Right Ventricular Strain

Definition

= Repolarisation abnormality due to right ventricular hypertrophy or dilatation.

Electrocardiographic Features

ST depression and T wave inversion in the leads corresponding to the right ventricle, i.e

• The right precordial leads:  V1-3, often extending out to V4
• The inferior leads:  II, III, aVF, often most pronounced in lead III as this is the most rightward-facing lead.

NB. Compare this to the left ventricular strain pattern, where ST/T-wave changes are present in the left ventricular leads (I, aVL, V5-6).

Causes

Associated with increased pulmonary artery pressures in the setting of acute or chronic right ventricular hypertrophy or dilatation:

• 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

ECG Examples

Example 1 – Right ventricular hypertrophy 

• Typical right ventricular strain pattern: ST depression and T-wave inversion in V1-4 (plus lead III), in this case due to right ventricular hypertrophy.

Example 2 – Acute right ventricular dilatation due to massive PE

• Right ventricular strain pattern involving both the precordial and inferior leads:  T-wave inversions are seen in the right precordial (V1-4) and inferior leads (III, aVF) in this patient with acute right ventricular dilatation due to massive pulmonary embolism.

Related Topics

For more great examples of right heart strain check out these ECG library pages:

• Right Ventricular Hypertrophy
• The ECG in Pulmonary Embolism

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.