Transcript 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
page.
Case 1 continued
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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 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 (>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)¹
Heart localized to the right side of chest instead of left
Rarely accompanied by other congenital heart defects
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 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 heart
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 (>10ms)
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
WPW
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
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 xray 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 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
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
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 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.
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 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 defibrillator