R Wave Progression

Normal QRS progression in chest leads
  • QRS predominantly downgoing in V1
  • QRS predominantly upgoing in V5 or V6
  • There is a gradual increase in the R/S ratio from V1 -> V4
QRS predominantly upgoing in V1 (R/S ratio > 1) – differential diagnosis:
  • QRS wide>0.12
    • ​RBBB: V1 rSR'
    • VT: fast, V1 not consistent with RBBB, typically no P-QRS relationship
    • WPW: short PR, delta wave, V1 not consistent with RBBB
    • BiV paced: pacer spikes in front of QRS complexes
  • QRS narrow <.11​​
    • ​RVH: T negative in V1, RAD, deep S waves in V5-V6, clinical picture (emphysema)
    • Posterior MI: T upright in V1, inverted Ts in lateral and inferior leads, clinical picture (chest pain)
    • Subtle preexcitation: short to short-normal PR, subtle delta wave
    • V1-V3 lead reversal: R wave regression from V1 to V3, may be read as anterior MI, biphasic P wave in V3
    • Normal Variant: no other signs of WPW, RVH, MI
QRS predominantly downgoing in V5 and V6
  • ​QRS wide>0.12
    • paced rhythm
    • WPW
    • VT
  • QRS narrow <.11
    • ​emphysema
    • RVH
    • LAFB
    • lateral MI
Regression of R/S ratio in chest leads
  • Possible anterior MI
  • Severe emphysema, RVH
  • Morbid obesity
  • RBBB
  • Dextrocardia
  • Incorrect electrode placement