The 5 findings (pentalogy) seen in pulmonary emphysema:
(1) prominent P waves in leads II, III and aVF.
(2) exaggerated atrial repolarization (TP or Ta) waves, resulting in ST segment depression greater than 1 mm (0.1 mV) in leads II, III and aVF.
(3) vertical cardiac position in the frontal plane: The QRS axis is usually directed inferiorly (+90°) but occasionally may be direct superiorly (-90°). It is usually not inclined much to either side.
(4) marked clockwise rotation, with decreased progression of the R wave amplitude in the precordial leads (V1 to V6). This is sometimes called poor R wave progression.
(5) tendency to generalized low voltage in the QRS complexes, particularly in the left precordial leads (V4 – V6)
Poor R wave progression:
(1) Normally the R wave is small and the S wave large in V1, with the R wave becoming larger and the S wave smaller as precordial leads progress to V6. The R wave and S wave have similar amplitudes in V3 or V4.
(2) In poor R wave progression the R waves are small and the point of equal amplitude for R and S waves is V4 or V5.
