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 page.

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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 EKGrSR’ pattern seen in V1 precordial leadT wave in lead V1 invertedV6- large, deep S wave (slurred S wave)Wide QRS complex in EKG (>120 ms)Often accompanied by LAHB

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.

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What is the most likely explanation for the prominent R wave in V1 on this EKG?

Dextrocardia

Dextrocardia

Rare congenital condition (1:10,000 births)¹Heart localized to the right side of chest instead of leftRarely accompanied by other congenital heart defectsUsually asymptomaticMay be accompanied by situs inversus in which abdominal organs reversed as wellEKGs often misleading, with prominent R wave in V1, V2Isolated dextrocardia (without situs inversus) associated with much higher rate of congenital disease

2004, Saha et al, Heart 90:374

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, he’s “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.

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What is the underlying arrhythmia in this patient that was missed by the ER physician?

WPW

WPW

WPW is a “pre-excitation syndrome” in which there is an accessory conduction pathway through the heartAffects 0.15-0.2% of the general population60-705 with no evidence of heart disease60-70% maleUsually presents with young patient in dysrhythmia

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EKG findings include a shortened PR interval (less than 120 ms) with an elongated QRS complex (>10ms)QRS complex with delta wave (slurred upstroke)Definitive treatment is ablation of aberrant conduction pathway

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

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.

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A likely cause of this gentleman’s tall R waves in V1 would be:

Right ventricular hypertrophy

RVH

Right axis deviation (>90 degrees)R wave> S wave in V1Deep S wave V5-V6, I, aVLRR’ pattern may be present in V1Often see “right ventricular strain pattern” characterized by ST depression and T wave inversion in right chest leads

RVH

RVH present when there is increase in muscle mass in right ventricleMay 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 husband’s medicine cabinet.

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What is the most likely cause of this patient’s prominent R wave?

Posterior wall MI, acute

Posterior wall MI

True posterior wall MI’s are uncommon because of the relatively small size of the posterior surface and excellent blood supply to the areaNo 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 RUpright T-wave in V1 (mirror image of posterior wall T-wave inversion)Often associated with inferior wall MICan 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. He’s hypotensive, unresponsive, and appears to be hypoperfused. An EKG is obtained in the emergency department.

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 descentAssociated with a mutation in the sodium ion channel (SCN5A)EKG findings are RBB pattern with ST elevationFindings may be invoked by arrhythmic challengeDefinitive treatment with implantable defibrillator