Download Tall R waves in leads V1 to V3

Electrocadiographic Report
Tall R waves in leads V1 to V3
Rangadham Nagarakanti, MD, and D. Luke Glancy, MD
Figure 1. Electrocardiogram. See text for explication.
A
51-year-old security officer had an electrocardiogram
recorded because of a strong family history of coronary
arterial disease (Figure 1). His medical history was significant for a gunshot wound to the left side of his chest
in the line of duty 25 years earlier.
The electrocardiogram shows sinus rhythm and prominent
R waves in leads V1 to V3 and otherwise is normal. The Table
lists many of the causes of tall R waves in the right precordial
leads and confirming clues to their diagnoses (1).
In this patient, the chest radiograph makes the diagnosis
(Figure 2). Eventration of the left hemidiaphragm, the result of
left phrenic nerve damage from the gunshot, allows upward displacement of the gut that pushes the heart far enough to the right
that leads V1 to V3 lie over the left ventricle and record complexes
resembling those usually recorded from the left precordial leads.
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A similar appearance may occur when atelectasis of the right lung
causes a rightward displacement of the heart (2).
1.
2.
Casas RE, Marriott HJ, Glancy DL. Value of leads V7 –V9 in diagnosing
posterior wall acute myocardial infarction and other causes of tall R waves
in V1–V2. Am J Cardiol 1997;80(4):508–509.
Velasquez EM, Glancy DL, Dhurandhar RW. Pulled over: dyspnea
and atypical chest pain associated with tall R waves and deep S waves
in electrocardiographic leads V1 and V2. Proc (Bayl Univ Med Cent)
2004;17(4):473–474.
From the Sections of Cardiology, Departments of Medicine, Louisiana State
University Health Sciences Center and the Medical Center of Louisiana, New
Orleans.
Corresponding author: D. Luke Glancy, MD, 7300 Lakeshore Drive, #30, New
Orleans, Louisiana 70124 (e-mail: [email protected]).
Proc (Bayl Univ Med Cent) 2010;23(4):432–433
Table. Causes and diagnosis of tall R waves in lead V1*
Diagnosis
True posterior infarct
Confirmatory clues
ST↓, T↑ in V1–V2; V7–V9 Q’s and ST↑
Right ventricular hypertrophy
RAD, RAE; secondary ST–T’s; V7–V9
normal
Ventricular septal hypertrophy
Associated Q waves; LVH; V7 –V9
normal or deep and narrow Q’s
Duchenne’s dystrophy
Deep, narrow Q’s in V4–V6, V7–V9 (?)
and in I, aVL or II, III, aVF
Right bundle branch block
Wide QRS; broad S in I, V6; R peaks late
in V1; V7–V9 normal or broad S’s
Wolff-Parkinson-White syndrome
Short PR; wide QRS; delta wave; V7–V9
normal or wide QRS with delta wave
Rightward cardiac displacement
Abnormal chest radiograph
Misplacement of precordial leads
No limb lead abnormalities
Normal variant
No other abnormalities
LVH indicates left ventricular hypertrophy; RAD, right axis deviation; RAE, right atrial
enlargement.
Figure 2. Anteroposterior chest radiograph showing eventration of the left
hemidiaphragm. Much of the gut is at the level of the heart and pushes it toward
the right side of the chest.
*Modified from Casas, Marriott, and Glancy, 1997 (1). Reproduced with permission
from Elsevier.
October 2010
Tall R waves in leads V1 to V3
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