Poor R Wave Progression (PRWP)

Poor R Wave Progression Overview

Causes of PRWP

The major causes associated with PRWP include:

• Prior anteroseptal MI
• Left Ventricular Hypertrophy (LVH)
• Right Ventricular Hypertrophy (RVH)
• Inaccurate lead placement (e.g. transposition of V1 and V3)
• Dilated cardiomyopathy
• May be a normal variant

ECG Examples

Example 1

Poor R wave progression secondary to prior anteroseptal MI

Example 2

Poor R wave progression due to electrode misplacement (leads V1 and V3 reversed)

Related Topics

• R Wave
• Anterior STEMI
• Left Ventricular Hypertrophy
• Right Ventricular Hypertrophy
• Dilated cardiomyopathy

References

• Zema MJ, Kligfield P. ECG poor R-wave progression: review and synthesis. Arch Intern Med. 1982 Jun;142(6):1145-8. [PMID 6212033]

Advanced Reading

Online

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.
• Wiesbauer F. Little Black Book of ECG Secrets. Medmastery PDF

Textbooks

• Zimmerman FH. ECG Core Curriculum. 2023
• Mattu A, Berberian J, Brady WJ. Emergency ECGs: Case-Based Review and Interpretations, 2022
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Hampton J, Adlam D. The ECG Made Practical 7e, 2019
• Kühn P, Lang C, Wiesbauer F. ECG Mastery: The Simplest Way to Learn the ECG. 2015
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

LITFL Further Reading

• ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
• ECG A to Z by diagnosis – ECG interpretation in clinical context
• ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
• 100 ECG Quiz – Self-assessment tool for examination practice
• ECG Reference SITES and BOOKS – the best of the rest