What is the most common cause of right ventricular hypertrophy

Electrocardiographic Features

• 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).

ECG Pearl

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.

Causes

• 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

ECG Examples

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.

References

• 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 Yellow Belt online course: Become an ECG expert. Medmastery
• Wiesbauer F, Kühn P. ECG Blue Belt online course: Learn to diagnose any rhythm problem. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.

Textbooks

• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Hampton J. The ECG Made Practical 7e, 2019
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography 1e, 2009
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004
• Smith SW. The ECG in Acute MI. 2002 [PDF]

• 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

ECG LIBRARY

Electrocardiogram

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

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner