ECG Findings Suggestive of Right Ventricular Dysfunction
The most important ECG findings suggestive of right ventricular dysfunction include right axis deviation, prominent anterior forces in right precordial leads, and ST depression with T-wave inversion in right precordial leads. 1
Key ECG Patterns
Vector and Conduction Changes
- Right ventricular hypertrophy (RVH) causes displacement of the QRS vector toward the right and anteriorly, often with delayed R-wave peak in right precordial leads 1
- QRS duration >140 ms is an independent predictor of right ventricular dilation and dysfunction with high sensitivity (>95% for dysfunction) 2
- Right axis deviation is a common finding and should be required for diagnosis of RVH in nearly all cases 1
Amplitude and Morphology Changes
- Tall R waves in right precordial leads (as part of Rs, R, or Qr complexes), particularly in V1 1
- Increased R-wave amplitude in V1 relative to normal, especially in patients with chronic obstructive pulmonary disease 1
- Deep S waves in precordial leads, particularly in patients with chronic lung disease 1
- R' duration ≥100 ms in V1 is predictive of right ventricular systolic dysfunction in patients with RBBB (specificity 82.9%) 3
ST-T Wave Changes
- ST depression and T-wave inversion in right precordial leads (V1-V3) 1, 4
- Negative T waves in precordial leads V1-V5 (43% incidence in CTEPH patients) 4
- Negative T waves in leads II, III, aVF (32% incidence in CTEPH patients) 4
P Wave Abnormalities
- Rightward P-wave axis (greater than 60 degrees) 1
- "Pulmonary P wave" pattern (30% incidence in CTEPH patients) 4
Pattern Recognition Based on Etiology
Pressure Overload Pattern
- Predominantly tall R waves in right precordial leads 1
- Right axis deviation 1
- ST depression and T-wave inversion in right precordial leads 1
Volume Overload Pattern
- Similar to incomplete right bundle branch block 1
- Right axis deviation 1
- Secondary ST-T abnormalities 1
Chronic Obstructive Pulmonary Disease Pattern
- Low voltage in limb leads 1
- Frontal plane QRS axis that is rightward, superior, or indeterminate 1
- Rightward P-wave axis (>60 degrees) 1
- Persistent S waves in all precordial leads 1
- Low R-wave amplitude in V6 1
- RVH is suggested only if R-wave amplitude in V1 is relatively increased 1
Special Considerations
Arrhythmogenic Right Ventricular Cardiomyopathy
- Anterior precordial T wave inversion, particularly in lead V2 5
- QRS complex duration ≥110 ms in right precordial leads 5
- Epsilon waves (low-voltage waves in terminal portion of QRS complex) are markers of poor prognosis 6
Diagnostic Accuracy
- Sensitivity of ECG criteria for RVH is generally low, but some criteria have high specificity 1
- Greatest accuracy in congenital heart disease, intermediate in acquired heart disease and primary pulmonary hypertension, lowest in chronic lung disease 1
- Clinical context is essential for proper interpretation, as many ECG findings can occur as normal variants 1
Pediatric Considerations
- Age-specific criteria exist for RVH diagnosis in pediatric populations 1
- R-wave amplitude in V1 and S-wave amplitude in V6 vary significantly with age 1
Clinical Application
- No single criterion should be used exclusively; multiple criteria improve diagnostic accuracy 1
- Criteria should be adjusted for age, gender, race, and body habitus 1
- Probability estimates should be adjusted based on clinical diagnoses suggesting congenital heart disease, valvular heart disease, or chronic pulmonary disease 1