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Study Highlights the Clinical Significance of Right Atrial Enlargement on ECG in Previously Healthy Young Patients

July 9, 2024

The Heart Institute at UPMC Children's Hospital of Pittsburgh recently conducted a study examining the correlation between right atrial enlargement (RAE) on electrocardiograms (ECGs) and true RAE confirmed by echocardiograms in previously healthy young patients.

The study, led by pediatric cardiology fellow Lindsay Haack, MD, and senior author Gaurav Arora, MD, director of cardiac electrophysiology at the Heart Institute, provides new insights into the diagnostic value and clinical implications of RAE observed on ECG.

The study was published in The Journal of Pediatrics in February 2024.

Study Overview and Important Findings

Dr. Arora and colleague’s study included a cohort of 162 young patients whose ECGs were initially interpreted as indicating RAE by a pediatric cardiologist. To confirm these findings, each patient also underwent an echocardiogram within 90 days of the initial ECG. The study's objective was to assess the positive predictive value (PPV) of RAE on ECG compared to echocardiogram results and to identify which patient subgroups might benefit from further cardiac evaluation.

The study showed that the PPV of RAE on ECG for true RAE on echocardiogram was relatively low at 14%. The PPV differed with age, increasing to 35% for patients under one year old, while dropping to 7% for those older than one year.

Patients with true RAE were more likely to meet RAE criteria in the anterior precordial leads (V1-V3), with a notable 48% versus 5% in patients without true RAE. Additionally, 22% of patients with true RAE also showed right ventricular hypertrophy (RVH) on ECG compared to 6% without true RAE.

Among those with true RAE, 74% were newly diagnosed with congenital heart disease (CHD), including conditions such as atrial septal defects and pulmonary stenosis.

What the Study Means for Clinical Practice

The findings from Dr. Arora and colleague’s study suggest that while RAE on ECG has a low overall predictive value for true RAE, like that seen in prior studies in adults, specific patient characteristics may be able to enhance the diagnostic accuracy. Younger patients, those with RAE findings from the anterior precordial leads, and those displaying RVH on ECG are more likely to have true RAE and may benefit from additional echocardiographic evaluation. The study also suggests that echocardiograms should be considered for patients under one year old with RAE on ECG, particularly if they also meet criteria in the anterior precordial leads or have RVH.

For older children with isolated RAE on ECG and no other abnormalities, the need for of an echocardiogram may be lower, which could potentially reduce unnecessary testing and associated health care costs.


Haack L, Das N, Hoskoppal A, DeBrunner M, Alsaied T, Arora G. Right Atrial Enlargement on Electrocardiogram in Previously Healthy Young Patients. J Pediatr. 2024; 265: 113814.