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

• Pulmonary hypertension
• Mitral stenosis
• Pulmonary embolism
• Chronic lung disease (cor pulmonale)
• Congenital heart disease (e.g. Tetralogy of Fallot, pulmonary stenosis)
• Arrhythmogenic right ventricular cardiomyopathy

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

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

• Right ventricular strain.
• The ECG in pulmonary embolism.
• The ECG in chronic lung disease.
• Left ventricular hypertrophy.

Further Reading

• ECG BASICS — Waves, Intervals, Segments and Clinical Interpretation
• ECG CLINICAL CASES — Your favourite ECG’s placed in clinical context with a challenging Q&A approach
• ECG and Cardiology Eponymous Syndromes — Cheats guide to eponymous emancipation
• ECG Exam Template — a framework for the FACEM part 2 exam.
• ECG Reference Sites on the WEB — the best of the rest

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.