Differential Diagnosis of Tall R Waves in Lead V1 - PowerPoint PPT Presentation


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Differential Diagnosis of Tall R Waves in Lead V1


Differential Diagnosis of Tall R Waves in Lead V1 Eric J Milie, DO – PowerPoint PPT presentation

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Title: Differential Diagnosis of Tall R Waves in Lead V1

Differential Diagnosis of Tall R Waves in Lead V1
  • Eric J Milie, DO

Case 1
  • A 45 year old white male presents for medical
    clearance prior to undergoing an orthopedic
    procedure to repair a torn ACL. He has no
    significant medical history, and takes no
    medications. Pre-op testing was ordered by the
    orthopedic surgeon. His EKG is on the following

Case 1 continued
Case 1 continued
  • What is the most likely cause of this patients
    abnormal EKG?
  • Right Bundle Branch Block

Right Bundle Branch Block
  • Generally considered a benign finding on EKG
  • rSR pattern seen in V1 precordial lead
  • T wave in lead V1 inverted
  • V6- large, deep S wave (slurred S wave)
  • Wide QRS complex in EKG (gt120 ms)
  • Often accompanied by LAHB

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Case 2
  • A 32 year old female presents to the emergency
    department with LUQ pain which began after eating
    a meal high in fat. ER workup showed elevated
    alkaline phospatase and eleveated serum
    bilirubin. A CT scan of the abdomen was
    obtained, and she was diagnosed with acute
    cholecystitis. Pre-op testing was performed,
    including an EKG and chest x-ray.

Case 2 continued
Case 2 continued
Case 2 continued
  • What is the most likely explanation for the
    prominent R wave in V1 on this EKG?
  • Dextrocardia

  • Rare congenital condition (110,000 births)¹
  • Heart localized to the right side of chest
    instead of left
  • Rarely accompanied by other congenital heart
  • Usually asymptomatic
  • May be accompanied by situs inversus in which
    abdominal organs reversed as well
  • EKGs often misleading, with prominent R wave in
    V1, V2
  • Isolated dextrocardia (without situs inversus)
    associated with much higher rate of congenital

2004, Saha et al, Heart 90374
Case 3
  • A fiteen year old boy is brought to the emergency
    department after telling his mother that his
    heart was racing. On the monitor, his heart
    rate is approaching 200, hes trying to go
    tachy. He is hypotensive and rapidly
    decompensating. The ER doctor responds by giving
    the child atropine, feeling that this is SVT. The
    child rapidly decompensates and dies. Prior to
    dying, the following 12 lead EKG was obtained.

Case 3 continued
Case 3 continued
  • What is the underlying arrhythmia in this patient
    that was missed by the ER physician?
  • WPW

  • WPW is a pre-excitation syndrome in which there
    is an accessory conduction pathway through the
  • Affects 0.15-0.2 of the general population
  • 60-705 with no evidence of heart disease
  • 60-70 male
  • Usually presents with young patient in dysrhythmia

WPW continued
  • EKG findings include a shortened PR interval
    (less than 120 ms) with an elongated QRS complex
  • QRS complex with delta wave (slurred upstroke)
  • Definitive treatment is ablation of aberrant
    conduction pathway

WPW continued
  • Atrial fibrillation present in 11-38 of cases of
  • Treatment of arrhythmia by normal methods (beta
    blockers, CCBs, Digoxin, Adenosine) leads to
    unopposed conduction by the aberrant tract
  • Pts quickly deteriorate into V.Fib, therefore
    first line treatment of decompensating patients
    is electrocardioversion

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Case 4
  • A 75 year old white male with a 200 pack year
    smoking history presents to the office for a
    routine physical exam. The patient denies any
    chest pain, but does admit to being chronically
    short of breath with exertion and has a chronic
    cough. Routine blood work, EKG, and chest x-ray
    are obtained on the patient.

Case 4 continued
Case 4 continued
Case 4 continued
  • A likely cause of this gentlemans tall R waves
    in V1 would be
  • Right ventricular hypertrophy

  • Right axis deviation (gt90 degrees)
  • R wavegt S wave in V1
  • Deep S wave V5-V6, I, aVL
  • RR pattern may be present in V1
  • Often see right ventricular strain pattern
    characterized by ST depression and T wave
    inversion in right chest leads

  • RVH present when there is increase in muscle mass
    in right ventricle
  • May be seen in valvular heart disease (mitral,
    pulmonic, or tricuspid stenosis) cor pulmonale,
    or severe lung disease

Case 5
  • A 60 year old woman presents to the emergency
    department within one hour of acute, left sided
    chest pain with radiation to the jaw and int the
    left arm. This is accompanied by diaphoresis and
    shortness of breath. She was shoveling her side
    walk after a recent blizzard prior to the onset
    of this pain. She received some relief from a
    sublingual nitro which she took from her
    husbands medicine cabinet.

Case 5 continued
Case 5 continued
  • What is the most likely cause of this patients
    prominent R wave?
  • Posterior wall MI, acute

Posterior wall MI
  • True posterior wall MIs are uncommon because of
    the relatively small size of the posterior
    surface and excellent blood supply to the area
  • No lead overlies posterior wall, diagnosis is
    made on reciprocal changes to chest leads

Posterior Wall MI EKG findings
  • Large R wave, V1 (mirror image of posterior wall
    Q-wave), which is difficult to distinguish from
    RVH or other causes of tall R
  • Upright T-wave in V1 (mirror image of posterior
    wall T-wave inversion)
  • Often associated with inferior wall MI
  • Can use 15 lead EKG with V7-V9 or back EKG

Case 6
  • A 39 year old man from Thailand presents to the
    emergency department in the middle of the summer
    in an acutely decompensated state. Hes
    hypotensive, unresponsive, and appears to be
    hypoperfused. An EKG is obtained in the emergency

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Case 6
  • Shortly after arriving in the ED, the patients
    goes into Vfib and dies. The tall R waves in the
    preceding EKG are most likely secondary to
  • Brugada syndrome

Brugada syndrome
  • Most common cause of sudden cardiac death in
    young men of Thai and Laos descent
  • Associated with a mutation in the sodium ion
    channel (SCN5A)
  • EKG findings are RBB pattern with ST elevation
  • Findings may be invoked by arrhythmic challenge
  • Definitive treatment with implantable
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