Right ventricular hypertrophy (RVH):

The ECG is insensitive for the diagnosis of RVH. In addition, in 100 cases of RVH from our echo lab, only 33% had RAD, because of the confounding effects of LV disease. Published ECG criteria for RVH are listed below, all of which have > 97% specificity. Right atrial enlargement is synonymous with RVH, with rare exceptions.

QRS criteria for RVH:

  1. Right axis deviation (>90°), or
  2. An R/S ratio > 1 in lead V1 (absent posterior MI or RBBB) or
  3. An R wave > 7 mm tall in Vl, (not the R' of RBBB) or
  4. An rsR' complex in V 1 (R' > 10 mm), with a QRS duration of < 0.12 seconds (incomplete RBBB), or
  5. An S wave > 7 mm deep in leads V5 or V6 (in the absence of a QRS axis more negative than +30°), or
  6. RBBB with RAD (axis derived from first 60 msec of the QRS). Consider RVH in RBBB if the R/S ratio in lead I is < 0.5.
A variant of RVH (type C loop) may produce false positive signs for anterior MI.

The paradox of left posterior fascicular block and right ventricular hypertrophy:
RVH and LPFB produce right axis deviation (33% and 100% of cases, respectively) with qR complexes in lead III. Because chronic LPFB is rare, this diagnosis is generally discouraged in the presence of RAD, despite positive ECG criteria. Almost all cases of RVH with RAD will produce false positive criteria for LPFB, i.e., RAD with a qR complex in lead III. The presence of RAE almost certainly decides in favor of RVH. Because LPFB does not alter the QRS morphology of leads V1-3, signs of RVH in these leads would take precedence in diagnosis. In cases of RBBB and RAD, it may be impossible to distinguish between RVH and LPFB using the ECG alone. In these cases, younger age suggests RVH, while older age and/or prior MI suggest LPFB.

Repolarization abnormalities in RVH:
The morphology of repolarization abnormalities in RVH is identical to those in LVH, when a particular lead contains tall R waves reflecting the hypertrophied RV or LV. In RVH, these typically occur in leads V1-2 or 3 and leads aVF and III. This morphology of repolarization abnormalities due to ventricular hypertrophy is illustrated on the previous page (CLASSICAL pattern). In cases of RVH with massive dilatation, all precordial leads may overlie the diseased RV and may contain repolarization abnormalities.

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