Diagnosis and Management of RSR' Pattern in Leads 3, V1, V2 with Inverted T Wave in V1
The RSR' pattern in leads 3, V1, and V2 with an inverted T wave in V1 is most consistent with incomplete right bundle branch block (RBBB), which typically requires no specific treatment unless associated with underlying structural heart disease.
Understanding the ECG Pattern
RSR' Pattern Characteristics
- An RSR' pattern consists of an initial positive deflection (R), followed by a negative deflection (S), and then a second positive deflection (R')
- When this pattern appears in leads V1-V2, it commonly indicates:
- Incomplete RBBB (QRS duration 110-119 ms)
- Complete RBBB (QRS duration ≥120 ms)
- Normal variant, especially in children and young adults (QRS duration <110 ms)
Diagnostic Criteria for RBBB
According to the AHA/ACCF/HRS recommendations 1, RBBB is characterized by:
- QRS duration ≥120 ms (complete) or 110-119 ms (incomplete)
- RSR' pattern in leads V1 and/or V2
- S wave duration greater than R wave or >40 ms in leads I and V6
- Normal R peak time in leads V5 and V6 but ≥50 ms in lead V1
T Wave Inversion in V1
- T wave inversion in V1 is often a normal finding, especially when associated with RBBB
- When combined with RSR' pattern, it typically represents secondary repolarization changes due to the conduction delay
Diagnostic Algorithm
Measure QRS duration:
- <110 ms: Normal variant or incomplete RBBB
- 110-119 ms: Incomplete RBBB
- ≥120 ms: Complete RBBB
Rule out pathological conditions:
- Check for signs of myocardial infarction (MI):
- Abnormal Q waves in other leads
- ST-segment elevation or depression in other leads
- Assess for posterior MI (which can present with ST depression in V1-V3) 1
- Evaluate for Brugada pattern (coved or saddleback ST elevation in V1-V2)
- Check for signs of myocardial infarction (MI):
Consider lead placement issues:
- High placement of V1-V2 leads can create RSR' pattern 2
- Verify proper lead placement to avoid misdiagnosis
Management Approach
For Isolated Incomplete RBBB (Most Likely Diagnosis)
- No specific treatment required if asymptomatic and no underlying heart disease 3
- Routine follow-up with annual ECG if there are risk factors for progression
For Complete RBBB
- Comprehensive cardiac evaluation including echocardiography 3
- Monitor for progression to higher degrees of heart block
- Evaluate for underlying structural heart disease
When to Suspect Underlying Pathology
- Presence of symptoms (syncope, palpitations, chest pain)
- Family history of sudden cardiac death
- Evidence of structural heart disease on imaging
- Progression of conduction abnormalities on serial ECGs
Red Flags Requiring Further Evaluation
- QRS duration ≥120 ms (complete RBBB)
- ST-segment abnormalities in other leads
- Q waves in other leads suggesting MI
- Symptoms such as syncope, palpitations, or chest pain
- Family history of sudden cardiac death or cardiomyopathy
Specific Considerations
Myocardial Infarction
- RSR' pattern in leads V1-V2 can sometimes represent a myocardial infarction scar 4
- Poor R-wave progression in precordial leads may indicate anterior MI 5
- If clinical suspicion for MI exists, cardiac biomarkers and imaging studies should be performed
Posterior Wall MI
- ST depression in V1-V3 with upright T waves may indicate posterior wall MI 1
- Consider additional posterior leads (V7-V9) if posterior MI is suspected
Brugada Syndrome
- Differentiate from Brugada pattern, which has specific ST-segment morphology
- Brugada pattern has coved (type 1) or saddleback (type 2) ST elevation in V1-V2
Conclusion
The RSR' pattern in leads 3, V1, V2 with inverted T wave in V1 most commonly represents incomplete RBBB, which is often a benign finding requiring no specific treatment. However, a systematic approach to rule out underlying pathology is essential, particularly when there are concerning clinical features or additional ECG abnormalities.