Management of RSR' Pattern in Lead V2 on ECG
The primary management decision hinges on measuring the QRS duration: if <110 ms, this represents a benign normal variant requiring no treatment; if 110-119 ms (incomplete RBBB), annual monitoring is needed; if ≥120 ms (complete RBBB), evaluate for structural heart disease with echocardiography. 1, 2
Initial ECG Assessment
Measure QRS duration as the critical first step:
- QRS <110 ms: Normal variant or non-specific intraventricular conduction delay 1, 2
- QRS 110-119 ms: Incomplete right bundle branch block (RBBB) 1, 3
- QRS ≥120 ms: Complete RBBB requiring further evaluation 1, 3
Verify correct lead placement to exclude false RSR' pattern from V1-V2 leads placed too high or too far right 2, 4
Exclude Brugada Syndrome
The RSR' pattern must be distinguished from the dangerous Brugada Type 1 pattern, which shows a coved ST-segment elevation ≥2 mm with terminal T-wave inversion 5, 1
Apply the Corrado index (STJ/ST80 ratio):
- Ratio <1: Benign RSR' pattern with upsloping ST-segment 5, 1
- Ratio >1: Concerning for Brugada pattern with downsloping ST-segment requiring immediate electrophysiology referral 5, 1
If the pattern is unclear, perform a high precordial lead ECG with V1-V2 placed in the 2nd or 3rd intercostal space 5, 4
Symptom Assessment
Evaluate for concerning symptoms that mandate further workup regardless of QRS duration:
- Syncope or pre-syncope 1
- Palpitations or documented arrhythmias 1
- Dyspnea or heart failure symptoms 1
- Family history of sudden cardiac death or inherited arrhythmia syndromes 1
Management Algorithm by QRS Duration
QRS <110 ms (Normal Variant)
No specific treatment required 1, 2
- Routine follow-up only 1
- Particularly common and benign in children, young adults, and athletes 2, 3
- Do not use confusing terminology like "normal RSR'" 2
QRS 110-119 ms (Incomplete RBBB)
Annual follow-up to monitor for progression 1
- No immediate intervention needed if asymptomatic 1
- Consider echocardiography if new-onset to assess for structural disease 2
QRS ≥120 ms (Complete RBBB)
Obtain echocardiogram to evaluate for:
- Structural heart disease 1, 2
- Right ventricular pressure or volume overload 2
- Conduction system disease 2, 3
Monitor for development of higher-degree conduction disorders 1
Immediate Electrophysiology Referral Indicated For:
- Brugada Type 1 pattern (coved ST-elevation ≥2 mm, STJ/ST80 ratio >1) 5, 1
- Symptomatic patients with syncope or pre-syncope 1
- Family history of sudden cardiac death 1
- Progressive conduction disease on serial ECGs 1
Common Pitfalls to Avoid
Incorrect lead placement is a frequent cause of false RSR' patterns—always verify V1-V2 are in the 4th intercostal space at standard position 2, 4
Do not confuse with other conditions that can produce RSR' patterns:
- Ventricular aneurysm (RSR' in left-sided leads, not V2) 6
- Old myocardial infarction with scar tissue (wide QRS ≥110 ms with wall motion abnormalities) 7
- Cardiac sarcoidosis with RV involvement (large R' wave surface area ≥1.65 mm²) 8
Athletes with isolated RSR' and normal QRS duration represent normal physiologic adaptation and require no evaluation 3