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:

 Right axis deviation

 Dominant R wave in V1
 Dominant S wave in V5 or V6
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 dysplasia (ARVD)

ECG Examples

Example 1
 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

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
 Left Ventricular Hypertrophy (LVH)
ECG Diagnostic criteria

 There are numerous voltage criteria for diagnosing LVH, summarised below

 The most commonly used are the Sokolov-Lyon  criteria: S wave depth in V1 +
tallest R wave height in V5-V6 > 35 mm
 Voltage criteria must be accompanied by non-voltage criteria to be
considered diagnostic of LVH

Voltage Criteria

Limb Leads

 R wave in lead I + S wave in lead III > 25 mm

 R wave in aVL > 11 mm
 R wave in aVF > 20 mm
 S wave in aVR > 14 mm
Precordial Leads

 R wave in V4, V5 or V6  > 26 mm

 R wave in V5 or V6 plus S wave in V1 > 35 mm
 Largest R wave plus largest S wave in precordial leads > 45 mm

Non Voltage Criteria

 Increased R wave peak time > 50 ms in leads V5 or V6

 ST segment depression and T wave inversion in the left-sided leads: AKA the
left ventricular ‘strain’ pattern

Pathophysiology

 The left ventricle hypertrophies in response to pressure overload secondary

to conditions such as aortic stenosis and hypertension
 This results in increased R wave amplitude in the left-sided ECG leads (I, aVL
and V4-6) and increased S wave depth in the right-sided leads (III, aVR, V1-3)
 The thickened LV wall leads to prolonged depolarisation (increased R wave
peak time) and delayed repolarisation (ST and T-wave abnormalities) in the
lateral leads

Additional ECG changes seen in LVH

 Left atrial enlargement

 Left axis deviation
 ST elevation in the right precordial leads V1-3 (“discordant” to the deep S
waves)
 Prominent U waves (proportional to increased QRS amplitude)

LVH by voltage criteria: S wave in V2 + R wave in V5 > 35 mm

LV strain pattern: ST depression and T wave inversion in the lateral leads

Causes of LVH

 Hypertension (most common cause)

 Aortic stenosis
 Aortic regurgitation
 Mitral regurgitation
 Coarctation of the aorta
 Hypertrophic cardiomyopathy

Handy Tips

 Voltage criteria alone are not diagnostic of LVH

 ECG changes are an insensitive means of detecting LVH (patients with
clinically significant left ventricular hypertrophy seen on echocardiography
may still have a relatively normal ECG)

ECG Examples

Example 1
 Left ventricular hypertrophy (LVH):

 Markedly increased LV voltages: huge precordial R and S waves that overlap

with the adjacent leads (SV2 + RV6 >> 35 mm).
 R-wave peak time > 50 ms in V5-6 with associated QRS broadening.
 LV strain pattern with ST depression and T-wave inversions in I, aVL and V5-6.
 ST elevation in V1-3.
 Prominent U waves in V1-3.
 Left axis deviation.
Severe LVH such as this appears almost identical to  left bundle branch block  —
the main clue to the presence of LVH is the excessively high LV voltages. 
Example 2
 ECG reproduced from  Dr Smith’s ECG blog
 There are massively increased QRS voltages — the S waves in V3 are so deep
they are literally falling off the page!
 The ST elevation in V1-3 is simply in proportion to the very deep S waves
(“appropriate discordance”).
 The LV strain pattern is seen in all leads with a positive R wave (V5-6, I, II, III,
aVF)
 Right Ventricular Hypertrophy (RVH)
Diagnostic criteria

 Right axis deviation of +110° or more.

 Dominant R wave in V1 (> 7mm tall or R/S ratio > 1).
 Dominant S wave in V5 or V6 (> 7mm deep or R/S ratio < 1).
 QRS duration < 120ms (i.e. changes not due to RBBB).

Supporting criteria

 Right atrial enlargement (P pulmonale).

 Right ventricular strain pattern = ST depression / T wave inversion in the right
precordial (V1-4) and inferior (II, III, aVF) leads.
 S1 S2 S3 pattern = far right axis deviation with dominant S waves in leads I, II and III.
 Deep S waves in the lateral leads (I, aVL, V5-V6).

Other abnormalities caused by RVH

 Right bundle branch block (complete or incomplete).

ECG Pearl
There are no universally accepted criteria for diagnosing RVH in the presence
of RBBB; the standard voltage criteria do not apply. 

However, the presence of incomplete / complete RBBB with a tall R wave in

V1, right axis deviation of +110° or more and supporting criteria (such as RV
strain pattern or P pulmonale) would be considered suggestive of RVH.

Causes
 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
 Typical appearance of RVH:

 Right axis deviation (+150 degrees).

 Dominant R wave in V1 (> 7 mm tall; R/S ratio > 1)
 Dominant S wave in V6 (> 7 mm deep; R/S ratio < 1).
 Right ventricular strain pattern with ST depression and T-wave inversion in V1-4.

Example 2

 Right axis deviation (+150 degrees)

 P pulmonale (P wave in lead II > 2.5 mm)
 Incomplete RBBB
 Right ventricular strain pattern with T-wave inversion and ST depression in the right
precordial (V1-3) and inferior (II, III, aVF) leads.
This ECG was originally posted by Johnson Francis on  Cardiophile.org.
 Example 4

Right ventricular hypertrophy in a patient with arrhythmogenic right

ventricular cardiomyopathy (ARVC):

 Right axis deviation.

 R/S ratio in V1 > 1
 Right ventricular strain pattern with T-wave inversion and ST depression in the right
precordial (V1-3) and inferior (II, III, aVF) leads.