RWJ Cardiology Fellows

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EKG Board Review

• RWJ Cardiology Fellows
• 7-9-07

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3 Types of RVH

• 1) Typical RVH pattern
• 2) Incomplete RBBB
• 3) Posterior and rightward displacement of QRS
  axis

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Typical RVH Pattern

• 1) Tall R wave in V1 (gt0.7 mV)
• 2) Right axis deviation (gt110º)
• 3) T wave inversion in V1 through V3
• 4) Delayed precordial transition zone (rS in V6)
• 5) Right atrial abnormality

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Typical RVH Pattern

• Differential Diagnosis
• RV pressure overload
• True posterior wall MI
• Type A WPW
• RBBB
• Dextrocardia
• Lead misplacement
• Normal young adults

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Typical RVH Pattern

• QRS Patterns
• 1) qR pattern in Lead V1 most specific sign of
  severe RVH
• 2) S1S2S3 pattern
• Seen in normal pts, emphysema, or RVH
• R/S ratio 1 in lease I, II, and III
• 3) S1Q3T3 pattern
• S wave in lead I (as an RS or rS complex)
• Abnormal Q wave in lead III
• Inverted T wave in the inferior leads

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(No Transcript)
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Incomplete RBBB

• Due to delayed activation of the hypertrophied RV
  outflow tract
• Differential Diagnosis
• 1) Normal individuals
• 2) Acute RV dilatation
• 3) True posterior MI
• 4) Extracardiac abnormalities (pectus excavatum)
• 5) RV overload (ex. Pulmonary HTN, ASD)
• Pattern disappears within days of corrective
  surgery suggesting slowing of intraventricular
  conduction due to stretching of peripheral
  conducting system in dilated RV

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Patterns in Chronic Lung Disease

• Due to changes in the spatial orientation of the
  heart and the insulating effect of the
  overaerated lungs
• Patterns
• 1) Peaked p waves in II, III, aVF
• 2) Low R wave amplitude in all leads
• 3) Slurred S wave in I, II, III, V4, V5, and V6
• 4) Right axis deviation in the frontal plane
• 5) Delayed transition in the precordial leads

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Pulmonary emphysema simulating anterior
infarction in a 58-year-old man with no clinical
evidence of coronary disease. Note the relative
normalization of R wave progression with
placement of the chest leads an interspace below
their usual position (5V1, 5V2, and so forth).
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RVH in Other Clinical Conditions

• Pulmonary Hypertension in Mitral Stenosis
• Rhythm is usually sinus tachycardia
• EKG often shows incomplete right bundle branch
  block
• Usually occurs when PAP 42mmHg
• Left atrial abnormality (enlargement) indicated
  by prominent biphasic P wave in lead V1
• Frequently see concomitant right atrial
  enlargement (biatrial abnormality) as indicated
  by Tall P wave in lead II
• Nonspecific ST-T changes
• Combination of right ventricular hypertrophy and
  left atrial abnormality (enlargement) is highly
  suggestive of mitral stenosis

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45-year-old woman with severe mitral stenosis
shows multiple abnormalities.
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RVH in Other Clinical Conditions

• Atrial Septal Defect