From the Guidelines
Right ventricular hypertrophy (RVH) is characterized by right axis deviation and prominent anterior forces in the right precordial leads on an electrocardiogram (EKG) 1.
EKG Findings
- Right axis deviation: a key feature of RVH, often associated with prominent anterior forces in the right precordial leads 1
- Prominent R waves: in right precordial leads, suggesting pressure overload 1
- ST depression and T-wave inversion: in right precordial leads, referred to as "secondary ST-T abnormality" 1
- Low voltage in limb leads: and a rightward, superior, or indeterminate frontal plane QRS axis, often seen in chronic obstructive pulmonary disease 1
Diagnostic Criteria
The diagnosis of RVH on EKG is often based on criteria that include the amplitude of R and S waves in leads I, V1, and V6, as well as the R-wave peak time in V1 1. However, the sensitivity of these criteria is generally low, and the use of ancillary clinical information is crucial in making an accurate diagnosis 1. In congenital heart disease, the EKG may show a pattern similar to incomplete right bundle branch block (RBBB), suggesting volume overload, or a pattern with predominantly tall R waves in right precordial leads, suggesting pressure overload 1. The EKG findings in RVH can be variable, and the diagnosis should be made in conjunction with clinical and other diagnostic information 1.
From the Research
EKG Findings of Right Ventricular Hypertrophy
The EKG findings of right ventricular hypertrophy (RVH) include:
- AQSR to the right of + 90 degrees (in adults over 30) 2
- RV1 greater than or equal to 5 mm 2
- SV5 or V6 greater than or equal to 7 mm 2
- R/SV1 greater than or equal to 1 and/or R/SV5, V6 less than or equal to 1 2
- RV1 + SV5 or V6 greater than 10.5 mm 2
- SV1 less than 2 mm 2
- Pathological progression of R/S in precordial leads to the right of the intermediate zone 2
- R/S less than 1 and S greater than 4 mm in 1st lead 2
- TV1--V3--negative 2
- P-pulmonale 2
- R to S wave ratio or incidence of qR pattern in lead V(1) 3
Sensitivity and Specificity of EKG Criteria
The sensitivity and specificity of EKG criteria for RVH vary:
- One study found that EKG criteria had a sensitivity of 31% and a specificity of 85% in diagnosing RVH 4
- Another study found that EKG criteria had a sensitivity of 27% and a specificity of 88% in diagnosing RVH 4
- A study found that a new combination of EKG criteria attained a 63% sensitivity and a 96% specificity 5
- The sensitivity of ECG criteria for biventricular hypertrophy (BVH) was 24.6%, specificity was 86.4%, and positive predictive value was 85% 6
Comparison with Other Diagnostic Methods
EKG findings are compared with other diagnostic methods:
- Echocardiography had a sensitivity of 93% and a specificity of 95% in diagnosing RVH at necropsy, while ECG had a sensitivity of 31% and a specificity of 85% 4
- Cardiac magnetic resonance (CMR) is used to define right ventricular systolic dysfunction (RVSD) and ECG-RVH findings are compared with CMR-RVSD 3