Mitral stenosis electrocardiogram

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

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The electrocardiogram (ECG) in mitral stenosis might have no significant abnormalities. Findings suggestive of left atrial enlargement and hypertrophy might be present, such as a broad, bifid P wave in lead II (referred to as P mitrale) and an enlarged terminal negative portion of the P wave in V1. The ECG might demonstrate findings of pulmonary hypertension and right ventricular hypertophy. Atrial fibrillation is not an uncommon finding among patients with mitral stenosis.


Left Atrial Enlargement

Left atrial enlargement produces a broad, bifid P wave in lead II (P mitrale) and enlarges the terminal negative portion of the P wave in V1.[1][2]

Shown below is an ECG depicting the following in lead II:[3]

  • Bifid P wave with > 40 ms between the two peaks
  • Total P wave duration > 110 ms
P mitrale.gif

Shown below is an ECG depicting the following in lead V1:[4]

  • Biphasic P wave with terminal negative portion > 40 ms duration
  • Biphasic P wave with terminal negative portion > 1mm deep
Left atrial enlargement as seen in lead V1

Copyleft image obtained courtesy of,

Right Ventricular Hypertrophy

ECG findings suggestive of right ventricular hypertrophy include:

  • Right axis deviation of +90 degrees or more
  • RV1 = 7 mm or more
  • RV1 + SV5 or SV6 = 10 mm or more
  • R/S ratio in V1 = 1.0 or more
  • S/R ratio in V6 = 1.0 or more
  • Late intrinsicoid deflection in V1 (0.035+)
  • Incomplete RBBB pattern
  • ST T strain pattern in 2,3,aVF
  • P pulmonale or Right atrial enlargement or P congenitale
  • S1 S2 S3 pattern in children
  • Tall R wave in V1 or qR in V1
  • R wave greater than S wave in V1
  • R wave progression reversal
  • Inverted T wave in the anterior precordial leads

Rigth Axis Deviation

In right axis deviation, the mean QRS axis in the frontal plane moves toward the right as pulmonary hypertension worsens.

Atrial Fibrillation

Atrial fibrillation is commonly seen with mitral stenosis. Atrial fibrillation is characterized by an irregularly irregular rhythm with absent P waves.

EKG Examples of Mitral stenosis

Shown below is an ECG image of a patient with mitral stenosis.

Left atrial enlargement, a 12 lead ECG

Copyleft image obtained courtesy of,


  1. Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). "Valvular heart disease: diagnosis and management". Mayo Clin Proc. 85 (5): 483–500. doi:10.4065/mcp.2009.0706. PMC 2861980. PMID 20435842.
  2. TROUNCE JR (1952). "The electrocardiogram in mitral stenosis". Br Heart J. 14 (2): 185–92. PMC 479442. PMID 14916061.
  3. Pérez-Riera, Andrés Ricardo; de Abreu, Luiz Carlos; Barbosa-Barros, Raimundo; Grindler, José; Fernandes-Cardoso, Acácio; Baranchuk, Adrian (2016). "P-wave dispersion: an update". Indian Pacing and Electrophysiology Journal. 16 (4): 126–133. doi:10.1016/j.ipej.2016.10.002. ISSN 0972-6292.
  4. Pérez-Riera AR, de Abreu LC, Barbosa-Barros R, Grindler J, Fernandes-Cardoso A, Baranchuk A (2016). "P-wave dispersion: an update". Indian Pacing Electrophysiol J. 16 (4): 126–133. doi:10.1016/j.ipej.2016.10.002. PMC 5197451. PMID 27924760.

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