ECG Diagnosis of RVH

8/13/2019 ECG Diagnosis of RVH

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ECG Diagnosis of RVH

Detection of right ventricular enlargement in adults by ECGcriteria is often exceedingly difficult. This is because the leftventricle is normally so much larger and thicker than the right

ventricle in adults that it masks even moderate increases inright ventricular chamber size. As a result, many patients with

RVH won'tbe identifiedIF assessment for chamber enlargementis limited to obtaining an ECG (an Echo is needed to know for sure).

Think of the ECG diagnosis of RVH as similar to making a"detective" diagnosis. Rarely will any one finding clinchthe diagnosis. Instead determination of RVH is mostoften made by deduction (ie,from identifying a combinationof ECG findingsfrom the Table below):

KEY:None of the above criteria is enough by itself to diagnose

RVH. Butseveralof these criteria (when seentogetheron asingle tracing)is verysuggestive of RVHespecially when theyoccur in a likely setting (ie, COPD, right-sided heart failure,pulmonary hypertension).

Suspectpulmonary disease IF you see 3 of the first 5criteria.

Suspect pulmonary disease plusRVH IF in additionyousee a tall R wave in lead V1 (with/without ST-T wave

changes of RV strain).RAD i ti f RVH h i lik l


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Indeterminate Axis Alterations in lung volume withemphysema lead to rightward and posterior deviation in thetransverse plane (IF you see indeterminate axis ThinkRVH - COPD - obesity).

RAA Only one condition produces RAA without RVH (=tricuspid stenosis). Thus RAA is an indirect sign thatRVHis likely.

IRBBB (rSr in V1)The presence of an r (r prime)in leadV1 suggests that terminal electrical activity is directedtoward the right (Think possible COPD and RVH withterminal rightward activity).

Low Voltage Air is not a good conductor of electricity.The large emphysematous chest dampens (reduces) voltage.

Technicallylow voltagemeans QRS amplitude 5 mm(ie, 1 large box)in all6 limb leads (I,II,III,aVR,aVL,aVF)but we use low voltage as a relative term for overallreducedamplitude (Think COPD - hypothyroidism - obesity- pneumothorax - pericardial effusion).

Persistent S Waves QRS amplitude normally increasesas one moves across the precordial leads (as electricalactivity moves to the left where the larger LV lies). QRS

amplitude usually peaks (is tallest) in V4 or V5 and thendrops off (in V5,V6). IF there are still S wavesin V5,V6this implies significant rightwardactivity in these left-sidedleads (Think RVH COPD - large body habitus).

RV strain Just as LV strain is a sign of true LVH seeing strain in right-sided leads (II,III,aVF - or -V1,V2,V3) strongly supportsa diagnosis of RVH. PEARLAnterior ST depression is notalways ischemia (it may reflectRV strain from RVH or pulmonary embolus!).

Tall R in Lead V1 Lead V1 is a right-sided lead. As aresult, the QRS is normally negativein V1 (electrical activitymoves toward the larger LV and away from V1). IF the Ristallerthan the S wavein lead V1this means rightwardforcesare increased (which is a sign of RVH). Clinicallyby the time a tall R is seen in V1 in an adult withpulmonary diseasethe extent of RVHis usually marked(ie, the patient has end-stage COPD and/or pulmonary

hypertension).

Pediatric RVHThe ECG diagnosis of RVH is much easier tomake in infants and young children than it is in adults. This isbecause at birth the RV is comparablein size to the LVand itremains so for the first few years of life (ergo a much lesserdegree of RV enlargement is needed to produce the ECG signs of

RVH in infants or young children with congenital heart disease).


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Exampleof RVHMost of the ECG criteria for RVH are present in the tracing

shown below (RAD, RAA, tall R in V1, deep S waves in V5,V6). Notealso that there is "RV strain" (which is typically seen in inferiorand/oranterior leadsbothof which are present here).

Clinically by the time a tall R is seen in V1 in an adultwith pulmonary disease the extent of RVH is usuallymarked (end-stage COPD/pulmonary hypertension).


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Exampleof Pulmonary DiseasePulmonary disease (such as COPD) may sometimes be

suggested by ECG IF at least two of the first 5 findings in theRVH Table are seen (Seen below are RAD; RAA; rSr in V1; andpersistent precordial S waves up to V5,V6).


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Tracing Q-2This 12-lead ECG was obtained from a patient withnew-onset shortness of breath thought to be due to congestiveheart failure. What elsedo you suspect?

Answer toTracing Q-2: Sinus tachycardia at ~115/minute.The PR and QRS intervals are normal (the fast rate makes it difficultto comment on the QT). There is RAD (predominantly negative QRSin I; positive in aVF). An incomplete RBBB (rsR in V1) is seen.

There are nonspecific ST-T wave abnormalitiesbut no acutechanges.

There is RAA (tall, peaked, uncomfortable-to-sit-on P wave inlead II ). There is also LAA (very deep negative component tothe P wave in lead V1).

RVH is strongly suggested by RAD, RAA, IRBBB andpersistenceof precordial S waves in V5,V6.

Clinical IMPRESSION: This ECG should make one rethinkthe premise of CHF as the primary cause of this patients

new-onset shortness of breath. Instead longstanding/severepulmonarydisease is likely given thecombination of findings (and/or maybe pulmonaryembolus?).


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Pulmonary EmbolusThe ECG is usually not diagnostic of pulmonary embolism

(PE). But there are times when ECG willsuggest the diagnosisbeforeV/Q scan or chest CT is done. Consider P.E. IF:

IF the clinical setting is right (new-onset dyspnea -pleuritic chest pain - predisposing risk factors or previous

history of PE/DVT). IF the patient has sinus tachycardia (usually seen with

large PE, albeit clearly nonspecific for the diagnosis).

2 signs of acute right-heart strain (ie, RAD - RAA -RBBB - tall R in V1 - deep S in V5,V6).

RV strain (ST-T depression in II,III,aVF orV1,V2,V3). New-onset A Fib (common with PE, but nonspecific). Nonspecific ST-T wave changes (not diagnostic).

With an ECG (and history) as shown for Tracing Q-2. Academic P.S.The ECG finding known as S1-Q3-T3is

not accurate for detecting PE (and it should no longer beused).

PEARL: Clinically What2 entities should you think of giventhe symmetric T inversion in V1,V2,V3 (arrows) of this ECGobtained from an adult with new-onsetdyspnea?

ANSWER: In addition to ischemia this anteriorsymmetric T wave inversion may reflect RV strain (which with


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Diagnosis of LVH/RVH with BBB?

Diagnosis of ventricular chamber enlargement is difficultwith conduction defects (BBB,IVCD). Criteria for LVH/RVH arebased on normal ventricular activationwhich changeswith BBB.

Consider the following:

Criteria for LAA/RAAare unchangedby BBB/IVCD. Most patients with LBBB have underlying heart disease. IF

there is longterm hypertension, cardiomyopathy or heartfailure and LBBB the prevalence of LVH is ~80%, evenbefore one looks at the ECG. This goes up to >90% IFwithLBBBthere are deep S waves (>25-30mm)in V1,V2 orV3 (See Figure below).

Suspect LVH (despiteRBBB) IF the R in aVL is 12, orthe R wave in V5 or V6 is 25.

It is probably best not to even bother trying to diagnoseRVHwhen LBBB, RBBB or IVCD is present.

Chamber Enlargement despiteLBBB:

The Figure above shows sinus rhythm with typicalLBBB. LAAis suggested by the deep, negative P in V1 (circle). We diagnose

probableLVH despitethe LBBB because of the very deepS wavein V2 (>25mm).

ECG Diagnosis of RVH

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