Management of RSR' Pattern in Lead V2 on ECG

Understanding the RSR' Pattern

The American College of Cardiology and Circulation journal describe the RSR' pattern in V1-V2 as characterized by an initial small r wave, followed by an S wave, and then a terminal R' wave (r') deflection that is usually wider than the initial r wave 1, 2
The American College of Cardiology and Circulation journal state that this pattern can represent incomplete RBBB when QRS duration is between 110-119 ms, or complete RBBB when QRS duration is ≥120 ms 2, 3

The American College of Cardiology recommends evaluating for symptoms such as syncope, pre-syncope, palpitations, or dyspnea which may indicate underlying pathology 5, 6
The American College of Cardiology suggests assessing for family history of sudden cardiac death or inherited arrhythmia syndromes 7
The American College of Cardiology states that QRS duration should be measured, with <110 ms indicating a likely normal variant or non-specific intraventricular conduction delay, 110-119 ms consistent with incomplete RBBB, and ≥120 ms indicating complete RBBB requiring further evaluation 2, 3, 8

The American College of Cardiology and Circulation journal state that the RSR' pattern in V2 may represent incomplete or complete RBBB, which is the most common cause 2
The American College of Cardiology notes that the RSR' pattern may also represent Brugada syndrome, distinguished by coved ST-segment elevation ≥2 mm and terminal T-wave inversion 7

The American College of Cardiology recommends confirming ECG findings by verifying correct lead placement and assessing QRS duration and morphology criteria 2, 7
The American College of Cardiology suggests using the "Corrado index" to differentiate from Brugada pattern (STJ/ST80 ratio <1 in normal RSR' vs >1 in Brugada) 7
The American College of Cardiology recommends further testing based on clinical suspicion, including echocardiogram to evaluate for structural heart disease if complete RBBB (QRS ≥120 ms) is present, or if symptoms of heart failure or arrhythmia are present 3, 5

The American College of Cardiology states that asymptomatic patients with normal QRS duration (<110 ms) require no specific treatment, but should have routine follow-up 2, 5
The American College of Cardiology recommends that patients with incomplete RBBB (QRS 110-119 ms) should have annual follow-up to monitor for progression, and that patients with complete RBBB (QRS ≥120 ms) should be evaluated for underlying structural heart disease and monitored for development of higher-degree conduction disorders 2, 3, 5, 8
The American College of Cardiology suggests referring patients with concerning features, such as Brugada pattern, symptoms of syncope or pre-syncope, family history of sudden cardiac death, or evidence of progressive conduction disease, to an electrophysiologist 6, 7