Right Ventricular Hypertrophy

Electrocardiographic Features

Diagnostic criteria

  • Right axis deviation of +110° or more.
  • Dominant R wave in V1 (> 7mm tall or R/S ratio > 1).
  • Dominant S wave in V5 or V6 (> 7mm deep or R/S ratio < 1).
  • QRS duration < 120ms (i.e. changes not due to RBBB).

Supporting criteria

  • Right atrial enlargement (P pulmonale).
  • Right ventricular strain pattern = ST depression / T wave inversion in the right precordial (V1-4) and inferior (II, III, aVF) leads.
  • S1 S2 S3 pattern = far right axis deviation with dominant S waves in leads I, II and III.
  • Deep S waves in the lateral leads (I, aVL, V5-V6).

Other abnormalities caused by RVH 

NB. There are no universally accepted criteria for diagnosing RVH in the presence of RBBB; the standard voltage criteria do not apply. However, the presence of incomplete / complete RBBB with a tall R wave in V1, right axis deviation of +110° or more and supporting criteria (such as RV strain pattern or P pulmonale) would be considered suggestive of RVH.

Causes

Example ECGs

Example 1

Typical appearance of RVH:

  • Right axis deviation (+150 degrees).
  • Dominant R wave in V1 (> 7 mm tall; R/S ratio > 1)
  • Dominant S wave in V6 (> 7 mm deep; R/S ratio < 1).
  • Right ventricular strain pattern with ST depression and T-wave inversion in V1-4.

 

Example 2

RVH in an adult with uncorrected Tetralogy of Fallot:

  • Right axis deviation.
  • P pulmonale — peaked P wave in lead II > 2.5 mm.
  • Dominant R wave in V1 (> 7 mm tall; R/S ratio > 1)
  • Dominant S wave in V6 (> 7 mm deep; R/S ratio < 1).
  • Right ventricular strain pattern in V1-3.

 

Example 3

  • Right axis deviation (+150 degrees)
  • P pulmonale (P wave in lead II > 2.5 mm)
  • Incomplete RBBB
  • Right ventricular strain pattern with T-wave inversion and ST depression in the right precordial (V1-3) and inferior (II, III, aVF) leads.

This ECG was originally posted by Johnson Francis on Cardiophile.org.

 

Example 4

Arrhythmogenic right ventricular dysplasia

Right ventricular hypertrophy in a patient with arrhythmogenic right ventricular cardiomyopathy:

  • Right axis deviation.
  • R/S ratio in V1 > 1
  • Right ventricular strain pattern with T-wave inversion and ST depression in the right precordial (V1-3) and inferior (II, III, aVF) leads.

This ECG was originally posted by Jayachandran Thejus on the website HeartPearls.com.

 

Related Topics

Further Reading

Author Credits

References

  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
  • Harrigan RA, Jones K. ABC of clinical electrocardiography. Conditions affecting the right side of the heart. BMJ. 2002 May 18;324(7347):1201-4. Review. PMID: 12016190. Full text.
  • Mattu A, Brady W. ECGs for the Emergency Physician 1, BMJ Books 2003.
  • Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.
  • Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice (6th edition), Saunders 2008.
  • Wagner, GS. Marriott’s Practical Electrocardiography (11th edition), Lippincott Williams & Wilkins 2007.
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