An 11 year old boy is brought to your clinic with occasional chest pains mainly left sided.
You perform an ECG which is given below :
1 . Comment on R wave in this patient :
There is a tall R wave / Dominant R wave in V1.
2. What are the causes of Dominant R wave in V1?
Causes of Dominant R wave in V1
Normal in children and young adults
Right Ventricular Hypertrophy (RVH)
Pulmonary Embolus
Persistence of infantile pattern
Left to right shunt
Right Bundle Branch Block (RBBB)
Posterior Myocardial Infarction (ST elevation in Leads V7, V8, V9)
Wolff-Parkinson-White (WPW) Type A
Incorrect lead placement (e.g. V1 and V3 reversed)
Dextrocardia
Hypertrophic cardiomyopathy
Dystrophy
Myotonic dystrophy
Duchenne Muscular dystrophy
What is the Pathophysiology of this mechanism?
Pathophysiology
Tall R waves in V1 can be caused by abnormal electrical conduction (RBBB or left-sided VT, which slowly spreads across the right ventricle, or a left-sided accessory pathway), loss of posterior myocardium (old or acute posterior MI) or chronic anterior hypertrophy (HCM), chronic or acute RV strain (RVH, PE), congenital anomalies (dextrocardia or dystrophy), misplaced leads, or a normal variant (persisting juvenile pattern). This differential can be remembered by the mnemonic R-WAVED
RBBB (RsR’, QRS>120, wide S in V6, secondary repolarization abnormalities in anterior leads) or left-sided VT/ventricular ectopy
WPW left sided pathway: PR<120, QRS>110, delta wave, tall R in V1-2 with discordant ST/T wave changes.
Acute MI – posterior: tall R wave V1 or V2 and ST depression +/- inferior or lateral ST elevation +/- posterior ST elevation.
Ventricular hypertrophy: RVH (R/S >1 in V1 and <1 in V6, right axis deviation, secondary repolarization changes) or HCM.
Embolism: +/- sinus tach, RBBB, S1Q3T3, anterior/inferior TWI.
Dextrocardia (negative P wave, reversed R wave progression), dystrophy, or displaced leads (eg V1 and V3 switched)
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