Himalayan P waves

Himalayan P waves are tall (>5 mm) and peaked

Most prominent in lead II

Suggestive of enlargement of the right atrium.

Himalayan P waves

Classical for Ebstein anomaly

Also reported in –

  • Tricuspid atresia
  • Combined tricuspid and pulmonary stenosis.

Reported in

  1. Ebstein’s anomaly – Classically seen in this condition
  2. Tricuspid Atresia
  3. Tricuspid stenosis and pulmonary stenosis
  4. Several cardiomyopathies
  5. Chronic obstructive pulmonary disease.

Mechanism of Himalayan P waves

prolonged conduction of the electrical impulses throughout the enlarged right atrium and thus results in tall and broad P waves.

Congenital diseases such as Ebstein’s anomaly, tricuspid atresia, and combined tricuspid and pulmonary stenosis can lead to extremely tall P waves through elevated right atrial pressures and
the development of a large compliant right atrium.

Chronic obstructive pulmonary disease –


Mechanism for enlarged P wave formation in chronic obstructive pulmonary disease is thought to be severe hypoxemia.

During a chronic obstructive pulmonary disease exacerbation, bronchospasm occurs leading to
right atrial hypoxia and transient hemodynamic loads on the right atrium, thus increasing the amplitude and peaking of the P wave

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