What is the significance and recommended management of an rSr′ pattern in lead V2 on the ECG of a healthy 24‑year‑old female?

An rSr' Pattern in V2 in a Healthy 24-Year-Old Female is Almost Certainly a Normal Variant

In a healthy 24-year-old female with an rSr' pattern in lead V2 and a normal QRS duration (<110 ms), this finding represents a normal variant that requires no further workup or intervention. 1

Understanding the Finding

The AHA/ACCF/HRS standardization guidelines explicitly state that an rSr' pattern in V1 and V2 with a normal QRS duration is a normal variant 1. This is particularly common in young, healthy individuals and should not be confused with pathological conditions.

Key Diagnostic Criteria to Confirm This is Benign:

Check the QRS duration first:

• If QRS duration is <110 ms in adults, this is NOT incomplete RBBB 1
• The rSr' pattern alone, without QRS prolongation, does not meet criteria for any conduction abnormality

Verify lead placement:

• The pattern can be artifactually created when V1/V2 are placed too high (2nd intercostal space instead of 4th) 1, 2
• If uncertain, repeat the ECG with careful attention to proper lead positioning

What This is NOT (and Why)

Not Incomplete RBBB:

Incomplete RBBB requires both the rSr' morphology AND QRS duration of 110-119 ms 3, 1. Without the prolonged QRS, the diagnosis cannot be made, and the guidelines specifically discourage using terms like "normal rSr'" because they create confusion 1.

Not Brugada Pattern:

While Brugada Type 1 can show an rSr' pattern, it requires:

• Coved ST-segment elevation ≥2 mm in V1-V2
• Inverted terminal T-waves
• A downsloping ST segment (STJ/ST80 ratio >1) 4, 5

A simple rSr' without these features is not concerning for Brugada syndrome.

Not Structural Heart Disease:

In the absence of symptoms, family history of sudden death, or other ECG abnormalities, this finding does not suggest arrhythmogenic right ventricular dysplasia or other cardiomyopathies 6, 7.

Recommended Management Algorithm

For an asymptomatic 24-year-old female:

1. Confirm normal QRS duration (<110 ms) - if yes, proceed to step 2
2. Brief screening questions:
   • Any palpitations, syncope, or chest pain? (No = reassuring)
   • Family history of sudden cardiac death <50 years? (No = reassuring)
   • Any symptoms with exercise? (No = reassuring)
3. If all answers are negative: Provide reassurance and no further testing 3, 6, 7

No echocardiogram, no stress test, no Holter monitor, and no cardiology referral are needed in this scenario 6, 7.

Common Pitfalls to Avoid

• Don't over-interpret: The guidelines explicitly warn against calling this "incomplete RBBB" or suggesting it's pathological when QRS duration is normal 1
• Don't order unnecessary tests: In truly asymptomatic young patients with isolated rSr' and normal QRS duration, additional cardiac workup has extremely low yield and creates unnecessary anxiety 6, 7
• Don't confuse with high lead placement: If the pattern seems exaggerated, simply repeat the ECG with proper V1/V2 positioning in the 4th intercostal space 2, 8

When to Reconsider

Refer to cardiology only if:

• Symptoms develop (syncope, palpitations, exercise intolerance)
• Family history of sudden cardiac death emerges
• QRS duration is ≥110 ms (then it becomes incomplete RBBB and warrants evaluation) 3
• Other concerning ECG features appear (ST elevation, deep T-wave inversions, QTc prolongation)

The bottom line: this is a benign electrocardiographic variant in the vast majority of young, healthy individuals and should be treated as such 1, 6.