5d • General discussion
His right heart was begging
He’s in his mid-70s
Ex-smoker. Struggling for air
Cough that shakes the bed.
You print the ECG - and the story unfolds before the monitor even stops scrolling
Right-axis deviation.
Towering P waves in leads II, III, aVF.
Barely any R waves in V1–V3.
Deep S waves in V5
And a heart twisted vertically like it’s gasping for room.
This isn’t a left-heart problem.
It’s a lung problem written in electricity.
Cor pulmonale - chronic pulmonary strain.
Years of COPD, hypoxia, and back-pressure sculpted into this tracing
Here’s what’s happening:
Every breath he’s ever fought for forced the right ventricle to bulk up and twist the heart’s axis.
The result?
P pulmonale.
Right-axis deviation.
Low voltage left leads
The full electrical fingerprint of a lung-driven heart.
The danger?
People chase the oxygen, the infection, the wheeze -
and miss the story that’s right there on paper.
Because this isn’t “just COPD.”
It’s the right heart on its knees.
A useful teaching shortcut:
Cor pulmonale = right atrium + right ventricle under pressure
So on the ECG, look for P pulmonale + RAD + RVH ± RV strain/RBBB.
Importantly, none of these findings alone diagnoses cor pulmonale. The ECG in cor pulmonale may even be relatively unremarkable, and the diagnosis ultimately depends on the clinical picture and cardiac/pulmonary assessment.
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His right heart was begging
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