ECG criteria for diagnosis of right ventricular hypertrophy

ECG criteria for diagnosis of right ventricular hypertrophy are not as commonly used as that for left ventricular hypertrophy. One of the earliest set of criterias were by Myers et al in 1948 [2].

Tall R wave in V1 more than 6 mm, R/S ratio more than 1 in V1, deep S in V5 more than 10 mm or deep S in V6 more than 3 mm were proposed by them. Some of them are still very popular. There were a few more criteria by them based on small S in V1, small S in V5,6 and reduced R/S ratio in lateral leads, which are seldom used. QR in V1 was another criteria for RVH by Myers et al, which is considered significant even now.

All of us are quite familiar with the Sokolow et al criteria for left ventricular hypertrophy. Criteria for right ventricular hypertrophy were also proposed by them in 1949 [3]. They were tall R in aVR more than 4 mm and RV1 + SV5,6 more than 10.5 mm.

Criteria for RVH generally have low sensitivity. Higher sensitivity is noted in congenital heart disease, while intermediate sensitivity is noted in adults with acquired heart disease and primary pulmonary hypertension. Least sensitivity is noted in chronic lung disease.

Incomplete RBBB pattern in right ventricular volume overload and dominant R wave in right precordial leads in right ventricular pressure overload are well known. ST-T changes may be associated. Right axis deviation and prominent anterior forces in right precordial leads indicate right ventricular hypertrophy.

In chronic obstructive pulmonary disease (COPD), ECG changes reflect the low diaphragm from increased lung volume. Low voltage in limb leads, rightward frontal plane QRS axis, which could also be indeterminate, rightward axis of P wave, persistent S wave in all precordial leads and low R wave amplitude in V6 are usual [4].

References

1. Hancock EW, Deal BJ, Mirvis DM, Okin P, Kligfield P, Gettes LS, Bailey JJ, Childers R, Gorgels A, Josephson M, Kors JA, Macfarlane P, Mason JW, Pahlm O, Rautaharju PM, Surawicz B, van Herpen G, Wagner GS, Wellens H; American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; American College of Cardiology Foundation; Heart Rhythm Society. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2009 Mar 17;53(11):992-1002. doi: 10.1016/j.jacc.2008.12.015. PMID: 19281932.
2. MYERS GB, KLEIN HA, STOFER BE. The electrocardiographic diagnosis of right ventricular hypertrophy. Am Heart J. 1948 Jan;35(1):1-40. doi: 10.1016/0002-8703(48)90182-3. PMID: 18919647.
3. SOKOLOW M, LYON TP. The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads. Am Heart J. 1949 Feb;37(2):161-86. doi: 10.1016/0002-8703(49)90562-1. PMID: 18107386.
4. Selvester RH and Rubin HB. New criteria for the electrocardiographic diagnosis of emphysema and cor pulmonale. Am Heart J. 1965 Apr;69:437-47. doi: 10.1016/0002-8703(65)90413-8. PMID: 14270092.