Electrocardiographic Criteria for Right Ventricular Hypertrophy
The diagnosis of RVH relies on multiple ECG criteria derived from R and S wave amplitudes in leads I, V1, and V6, along with R-wave peak time in V1, though sensitivity is generally low (18-43%) while specificity remains high (83-95%). 1, 2
Core Diagnostic Approach
Right axis deviation (>90°) should be required for RVH diagnosis in nearly all cases, as this represents the fundamental shift of the QRS vector rightward and anteriorly that occurs with RVH. 3, 4
Primary Voltage Criteria
The following criteria have validated specificity for RVH diagnosis:
- R/S ratio in V5 or V6 ≤1 - This reflects the dominance of right ventricular forces over left ventricular forces 2
- S wave in V5 or V6 ≥7 mm - Indicates persistent rightward forces in lateral precordial leads 2
- Tall R waves in V1 (as part of Rs, R, or Qr complexes) - Represents anterior displacement of QRS forces 1, 3
- R-wave peak time delay in V1 - Reflects delayed right ventricular activation 1
Pattern Recognition by Etiology
RVH manifests in two distinct ECG patterns that provide diagnostic and etiologic information:
Pressure Overload Pattern:
- Predominantly tall R waves in right precordial leads (Rs, R, or Qr complexes in V1) 3, 4
- Right axis deviation 3
- ST segment depression and T wave inversion in right precordial leads 3, 4
Volume Overload Pattern:
- Resembles incomplete right bundle branch block 1, 3
- Right axis deviation 3
- Secondary ST-T abnormalities 3, 4
Recommended Diagnostic Strategy
Use any one of the following four criteria for RVH diagnosis: 2
- R/S ratio in V5 or V6 ≤1
- S wave in V5 or V6 ≥7 mm
- Right axis deviation >+90°
- P pulmonale
For higher specificity (95%), require any two of these criteria in combination. 2
Critical Context-Dependent Considerations
Accuracy by Clinical Setting
The diagnostic accuracy of ECG criteria varies dramatically by underlying condition:
- Highest accuracy: Congenital heart disease 1, 3, 4
- Intermediate accuracy: Acquired heart disease and primary pulmonary hypertension 1, 3
- Lowest accuracy: Chronic lung disease 1, 3, 4
Special Considerations in COPD
In patients with chronic obstructive pulmonary disease, additional findings suggest RVH:
- Low voltage in limb leads 3
- Frontal plane QRS axis deviation to the right, superior, or indeterminate 3
- Rightward P wave axis (>60°) 3
- Persistent S waves in all precordial leads 3
- Low R wave amplitude in V6 3
- RVH is suggested only if R wave amplitude in V1 is relatively increased compared to baseline 3
Pediatric Criteria
Age-specific criteria must be used in children, as normal R wave amplitude in V1 and S wave amplitude in V6 vary significantly with age. 1, 4
For children ≥5 years:
Biventricular Hypertrophy Recognition
When ECG criteria for LVH are present, suspect concurrent RVH if:
- Prominent S waves in V5 or V6 1, 3
- Right axis deviation 1, 3
- Unusually tall biphasic R/S complexes in several leads 1, 3
- Signs of right atrial abnormality 1, 3
In congenital heart disease with RVH, combined R and S wave amplitudes in V2-V6 >60 mm (6.04 mV) suggests coexistent LVH. 1, 3
Common Pitfalls
The major limitation is low sensitivity (27-43%) - considerable RVH must be present to overcome the normal left ventricular dominance of QRS forces. 1, 5 Many patients with anatomically confirmed RVH will have normal ECGs.
ECG diagnosis is particularly unreliable in the presence of:
Do not rely on a single criterion - using multiple criteria improves diagnostic accuracy, though this must be balanced against reduced sensitivity. 1, 3, 4
Echocardiographic Correlation
When ECG findings are equivocal or clinical suspicion is high despite negative ECG, echocardiography is far more sensitive (93% vs 27-31%) for detecting RVH, with RV wall thickness ≥5 mm defining hypertrophy. 5, 6