Tutorial 5: Right Ventricular Hypertrophy

RVH Criteria

• Tall R waves (R:S ratio > 1) in V1-V2
• S waves in V5-V6
• Right Axis Deviation

Understanding the Criteria

The diagnosis of right ventricular hypertrophy follows the same logic as that of LVH. RVH is an important finding as it can be indicitive of right-sided valvular pathology (pulmonic, tricuspid), as well as significant pulmonary disease

The R wave in the anterior leads (V1-V2) is what indicates the depolarization of the right ventricle. In a normal heart this depolarization is masked by the much larger signal from the left ventricle, which pulls in the opposite direction and so only the S wave is seen in the leads V1 and V2. In RVH, however, the signal is much stronger and comes through as an R-wave in leads V1V2, and similarly, as a deep S wave in leads V5-V6.

It`s important to note that several other conditions can mimic the findings of RVH. An important differential to know is the differential diagnosis for an increased R:S ratio in the anterior leads.

These include:

• Posterior Wall Infarction (?)

  This will be discussed elsewhere, but in this case the R-wave is actually the Q-wave occuring on the posterior wall.

• WPW syndrome (?)

  Abnormal depolarization tracts towards the anterior leads.

• Early depolarization
• Poor lead placement
• Hypertrophic cardiomyopathy (?)

  The enlargement of just the septum can mimick RVH as well.

Teasing out your diagnosis means looking for other hints or suggestions that this is indeed RVH. These include a right-axis deviation, evidence of right atrial enlargement, and incomplete bundle branch block.