ECG Findings Suggestive of Right Ventricular Dysfunction

Key ECG Patterns

The American College of Cardiology suggests that right ventricular hypertrophy (RVH) causes displacement of the QRS vector toward the right and anteriorly, often with delayed R-wave peak in right precordial leads 1
Right axis deviation is a common finding and should be required for diagnosis of RVH in nearly all cases, as recommended by the American College of Cardiology 2
The American College of Cardiology notes that tall R waves in right precordial leads (as part of Rs, R, or Qr complexes), particularly in V1, are indicative of RVH 3
Increased R-wave amplitude in V1 relative to normal, especially in patients with chronic obstructive pulmonary disease, is suggested by the American College of Cardiology 4

The American College of Cardiology recommends that predominantly tall R waves in right precordial leads, right axis deviation, and ST depression and T-wave inversion in right precordial leads are indicative of a pressure overload pattern 3
A volume overload pattern is characterized by similar ECG findings to incomplete right bundle branch block, right axis deviation, and secondary ST-T abnormalities, as suggested by the American College of Cardiology 3

The American College of Cardiology states that the sensitivity of ECG criteria for RVH is generally low, but some criteria have high specificity, and clinical context is essential for proper interpretation 2
The American College of Cardiology notes that the greatest accuracy in diagnosing RVH is in congenital heart disease, intermediate in acquired heart disease and primary pulmonary hypertension, and lowest in chronic lung disease 2
Clinical context is essential for proper interpretation, as many ECG findings can occur as normal variants, as recommended by the American College of Cardiology 4

The American College of Cardiology suggests that age-specific criteria exist for RVH diagnosis in pediatric populations, and R-wave amplitude in V1 and S-wave amplitude in V6 vary significantly with age 5

The American College of Cardiology recommends that no single criterion should be used exclusively, and multiple criteria improve diagnostic accuracy, and criteria should be adjusted for age, gender, race, and body habitus 6
Probability estimates should be adjusted based on clinical diagnoses suggesting congenital heart disease, valvular heart disease, or chronic pulmonary disease, as suggested by the American College of Cardiology 6

Journal of the American College of Cardiology, 2009