If we see a peaked P wave in lead 2,3 or avf and it's due to RVH secondary to COPD, does this also indicate that atria is generating it's own rhythm?
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COPD P pulmonale peaked P wave right atrial enlargement ECG
No. A peaked P wave in II, III, and aVF, called P pulmonale, mainly indicates a right atrial enlargement or increased right atrial depolarization vector. In COPD, this may occur with pulmonary hypertension, cor pulmonale, and often RV hypertrophy.
It does not by itself mean the atrium has an independent or ectopic rhythm.
To determine that the rhythm is sinus versus atrial ectopic, check the P-wave axis and relationship to QRS:
- Sinus rhythm: P waves are upright in II and usually III/aVF, negative in aVR, and each P is followed by a QRS with a consistent PR interval.
- Ectopic atrial rhythm: P-wave morphology/axis is abnormal for sinus origin, often negative in the inferior leads if the impulse originates low in the atrium and travels upward.
- Atrial fibrillation: no discrete P waves.
- Multifocal atrial tachycardia, which can occur in COPD: at least 3 distinct P-wave morphologies, irregular rhythm, and variable PR intervals.
So, a tall pointed P wave is about atrial size/vector, not proof that the atrium is pacing independently. The medical texts describe P pulmonale as a marker of right atrial enlargement, often alongside RVH in cor pulmonale. MSD ECG reference
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