Transient Super-Himalayan P-waves in severe pulmonary emphysema

Himalayan P-waves are classically associated with congenital heart diseases with right to left shunt where they indicate a dilated right atrium and tend to be persistent. We report a case of transient Himalayan P-waves of 9-mm amplitude associated with a severe emphysema exacerbation. Patient had a normal right atrial size. The giant P-waves were likely the result of severe pulmonary hyperinflation, right atrial hypoxia, and transient mechanical load on the right atrium directly resulting from the bronchospasm. Transient Himalayan P-waves of quite such amplitude have not been reported previously, which makes our case the first such report in literature.