Electrocardiographic recognition of right ventricular ...

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Journal of Electrocardiology xx (2017) xxx ? xxx

Review



Electrocardiographic recognition of right ventricular hypertrophy

Kjell Nikus, MD, PhD, a, b, Andr?s Ricardo P?rez-Riera, MD, PhD, c Kaari Konttila, MS, b Raimundo Barbosa-Barros, MD d

a Heart Center, Tampere University Hospital, Tampere, Finland b Faculty of Medicine and Life Sciences, University of Tampere, Finland c Design of Studies and Scientific Writing Laboratory in the ABC School of Medicine, Santo Andr?, S?o Paulo, Brazil d Coronary Center of the Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceara, Brazil

Abstract Keywords:

The electrocardiogram (ECG) is a relatively insensitive tool for the detection of right ventricular hypertrophy (RVH), but some criteria have high specificity. The recommended ECG screening criteria for RVH are not sufficiently sensitive or specific for screening for mild RVH in adults without clinical cardiovascular disease. The greatest accuracy of the ECG is in congenital heart disease, with intermediate accuracy in acquired heart disease and primary pulmonary hypertension in adults. ? 2017 Elsevier Inc. All rights reserved. ECG; Right ventricular hypertrophy; ECG screening

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Clinical causes of RVH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 The three main hemodynamic modalities, severity of RVH and ECG correlates . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 VCG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Criteria for RVH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

Introduction

The electrocardiogram (ECG) is a relatively insensitive tool for the detection of right ventricular hypertrophy (RVH), but some criteria have high specificity [1]. The right ventricle (RV) is located in front and to the right of the left ventricle (LV). Consequently, its forces are directed rightwards and anteriorly. In adolescents and adults, the RV forces are almost completely masked by the dominant forces of the LV (the ECG is a "levocardiogram"). Additionally, RVH causes 35 ms delay in the R-wave peak time in the right precordial leads [2]. RVH is more likely to be detected by the ECG in moderately/severely increased RV pressure. RVH is much rarer than left ventricular hypertrophy (LVH),

Corresponding author at: Heart Center, Tampere University Hospital, Arvo Ylp?n katu 6, 33520 Tampere, Finland.

E-mail address: kjell.nikus@sydansairaala.fi.

0022-0736/? 2017 Elsevier Inc. All rights reserved.

and in its extensive form it is encountered in several congenital heart diseases. The recommended ECG screening criteria for RVH are not sufficiently sensitive or specific for screening for mild RVH in adults without clinical cardiovascular disease [3].

The greatest accuracy of the ECG is in congenital heart disease, with intermediate accuracy in acquired heart disease and primary pulmonary hypertension in adults [4]. The ECG pattern resulting from RVH is highly variable and dependent on intrinsic and extrinsic factors such as the hemodynamic pattern of overload (systolic or diastolic), severity, concomitant LVH, coexistence of bundle branch blocks, fascicular blocks, myocardial scars, rotation of the heart, and consequences from increased lung volume with a downshift of the diaphragm.

In the following different clinical entities are briefly presented with ECG and vectorcardiographic (VCG) correlations. It has to be pointed out that most

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K. Nikus et al. / Journal of Electrocardiology xx (2017) xxx?xxx

criteria were derived from autopsy studies in selected patient populations.

Clinical causes of RVH

A) Congenital heart disease I. Acyanotic congenital heart diseases

Secundum atrial septal defect (ASD), common atrioventricular canal, pulmonary stenosis, ventricular septal defects with pulmonary stenosis, patent ductus arteriosus, aortic coarctation in the first 6 months of life, primary pulmonary hypertension. II. Cyanotic congenital heart diseases Fallot's tetralogy, double-outlet right ventricle, transposition of the great arteries, single ventricle, aortic atresia, congenital mitral stenosis/atresia, truncus arteriosus, Einsenmenger syndrome. B) Acquired causes

Athlete's heart, mitral stenosis [5], tricuspid insufficiency, chronic obstructive pulmonary disease, acute pulmonary embolism, chronic thromboembolic pulmonary hypertension and miscellaneous.

intraventricular pressure: tall R waves in V1 [6] with Rs/R, and V3 showing negative QRS predominance. A typical example is Fallot's tetralogy. II ) Severe systolic overload with strain pattern of repolarization in the right precordial leads Right intraventricular pressure may exceed the systemic one (supra-systemic): tall R waves or qR complexes in V1, predominantly positive QRS complexes in V2-V3. A typical example is severe pulmonary stenosis.

VCG

I ) RVH type A with adaptation overload. QRS loop with initial 10?20 ms preserved: directed to the front, and counter-clockwise rotation predominantly located in the anterior quadrants.

II ) RVH type A with systolic overload and the strain pattern. QRS loop with initial 10?20 ms directed to the back and leftward, and CW rotation predominantly located in the anterior quadrants.

1) B.) Pressure (systolic) overload: type B RVH (Fig. 2)

The three main hemodynamic modalities, severity of RVH and ECG correlates

1) A.) Pressure (systolic) overload: type A RVH Two subtypes (Fig. 1):

I) Adaptation overload Right intraventricular pressure never higher than left

2. Chronic obstructive pulmonary disease; type C RVH This condition often causes a characteristic ECG pattern

that reflects the low diaphragm resulting from the increased lung volume [7]. This pattern includes low QRS voltage in the limb leads, rightward shift of the QRS axis (superior or indeterminate), a rightward P-wave axis beyond + 60?; a persistent rS pattern across all

Fig. 1. ECG: Note prominent anterior QRS forces (PAF) aiding in the ECG diagnosis of RVH.

K. Nikus et al. / Journal of Electrocardiology xx (2017) xxx?xxx

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Fig. 2. These changes are present in moderate RVH and at an earlier disease stage. The QRS loop in the horizontal plane shows counterclockwise rotation. The QRS loop is displaced anteriorly and to the left: 70% of the area of the QRS loop of anterior location (in front of the X line = anterior quadrants), which generates prominent anterior forces. V3R and V1 show R/s ratio N 1. R wave in V1 7 mm; V5 and V6: qRS; ST/T vector deviated to the left and backward.

precordial leads, also called anterior pseudo-infarction pattern (Fig. 3A).

3. Diastolic, volumetric or eccentric RVH [8] The ECG shows typical incomplete right bundle branch block

(RBBB), suggesting volume overload of the RV. The most representative example is atrial septal defect, which causes eccentric dilatation of the RV with selective predominance of hypertrophy in the right ventricular outflow tract (RVOT) (Fig. 3B).

Criteria for RVH I) Precordial leads

? RV1 7 mm

? ? ? ?

SV1 b 2 mm Ventricular activation time 35 ms in V1 qR pattern in V1 Positive T wave in V1 after 3 days of life and

up

to

6 years of age, if R/S ratio N 1

? Negative "primary" (symmetrical) T waves in V1-V3 Ratio between precordial leads

? ? ? ?

RV1 + SV5/V6 N 10.5 mm (Sokolow-Lyon index). R/S ratio in V5 - V6 1 RV1 N RV6 Regression of R/S ratio across the precordium.

II) Limb leads

? Right axis deviation N+110? in adults. ? SI-SII-SIII pattern ? RaVR N 4 mm ? Q/R ratio of aVR 1 ? McGinn-White pattern: SI-QIII-TIII

III) Association of precordial with unipolar leads

? Deep S wave in V1 or V1-V2 associated with QRS complexes of positive predominance in aVR

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K. Nikus et al. / Journal of Electrocardiology xx (2017) xxx?xxx

Fig. 3. A) ECG: rS or QR across the precordial leads. VCG: QRS loop of RVH type C, characterized by counterclockwise rotation, posterior shift, and N70% of the QRS loop area in the posterior quadrants, and N20% in the right posterior one. B) ECG diagnosis: RVH diastolic tetraphasic pattern rsR's' type in V1 and R = S complexes from V2 through V6. Final broad S waves in the left leads: incomplete RBBB + diastolic, volumetric or eccentric RVH. Clincal diagnosis: ostium secundum ASD.

IV) Other

? RBBB associated with right atrial enlargement and right axis deviation

? RBBB of sudden onset, associated with sinus tachycardia, atrial fibrillation/flutter or left anterior fascicular block

Conclusion

The ECG has low sensitivity for the detection of RVH in the community. In a clinically ill population, the established ECG criteria may have clinical or prognostic utility. The highest sensitivity is observed in congenital heart diseases.

Acknowledgement

The authors have no conflict of interest or sources of funding to report.

References

[1] Hancock EW, Deal BJ, Mirvis DM, Okin P, Kligfield P, Gettes LS, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of

Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology.; American College of Cardiology Foundation.; Heart Rhythm Society. J Am Coll Cardiol 2009;53:992?1002. [2] P?rez-Riera AR, de Abreu LC, Barbosa-Barros R, Nikus KC, Baranchuk A. R-peak time: an electrocardiographic parameter with multiple clinical applications. Ann Noninvasive Electrocardiol 2016;21:10?9. [3] Whitman IR, Patel VV, Soliman EZ, Bluemke DA, Praestgaard A, Jain A, et al. Validity of the surface electrocardiogram criteria for right ventricular hypertrophy: the MESA-RV study (multi-ethnic study of atherosclerosis-right ventricle). J Am Coll Cardiol 2014;63:672?81. [4] Harrigan RA, Jones K. ABC of clinical electrocardiography. Conditions affecting the right side of the heart. BMJ 2002;324:1201?4. [5] Cowdery CD, Wagner GS, Starr JW, Rogers G, Greenfield Jr JC. New vectorcardiographic criteria for diagnosing right ventricular hypertrophy in mitral stenosis: comparison with electrocardiographic criteria. Circulation 1980;62:1026?32. [6] Zema MJ. Electrocardiographic tall R waves in the right precordial leads. Comparison of recently proposed ECG and VCG criteria for distinguishing posterolateral myocardial infarction from prominent anterior forces in normal subjects. J Electrocardiol 1990;23:147?56. [7] Chou TC, Masangkay MP, Young R, Conway GF, Helm RA. Simple quantitative vectorcardiographic criteria for the diagnosis of right ventricular hypertrophy. Circulation 1973;48(6):1262?7. [8] Mershon JC, Medina JR, Evans RW, Edgett JW, Kioschos JM, Kroetz FW, et al. Use of the vectorcardiogram to recognize right ventricular hypertrophy in mitral stenosis. Correlation with hemodynamic data. Chest 1973;64:173?81.

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