Right heart strain patterns on EKG's

[r54918]

What are some typical EKG changes which indicate Right Heart Strain. I know the classic EKG change suggestive of PE (S1Q3T3), but what other patterns may be suggestive of PE?

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[DrQuinn]

inverted T waves V1-v3, right atrial enlargement.

Q

 

[EMT2RN2MD]

peaked p waves also are a sign of R atrial hypertrophy.

 

[EM Guy]

Some ECG findings of Right Ventricular Hypertrophy:


R:S>1 in V1 and/or V2
-frequently deep S in V5V6
remember that a large R in V1 has a large dDx
-Obtaining a R:S ratio >1 from a right sided precordial lead (V3R or V4R) may be a more reliable indicator of RVH

Clues to the diagnosis of right ventricular hypertrophy include:
Right axis deviation (>+90)
RV1 >7 mm
RV1 + SV5 or V6 >10 mm
R/S ratio in V1 >1
S/R ratio in V6 >1
Late intrinsicoid deflection in V1.
Incomplete right bundle branch block
ST-T wave abnormalities ("strain") in inferior leads
Right atrial hypertrophy (P pulmonale)
S1S2S3 pattern (particularly in children)


Right Ventricular Hypertrophy with Strain Pattern:
1. Flipped asymmetric T's in V1V2
2. Concave down ST depression in V1V2

 

[EM Guy]

Some ECG findings of Right Ventricular Hypertrophy:


R:S>1 in V1 and/or V2
-frequently deep S in V5V6
remember that a large R in V1 has a large dDx
-Obtaining a R:S ratio >1 from a right sided precordial lead (V3R or V4R) may be a more reliable indicator of RVH

Clues to the diagnosis of right ventricular hypertrophy include:
Right axis deviation (>+90)
RV1 >7 mm
RV1 + SV5 or V6 >10 mm
R/S ratio in V1 >1
S/R ratio in V6 >1
Late intrinsicoid deflection in V1.
Incomplete right bundle branch block
ST-T wave abnormalities ("strain") in inferior leads
Right atrial hypertrophy (P pulmonale)
S1S2S3 pattern (particularly in children)


Right Ventricular Hypertrophy with Strain Pattern:
1. Flipped asymmetric T's in V1V2
2. Concave down ST depression in V1V2

 

[Big Ben]

Acute PE doesn't cause RV hypertrophy....your heart obviously doesn't hypertrophy that quickly. RV hypertrophy can occur with chronic thromboemboli or any other form right sided pressure overload, i.e., the full differential of pulmonary HTN.

EKG changes in PE are due to Acute RV dilation and strain, not the hypertrophy....and the classic S1Q3T3 is not specific to PE, it can occur with any cause of Acute Cor Pulmonale.

EKG changes that I look for...
1. Sinus tachycardia, easily forgotten
2. S1Q3T3-5% at best
3. New IVCD (with RBBB morphology) or Complete RBBB
4. Deep S waves in I/AVL with Q waves III (sparing other inferior leads)
5. Low voltage
6. TWI V1-V4/III/AVF-"RV strain"
7. Late R/S transition

 

[GRchief]

And, more importantly, does it matter?

 

[waterski232002]

It can.... it may be your best diagnostic modality in unstable patients that can't go for V/Q or CT.

 

[Big Ben]

don't forget echo as diagnostic modality, the patient doesn't need to travel and if it's a hemodynamically signfiicant PE, you'll pick up acute RV dilation or other signs pretty frequently...won't rule things out but certainly can help cinch diagnosis in right setting

 

[waterski232002]

Very true... Transthoracic echo +/- LE dopplars can be done in the ED regardless of stability. I did this last week on a guy who developed acute onset RV failure from pulm HTN secondary to Remicaide infusion. He ended up not having a PE. I could have sworn he had a PE... his EKG had S1Q3T3, D-Dimer of 2.5 (sent only for academic purposes), and a clear CXR. He was on Bipap of 15/5, and he ended up getting a CT 2 days later which was negative.