Right heart failure electrocardiogram

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Right heart failure is often accompanied by right ventricular hypertrophy and right ventricular dilatation. The general electrocardiographic findings of right ventricular hypertrophy include right axis deviation, an R/S ratio > 1 in V1, and the presence of P pulmonale.

Electrocardiogram

Summary of EKG Criteria for RVH

1. Right axis deviation of +90 degrees or more
2. The R wave in V₁ is 7 mm or more in height
3. RV₁ + SV₅ or SV₆ = 10 mm or more
4. R/S ratio in V₁ = 1.0 or more
5. S/R ratio in V₆ = 1.0 or more
6. Late intrinsicoid deflection in V₁ (0.035+)
7. Incomplete RBBB pattern
8. ST T strain pattern in 2,3,aVF
9. P pulmonale or P congenitale
10. S1 S2 S3 pattern in children

Differential Diagnosis of R>S in V1

1. RVH
2. Posterior MI
3. WPW
4. HCM (septal hypertrophy)
5. Kulbertus' block (septal fascicular block)
6. Duchenne Muscular Dystrophy
7. Normal variant
8. V₄r may be a more useful and reliable than lead V₁ in that it often reveals an r>s while v₁ remains normal
9. An incomplete right bundle branch block in the right precordial chest leads may signal the development of RVH
10. In the limb leads right axis deviation develops and at times prominent Q waves simulating an IMI appear in leads 2,3, and aVF.
11. In children an S1 S2 S3 pattern (i.e. an S wave deeper than R in all 3 standard leads) is a reliable index of RVH
12. RV strain can be seen in leads V1 and V2 but also in leads 2,3, aVF

EKG in Right Ventricular Hypertrophy

Shown below are images illustrating right ventricular hypertrophy and its EKG findings.

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  Right ventricular hypertrophy
• 
  Right ventricular hypertrohpy, the R wave > the S wave in V1

EKG in Right Atrial Enlargement

Right atrial enlargement is defined as either:

• A P wave >2.5 mm in leads II, III and aVF
• A P wave >1.5 mm in lead V1

Shown below are images illustrating right atrial enlargement and its EKG findings.

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  Right atrial enlargement
• 
  Right atrial enlargement
• 
  Right Atrial Enlargement