A 66-year-old woman is followed in the respiratory clinic for longstanding severe obstructive lung disease and bronchiectases:

• Sinus tachycardia, 110/min with one premature atrial complex
• Right atrial enlargement
• Right axis deviation
• Right ventricular hypertrophy

The presence of right atrial enlargement, right axis deviation and a QR pattern in V1 in this lady with severe pulmonary disease strongly favours the diagnosis of right ventricular hypertrophy. In fact, the echocardiogram showed pulmonary hypertension (PA pressure 75 mm Hg) and right ventricular enlargement. The 9th beat in the rhythm strip is a premature atrial complex.