How to manage a patient with an RSR' pattern in lead V2 on electrocardiogram (ECG)?

Management of RSR' Pattern in Lead V2 on ECG

The management of a patient with an RSR' pattern in lead V2 should focus on determining whether it represents a normal variant or indicates underlying cardiac pathology, with subsequent evaluation based on QRS duration, morphological features, and clinical context.

Diagnostic Approach

Step 1: Assess QRS Duration

• QRS < 110 ms: Likely a normal variant, especially in children and young adults 1
• QRS 110-119 ms: Consistent with incomplete right bundle branch block (RBBB) 2
• QRS ≥ 120 ms: Consistent with complete RBBB 2

Step 2: Evaluate RSR' Morphology

• Check if R' deflection is wider than the initial R wave (typical of RBBB) 2
• Assess S wave duration in leads I and V6 (should be greater than R wave or >40 ms in complete RBBB) 2
• Verify normal R peak time in leads V5 and V6 but >50 ms in lead V1 2

Step 3: Rule Out High Lead Placement

• Confirm proper placement of precordial leads, as high placement of V1-V2 leads can produce RSR' patterns that mimic pathology 1, 3
• If suspected, repeat ECG with correct lead placement

Management Algorithm

For Normal Variant (QRS <110 ms with typical morphology)

• No further evaluation needed if:
  • Patient is asymptomatic
  • No family history of sudden cardiac death
  • No other concerning ECG findings

For Incomplete RBBB (QRS 110-119 ms)

1. Perform echocardiography to evaluate for structural heart disease 1
2. Consider cardiac MRI if:
   • Suspicion for arrhythmogenic right ventricular cardiomyopathy (ARVC)
   • Family history of sudden cardiac death
   • Symptoms such as syncope or palpitations 2

For Complete RBBB (QRS ≥120 ms)

1. Perform comprehensive cardiac evaluation including echocardiography 2
2. Evaluate for:
   • Dilated cardiomyopathy
   • Hypertrophic cardiomyopathy
   • Left ventricular non-compaction
   • Sarcoidosis
   • Myocarditis 2
3. Consider exercise stress test if coronary artery disease is suspected 2
4. Monitor for development of higher degrees of heart block 1

Special Considerations

Rule Out Brugada Syndrome

• If RSR' pattern is accompanied by ST-segment elevation in V1-V2:
  • Evaluate ST segment morphology (coved vs. saddleback)
  • Consider pharmacological challenge with sodium channel blockers if Brugada syndrome is suspected 4
  • Refer to electrophysiologist if Brugada pattern is confirmed

Rule Out Ventricular Aneurysm

• If RSR' pattern is present in left-sided leads (V5-V6):
  • Consider ventricular aneurysm, especially with history of myocardial infarction 5, 6
  • Perform echocardiography and consider cardiac MRI

Follow-up Recommendations

• For normal variants: No specific follow-up needed
• For incomplete RBBB: Annual ECG if associated with structural heart disease
• For complete RBBB: Regular follow-up with ECG to monitor for progression to higher degrees of heart block 2

Important Pitfalls to Avoid

1. Misdiagnosing normal variants as pathology, especially in children and young adults where RSR' pattern can be normal 1
2. Overlooking Brugada syndrome when RSR' is accompanied by ST elevation in V1-V2 4
3. Failing to recognize RSR' pattern in left-sided leads as a potential marker of ventricular aneurysm 5, 6
4. Attributing RSR' pattern to RBBB when it may represent myocardial scarring or infarction 6

By following this systematic approach, clinicians can appropriately differentiate between benign RSR' variants and those requiring further evaluation and management.