From the Guidelines
ST depression with deep S waves in V1 and tall R waves in V6 is most likely indicative of left ventricular hypertrophy (LVH), which can be caused by various conditions such as hypertension, aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy, and chronic kidney disease. The ECG pattern reflects altered electrical forces as the enlarged left ventricle generates stronger leftward and posterior electrical forces, creating deep S waves in right precordial leads (V1) and tall R waves in left precordial leads (V6) 1. This pattern may be accompanied by repolarization abnormalities (ST depression and T wave inversion) in leads with tall R waves, known as "strain pattern" 1.
Some of the key conditions that can lead to LVH include:
- Hypertension: sustained high blood pressure forces the left ventricle to work harder, leading to muscle thickening 1
- Aortic valve disease: creates either pressure overload (stenosis) or volume overload (regurgitation), both resulting in compensatory LVH 1
- Hypertrophic cardiomyopathy: a genetic condition causing abnormal ventricular wall thickening 1
- Chronic kidney disease: can lead to LVH due to chronic volume overload and hypertension 1
It is essential to note that the ECG pattern of ST depression with deep S waves in V1 and tall R waves in V6 can also be seen in other conditions, such as:
- Myocardial ischemia: can cause ST depression and T wave inversion, especially in leads with tall R waves 1
- Ventricular conduction disturbances: can cause ST depression and T wave inversion, especially in leads with tall R waves 1
However, the presence of deep S waves in V1 and tall R waves in V6 is more suggestive of LVH, and patients with these findings should undergo echocardiography to confirm LVH and determine the underlying cause, followed by appropriate treatment of the primary condition 1.
From the Research
Causes of ST Depression with Deep S in V1 and Long R in V6
- ST depression in leads V1-V3, including deep S in V1, can indicate acute occlusion of an epicardial artery with ongoing transmural ischemia 2
- However, ST depression in leads other than V1-V3, such as V6 with a long R wave, may be indicative of subendocardial ischemia secondary to subocclusion of the epicardial artery, distal embolization to small arteries, or spasm supply/demand mismatch 2
- Non-ischemic etiologies, such as left ventricular hypertrophy or cardiomyopathies, can also cause ST depression 2
- Stress-induced cardiomyopathy can present with ischemic-like ECG changes, including ST depression, and should be considered in the differential diagnosis 3
- Depression has been independently associated with adverse outcomes in patients with myocardial infarction, including larger infarction size 4
ECG Interpretation
- The ECG should be read in conjunction with clinical assessment and comparison to previous ECGs to aid in diagnosis and interpretation 2
- Body surface mapping may improve the early diagnosis of acute myocardial infarction in patients presenting with chest pain and ST depression only on the 12-lead ECG 5
- Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in patients with STEMI, and early diagnosis and immediate reperfusion are crucial to limit myocardial ischemia and infarct size 6