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Right Ventricular Hypertrophy (RVH) • LITFL • ECG Library Diagnosis

• Right axis deviation of +110° or more.
• Dominant R wave in V1 (> 7mm tall or R/S ratio > 1).
• Dominant S wave in V5 or V6 (> 7mm deep or R/S ratio < 1).
• QRS duration < 120ms (i.e. changes not due to RBBB).

• Right atrial enlargement (P pulmonale).
• Right ventricular strain pattern = ST depression / T wave inversion in the right precordial (V1-4) and inferior (II, III, aVF) leads.
• S1 S2 S3 pattern = far right axis deviation with dominant S waves in leads I, II and III.
• Deep S waves in the lateral leads (I, aVL, V5-V6).

• Right bundle branch block (complete or incomplete).

There are no universally accepted criteria for diagnosing RVH in the presence of RBBB; the standard voltage criteria do not apply. 

However, the presence of incomplete / complete RBBB with a tall R wave in V1, right axis deviation of +110° or more and supporting criteria (such as RV strain pattern or P pulmonale) would be considered suggestive of RVH.

• Pulmonary hypertension
• Mitral stenosis
• Pulmonary embolism
• Chronic lung disease (cor pulmonale)
• Congenital heart disease (e.g. Tetralogy of Fallot, pulmonary stenosis)
• Arrhythmogenic right ventricular cardiomyopathy

Typical appearance of RVH:

• Right axis deviation (+150 degrees).
• Dominant R wave in V1 (> 7 mm tall; R/S ratio > 1)
• Dominant S wave in V6 (> 7 mm deep; R/S ratio < 1).
• Right ventricular strain pattern with ST depression and T-wave inversion in V1-4.

• Right axis deviation (+150 degrees)
• P pulmonale (P wave in lead II > 2.5 mm)
• Incomplete RBBB
• Right ventricular strain pattern with T-wave inversion and ST depression in the right precordial (V1-3) and inferior (II, III, aVF) leads.

This ECG was originally posted by Johnson Francis on Cardiophile.org.

Right ventricular hypertrophy in a patient with arrhythmogenic right ventricular cardiomyopathy (ARVC):

• Right axis deviation.
• R/S ratio in V1 > 1
• Right ventricular strain pattern with T-wave inversion and ST depression in the right precordial (V1-3) and inferior (II, III, aVF) leads.

This ECG was originally posted by Jayachandran Thejus on the website HeartPearls.com.

• Right ventricular strain.
• The ECG in pulmonary embolism.
• The ECG in chronic lung disease.
• Left ventricular hypertrophy.

• Harrigan RA, Jones K. ABC of clinical electrocardiography. Conditions affecting the right side of the heart. BMJ. 2002 May 18;324(7347):1201-4. Review. PMID: 12016190

Online

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.
• Wiesbauer F. Little Black Book of ECG Secrets. Medmastery PDF

Textbooks

• Zimmerman FH. ECG Core Curriculum. 2023
• Mattu A, Berberian J, Brady WJ. Emergency ECGs: Case-Based Review and Interpretations, 2022
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Hampton J, Adlam D. The ECG Made Practical 7e, 2019
• Kühn P, Lang C, Wiesbauer F. ECG Mastery: The Simplest Way to Learn the ECG. 2015
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

• ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
• ECG A to Z by diagnosis – ECG interpretation in clinical context
• ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
• 100 ECG Quiz – Self-assessment tool for examination practice
• ECG Reference SITES and BOOKS – the best of the rest

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

MBBS DDU (Emergency) CCPU. Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Co-creator of the LITFL ECG Library. Twitter: @rob_buttner

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