Electrocardiographic Features

Repolarisation abnormality due to right ventricular hypertrophy or dilatation. ST depression and T wave inversion in the leads corresponding to the right ventricle.

• The right precordial leads:  V1-3, often extending out to V4
• The inferior leads:  II, III, aVF, often most pronounced in lead III as this is the most rightward-facing lead.

**NB. Compare this to the left ventricular strain pattern, where ST/T-wave changes are present in the left ventricular leads (I, aVL, V5-6).

Causes

Associated with increased pulmonary artery pressures in the setting of acute or chronic right ventricular hypertrophy or dilatation:

• Pulmonary hypertension
• Mitral stenosis
• Pulmonary embolism
• Chronic lung disease (cor pulmonale)
• Congenital heart disease (e.g. Tetralogy of Fallot, pulmonary stenosis)
• Arrhythmogenic right ventricular cardiomyopathy

ECG Examples

Example 1

Right ventricular hypertrophy 

• Typical right ventricular strain pattern: ST depression and T-wave inversion in V1-4 (plus lead III), in this case due to right ventricular hypertrophy.

Example 2

Right ventricular strain pattern involving both the precordial and inferior leads:

• T-wave inversions are seen in the right precordial (V1-4) and inferior leads (III, aVF) in this patient with acute right ventricular dilatation due to massive pulmonary embolism.

Related Topics

• Right Ventricular Hypertrophy
• The ECG in Pulmonary Embolism

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

Advanced Reading

• Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric
• Wagner GS. Marriott’s Practical Electrocardiography 12e
• Chan TC. ECG in Emergency Medicine and Acute Care
• Rawshani A. Clinical ECG Interpretation
• Mattu A. ECG’s for the Emergency Physician
• Hampton JR. The ECG In Practice, 6e