Electrocardiographic recognition of right ventricular hypertrophy

Kjell Nikus, Andrés Ricardo Pérez-Riera, Kaari Konttila, Raimundo

Barbosa-Barros

PII: S0022-0736(17)30328-X
DOI: doi: 10.1016/j.jelectrocard.2017.09.004
Reference: YJELC 52503

To appear in: Journal of Electrocardiology

Please cite this article as: Nikus Kjell, Pérez-Riera Andrés Ricardo, Konttila Kaari,
Barbosa-Barros Raimundo, Electrocardiographic recognition of right ventricular hyper-
trophy, Journal of Electrocardiology (2017), doi: 10.1016/j.jelectrocard.2017.09.004

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Electrocardiographic recognition of right ventricular hypertrophy

Kjell Nikus MD PhD1,2; Andrés Ricardo Pérez-Riera MD PhD3; Kaari Konttila MS2,
Raimundo Barbosa-Barros, MD4.

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Heart Center, Tampere University Hospital, Tampere, Finland

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Faculty of Medicine and Life Sciences, University of Tampere, Finland

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3
Design of Studies and Scientific Writing Laboratory in the ABC School of Medicine,

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Santo André, São Paulo, Brazil https://ekgvcg.wordpress.com
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Coronary Center of the Hospital de Messejana Dr. Carlos Alberto Studart Gomes.
Fortaleza – CE- Brazil

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Address for Correspondence:

Kjell Nikus, MD, PhD
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Heart Center, Tampere University Hospital

Arvo Ylpön katu 6, 33520 Tampere, Finland
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Tel.: +358- 50 5575 396

E-mail: kjell.nikus@sydansairaala.fi
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Introduction
The electrocardiogram (ECG) is a relatively insensitive tool for the detection of right
ventricular hypertrophy (RVH), but some criteria have high specificity [1]. The right
ventricle (RV) is located in front and to the right of the left ventricle (LV). Consequently,
its forces are directed rightwards and anteriorly. In adolescents and adults, the RV forces

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are almost completely masked by the dominant forces of the LV (the ECG is a

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“levocardiogram”). Additionally, RVH causes ≥35ms delay in the R-wave peak time in the
right precordial leads [2]. RVH is more likely to be detected by the ECG in

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moderately/severely increased RV pressure. RVH is much rarer than left ventricular
hypertrophy (LVH), and in its extensive form it is encountered in several congenital heart

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diseases. The recommended ECG screening criteria for RVH are not sufficiently sensitive
or specific for screening for mild RVH in adults without clinical cardiovascular disease [3].

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The greatest accuracy of the ECG is in congenital heart disease, with intermediate accuracy
in acquired heart disease and primary pulmonary hypertension in adults [4]. The ECG
pattern resulting from RVH is highly variable and dependent on intrinsic and extrinsic
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factors such as the hemodynamic pattern of overload (systolic or diastolic), severity,
concomitant LVH, coexistence of bundle branch blocks, fascicular blocks, myocardial
scars, rotation of the heart, and consequences from increased lung volume with a downshift
of the diaphragm.
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In the following different clinical entities are briefly presented with ECG and
vectorcardiographic (VCG) correlations. It has to be pointed out that most criteria were
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derived from autopsy studies in selected patient populations.

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Clinical causes of RVH

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A) Congenital heart disease

I. Acyanotic Congenital Heart Diseases: Secundum atrial septal defect (ASD),

common atrioventricular canal, pulmonary stenosis, ventricular septal defects
with pulmonary stenosis, patent ductus arteriosus, aortic coarctation in the first 6
months of life, primary pulmonary hypertension.
II. Cyanotic Congenital Heart Diseases: Fallot’s tetralogy, double-outlet right
ventricle, transposition of the great arteries, single ventricle, aortic atresia,
congenital mitral stenosis/atresia, truncus arteriosus, Einsenmenger syndrome.

B) Acquired causes
Athlete’s heart, mitral stenosis [5], tricuspid insufficiency, chronic obstructive
pulmonary disease, acute pulmonary embolism, chronic thromboembolic pulmonary
hypertension and miscellaneous.
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The three main hemodynamic modalities, severity of RVH and ECG correlates
1. A) Pressure (systolic) overload: type A RVH
Two subtypes (Figure 1):
I. Adaptation overload: Right intraventricular pressure never higher than left

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intraventricular pressure: tall R waves in V1 [6] with Rs/R, and V3 showing

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negative QRS predominance. A typical example is Fallot´s tetralogy.

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II. Severe systolic overload with strain pattern of repolarization in the right
precordial leads: Right intraventricular pressure may exceed the systemic one

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(supra-systemic): tall R waves or qR complexes in V1, predominantly positive
QRS complexes in V2-V3. A typical example is severe pulmonary stenosis.

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Figure 1. ECG: Note prominent anterior QRS forces (PAF) aiding in the ECG diagnosis of
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RVH.
VCG:
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I. RVH type A with adaptation overload. QRS loop with initial 10-20 ms
preserved: directed to the front, and counter-clockwise rotation predominantly
located in the anterior quadrants.
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II. RVH type A with systolic overload and the strain pattern. QRS loop with initial
10-20 ms directed to the back and leftward, and CW rotation predominantly
located in the anterior quadrants.
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1. B) Pressure (systolic) overload: type B RVH (Figure 2)

Figure 2. These changes are present in moderate RVH and at an earlier disease stage.
The QRS loop in the horizontal plane shows counterclockwise rotation. The QRS loop
is displaced anteriorly and to the left: ≥70% of the area of the QRS loop of anterior
location (in front of the X line = anterior quadrants), which generates prominent
anterior forces. V3R and V1 show R/s ratio >1. R wave in V1 ≥7 mm; V5 and V6: qRS;
ST/T vector deviated to the left and backward.
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2. Chronic obstructive pulmonary disease; type C RVH

This condition often causes a characteristic ECG pattern that reflects the low diaphragm
resulting from the increased lung volume [7]. This pattern includes low QRS voltage in the
limb leads, rightward shift of the QRS axis (superior or indeterminate), a rightward P-wave
axis beyond +60°; a persistent rS pattern across all precordial leads, also called anterior

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pseudo-infarction pattern (Figure 3A).

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3. Diastolic, volumetric or eccentric RVH [8]

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The ECG shows typical incomplete right bundle branch block (RBBB), suggesting volume
overload of the RV. The most representative example is atrial septal defect, which causes
eccentric dilatation of the RV with selective predominance of hypertrophy in the right
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ventricular outflow tract (RVOT) (Figure 3B).
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Figure 3.
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A) ECG: rS or QR across the precordial leads.

VCG: QRS loop of RVH type C, characterized by counterclockwise rotation,
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posterior shift, and >70% of the QRS loop area in the posterior quadrants, and
>20% in the right posterior one.
B) ECG diagnosis: RVH diastolic tetraphasic pattern rsR’s’ type in V1 and R=S
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complexes from V2 through V6. Final broad S waves in the left leads: incomplete
RBBB + diastolic, volumetric or eccentric RVH. Clincal diagnosis: ostium
secundum ASD.

Criteria for RVH

I. Precordial leads
• RV1 ≥ 7 mm
• SV1 < 2 mm
• Ventricular activation time ≥35 ms in V1
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• qR pattern in V1
• Positive T wave in V1 after 3 days of life and up to 6 years of age, if R/S
ratio > 1
• Negative “primary” (symmetrical) T waves in V1-V3

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Ratio between precordial leads

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• RV1 + SV5/V6 >10.5 mm (Sokolow-Lyon index).

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• R/S ratio in V5-V6 ≤1
• RV1 > RV6

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• Regression of R/S ratio across the precordium.
II. Limb leads
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• Right axis deviation > +110º in adults.
• SI-SII-SIII pattern
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• RaVR > 4 mm
• Q/R ratio of aVR ≤ 1
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• McGinn-White pattern: SI-QIII-TIII

III. Association of precordial with unipolar leads
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• Deep S wave in V1 or V1-V2 associated with QRS complexes of positive

predominance in aVR
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IV. Other
• RBBB associated with right atrial enlargement and right axis deviation
• RBBB of sudden onset, associated with sinus tachycardia, atrial
fibrillation/flutter or left anterior fascicular block

Conclusion

The ECG has low sensitivity for the detection of RVH in the community. In a clinically ill
population, the established ECG criteria may have clinical or prognostic utility. The highest
sensitivity is observed in congenital heart diseases.

Acknowledgement
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The authors have no conflict of interest or sources of funding to report.

References

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Highlights
 The ECG is a relatively insensitive tool for the detection of right ventricular
hypertrophy, but some criteria have high specificity
 The recommended ECG screening criteria are not sufficiently sensitive or specific
for screening for mild right ventricular hypertrophy in adults without clinical

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cardiovascular disease

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 The greatest accuracy of the ECG is in congenital heart disease

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