![]() Because many causes of tall R waves in V1 are caused by abnormal depolarization (eg RBBB, RVH, WPW, HCM), they produce abnormal repolarization changes that can mask or mimic acute ischemia. These causes are not mutually exclusive but can co-exist, which can be challenging. Dextrocardia (negative P wave, reversed R wave progression), dystrophy, or displaced leads (eg V1 and V3 switched).Embolism: +/- sinus tach, RBBB, S1Q3T3, anterior/inferior TWI.Ventricular hypertrophy: RVH (R/S >1 in V1 and Acute MI – posterior: tall R wave V1 or V2 and ST depression +/- inferior or lateral ST elevation +/- posterior ST elevation.WPW left sided pathway: PR110, delta wave, tall R in V1-2 with discordant ST/T wave changes.RBBB (RsR’, QRS>120, wide S in V6, secondary repolarization abnormalities in anterior leads) or left-sided VT/ventricular ectopy.This differential can be remembered by the mnemonic R-WAVED 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). Physicians should therefore be familiar with the differential diagnosis for this important QRS configuration.” However, this ECG finding exists as a normal variant in only 1% of patients. Tall R waves in lead V1 (tall RV1), defined as an R/S ratio equal to or greater than 1, is not an infrequent occurrence the emergency department patients. ![]() The subsequent larger S wave (symbolized as ‘S’ to denote its larger size) occurs because of the dominant effect of the left ventricle. The initial small R wave (symbolized as ‘r’ to denote its small size) occurs because of septal depolarization from left to right. This results in a characteristic appearance of the QRS complex in lead V1 of the ECG, the rS configuration. ![]() “In the normal heart, the general direction of ventricular depolarization is in a right-to-left, downward direction because of the larger mass of the left ventricle compared with the right ventricle. Serial ECGĬase 7: 60yo history breast cancer with SOBOEĬase 8: 70yo with two days of constant chest painĪs a review article by Dr. ![]() Eight patients presented with ECGs that had a tall R wave in V1Ĭase 1: 70yo with recurring syncope at restĬase 2: 50yo with palpitations and presyncopeĬase 3: 40yo with three hours of chest painĬase 4: 55yo prior CABG with one hour of chest pain and diaphoresis, HR 40s, BP 70sĬase 5: 60yo with one hour of chest pain and SOB. ![]()
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