rhythm (EAT), atrial tachycardia (AT) & multifocal atrial tachycardia (MAT), Atrioventricular nodal reentry tachycardia (AVNRT): ECG features & management, Pre-excitation, Atrioventricular Reentrant (Reentry) Tachycardia (AVRT), Wolff-Parkinson-White (WPW) syndrome, Junctional rhythm (escape rhythm) and junctional tachycardia, Ventricular rhythm and accelerated ventricular rhythm (idioventricular rhythm), Ventricular tachycardia (VT): ECG criteria, causes, classification, treatment, Long QT (QTc) interval, long QT syndrome (LQTS) & torsades de pointes, Ventricular fibrillation, pulseless electrical activity and sudden cardiac arrest, Pacemaker mediated tachycardia (PMT): ECG and management, Diagnosis and management of narrow and wide complex tachycardia, Introduction to Coronary Artery Disease (Ischemic Heart Disease) & Use of ECG, Classification of Acute Coronary Syndromes (ACS) & Acute Myocardial Infarction (AMI), Clinical application of ECG in chest pain & acute myocardial infarction, Diagnostic Criteria for Acute Myocardial Infarction: Cardiac troponins, ECG & Symptoms, Myocardial Ischemia & infarction: Reactions, ECG Changes & Symptoms, The left ventricle in myocardial ischemia and infarction, Factors that modify the natural course in acute myocardial infarction (AMI), ECG in myocardial ischemia: ischemic changes in the ST segment & T-wave, ST segment depression in myocardial ischemia and differential diagnoses, ST segment elevation in acute myocardial ischemia and differential diagnoses, ST elevation myocardial infarction (STEMI) without ST elevations on 12-lead ECG, T-waves in ischemia: hyperacute, inverted (negative), Wellen's sign & de Winter's sign, ECG signs of myocardial infarction: pathological Q-waves & pathological R-waves, Other ECG changes in ischemia and infarction, Supraventricular and intraventricular conduction defects in myocardial ischemia and infarction, ECG localization of myocardial infarction / ischemia and coronary artery occlusion (culprit), The ECG in assessment of myocardial reperfusion, Approach to patients with chest pain: differential diagnoses, management & ECG, Stable Coronary Artery Disease (Angina Pectoris): Diagnosis, Evaluation, Management, NSTEMI (Non ST Elevation Myocardial Infarction) & Unstable Angina: Diagnosis, Criteria, ECG, Management, STEMI (ST Elevation Myocardial Infarction): diagnosis, criteria, ECG & management, First-degree AV block (AV block I, AV block 1), Second-degree AV block: Mobitz type 1 (Wenckebach) & Mobitz type 2 block, Third-degree AV block (3rd degree AV block, AV block 3, AV block III), Management and treatment of AV block (atrioventricular blocks), Intraventricular conduction delay: bundle branch blocks & fascicular blocks, Right bundle branch block (RBBB): ECG, criteria, definitions, causes & treatment, Left bundle branch block (LBBB): ECG criteria, causes, management, Left bundle branch block (LBBB) in acute myocardial infarction: the Sgarbossa criteria, Fascicular block (hemiblock): left anterior & left posterior fascicular block on ECG, Nonspecific intraventricular conduction delay (defect), Atrial and ventricular enlargement: hypertrophy and dilatation on ECG, ECG in left ventricular hypertrophy (LVH): criteria and implications, Right ventricular hypertrophy (RVH): ECG criteria & clinical characteristics, Biventricular hypertrophy ECG and clinical characteristics, Left atrial enlargement (P mitrale) & right atrial enlargement (P pulmonale) on ECG, Digoxin - ECG changes, arrhythmias, conduction defects & treatment, ECG changes caused by antiarrhythmic drugs, beta blockers & calcium channel blockers, ECG changes due to electrolyte imbalance (disorder), ECG J wave syndromes: hypothermia, early repolarization, hypercalcemia & Brugada syndrome, Brugada syndrome: ECG, clinical features and management, Early repolarization pattern on ECG (early repolarization syndrome), Takotsubo cardiomyopathy (broken heart syndrome, stress induced cardiomyopathy), Pericarditis, myocarditis & perimyocarditis: ECG, criteria & treatment, Eletrical alternans: the ECG in pericardial effusion & cardiac tamponade, Exercise stress test (treadmill test, exercise ECG): Introduction, Indications, Contraindications, and Preparations for Exercise Stress Testing (exercise ECG), Exercise stress test (exercise ECG): protocols, evaluation & termination, Exercise stress testing in special patient populations, Exercise physiology: from normal response to myocardial ischemia & chest pain, Evaluation of exercise stress test: ECG, symptoms, blood pressure, heart rate, performance, Normal (physiological) causes of sinus bradycardia, Abnormal (pathological) causes of sinus bradycardia, Treatment of sinus bradycardia: general aspects of management, Algorithm for acute management of bradycardia, Permanent (long-term) treatment of bradycardia, sinus bradycardia due to infarction/ischemia, conduction defects caused byischemia and infarction. Cardiac Magnetic Resonance-Measured Left Atrial Volume and Function and Incident Atrial Fibrillation: Results From MESA (Multi-Ethnic Study of Atherosclerosis). Read More Created for people with ongoing healthcare needs but benefits everyone. Electrocardiogram (ECG) This imaging test records the electrical actions of the heart, including the speed of the heartbeats. Expert Rev. Right atrial enlargement (hypertrophy) leads to stronger electrical currents and thus enhancement of the contribution of the right atrium to the P-wave. The Diagnostic Yield of Routine Electrocardiography in Hypertension and Implications for Care in a Southwestern Nigerian Practice. Biatrial abnormality implies that the ECG indicates both left and right atrial enlargement; i.e a large P-wave in lead II and a large biphasic P-wave in lead V1. Taina M, Sipola P, Muuronen A, Hedman M, Mustonen P, Kantanen AM, Jkl P, Vanninen R. PLoS One. Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. For the most common type of sinus arrhythmia, the time between heartbeats can be slightly shorter or longer depending on whether you're breathing in or out. Athletes with left axis deviation or left atrial enlargement exhibited larger left atrial and ventricular dimensions compared with athletes with a normal ECG and those with other . and transmitted securely. Electrocardiogram (ECG or EKG). Atrial fibrillation is both cause and effect of left atrial enlargement, although the presence of AF on the EKG makes it difficult to determine left atrial enlargement signs, because P waves are absent4. This is calledP mitrale, because mitral valve disease is a common cause (Figure 1). Privacy Policy. Disclaimer. 1 doctor answer 5 doctors weighed in Share Dr. John Munshower answered Family Medicine 32 years experience ECG criteria for left (LAE) and right atrial enlargement (RAE) were compared to CMR atrial volume index measurements for 275 consecutive subjects referred for CMR (67% males, 51 14 years). While left atrial enlargement can cause chest pain and breathing problems, alerting you to the dangerous condition, right atrial enlargement usually develops with no symptoms at all. The normal P wave measures less than 2.5 mm (0.25 mV) in height and less than 0.12 s in length (3 small squares). These cookies do not store any personal information. Join our newsletter and get our free ECG Pocket Guide! Echocardiographic diastolic ventricular abnormality in hypertensive heart disease: atrial emptying index. Calculates the QTc interval by entering QTinterval andHR, How not to overlook EKG changes in acute myocardial infarction, Detailed description of each of the EKG wave. This site needs JavaScript to work properly. could the abnormal been anxiety produced?, and is it something to be worried about? Right atrial enlargement means your heart has an abnormally large right atrium. In case of sale of your personal information, you may opt out by using the link. This rule does not apply to aVL. Difficulty breathing. Bombelli M, Facchetti R, Cuspidi C et al. Sinus bradycardia <40 bpm, Mobitz type 1 second degree AVB and junctional rhythm are not uncommon and don't warrant further investigation in asymptomatic athletes. Symptoms may vary depending on the degree of prolapse present and may include: Palpitations. Cardiac MRI. [8] In any case, LAE can be diagnosed and measured using an echocardiogram (ECHO) by measuring the left atrial volume (LAVI). Alterations of the mitral valve are the classic causes of left atrial enlargement, both mitral stenosis due to increased pressure, and mitral insufficiency due to volume increase. BMJ 2002;324:1264. doi: 3. 2023 American College of Cardiology Foundation. If a Type 2 pattern is seen, the ECG needs to repeated to ensure proper lead placement, and a repeat ECG with V1 and V2 in higher intercostal leads should be performed: if there is no evidence of a Type 1 Brugada pattern, no further assessment is required unless there is a history of syncope or relevant family history. An abnormal right axis can also occur in conditions with elevated right . For the person with symptoms of dizziness or fainting, maintaining adequate hydration (fluid volume in the blood vessels) with liberal salt and fluid intake is important. [Heart effect of arterial hypertension. Your findings of low voltage QRS and borderline left atrial enlargement may not be significant, but it is worthwhile to have a cardiologist evaluate y You took a b complex viramin then felt ill and went to ED. Conditions affecting the left side of the heart, Electrocardiography in Emergency, Acute, and Critical Care, Critical Decisions in Emergency and Acute Care Electrocardiography, Chous Electrocardiography in Clinical Practice: Adult and Pediatric, Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, Bifid P wave with > 40 ms between the two peaks, Biphasic P wave with terminal negative portion > 40 ms duration, Biphasic P wave with terminal negative portion > 1mm deep, Broad (>110ms), bifid P wave in lead II (P mitrale) with > 40ms between the peaks.