Right Ventricular Strain

Right ventricular strain is a repolarisation abnormality due to right ventricular hypertrophy (RVH) or dilatation.

ECG Features

ST depression and T wave inversion in leads corresponding to the right ventricle:

  • Right precordial leads V1-3 +/- V4
  • Inferior leads II, III, aVF, often most pronounced in lead III as this is the most rightward facing lead

Associated features often include those seen in RVH:

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


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

ECG Examples
Example 1
ECGH RVH Right ventricular hypertropy RV Strain

Right ventricular strain pattern due to RVH: 

  • ST depression and T-wave inversion in V1-4 and lead III
  • Other features of RVH are present, including right axis deviation, and a dominant R wave in V1

Example 2
ECG Massive Pulmonary embolus RVH RV Strain
Acute right ventricular dilatation due to massive PE. 

Right ventricular strain pattern due to acute right ventricular dilatation:

  • T-wave inversions are seen in the right precordial (V1-4) and inferior leads (III, aVF)
  • This patient had a massive pulmonary embolism

Advanced Reading



LITFL Further Reading


Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner


  1. Is there be a good method to differentiate these TWI from strain or Wellens type T waves? In example 2 they seem to look particularly similar to either.

  2. Hi Will,

    Differentiation between the two can sometimes be difficult on ECG alone. In example 2, T wave inversion extending to inferior leads is more suggestive of RV strain and specifically PE. In Wellens, T wave inversion is usually isolated to precordial leads.
    Most of the time, there will also be associated features of RVH (RAD, dominant R wave in V1) or other underlying pathology such as PE (sinus tachycardia, right axis deviation, RBBB morphology). In addition, clinical context will assist.

    I hope this helps.


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