R wave progression

• Home • Podcasts • Main Episodes • EM Quick Hits • Best Case Ever • Journal Jam • Blogs • ECG Cases • Journal Club • EMC GEM • CritCases • Waiting to Be Seen • BEEM Cases • Summaries • EMC Cases Summaries • Résumés EM Cases • Rapid Reviews Videos • EM Cases Digest • Videos • EM Cases Summit • Rapid Reviews • POCUS Cases • EMU 365 • Quiz Vault • About • Our Team • Advisory Board • Experts Bios • Newsletter Sign Up • EM Cases Learning System • Courses & Summit • CME Credits • FOAMed • Feedback • Conflict of Interest Policy • Six patients presented with poor R wave progression. Can you get the diagnosis based on the LATE mnemonic? Case 1: 70yo previously well with one month of fatigue, normal vitals Case 2: 90yo previously well with one month SOBOE and bipedal edema. Old then new ECG: Case 3: 85yo history of HTN and inferior MI with one day of SOB. Old then new ECG Case 4: 70yo with 5 hours of chest pain. Old then new ECG Case 5: 50yo previously well with 2 hours of chest pain. Went to clinic (first ECG) and then ED (second ECG, one hour later) Case 6: 70yo with 2 hours chest pain radiating to arms, with nausea/diaphoresis/SOB Poor R-wave progression and the LATE mnemonic Ventricular depolarization begins in the septum, where it proceeds from left to right. Then the ventricles depolarize simultaneously, but because of the greater mass of the left ventricle the sum of electrical vectors is directed leftwards. So the right sided lead V1 has an rS wave: small positive R wave fr...

Pathological R-wave progression Normal R-wave progression implies that the R-wave amplitude increases gradually from V1 to V5 and then diminishes again in V6. Refer to Figure 1. Abnormal R-wave progression implies that the gradual increase from V1 to V5 is absent. It may be broken, as in Figure 1. Any typeof infarction may cause pathologicalR-wave progression. However, the specificity for pathological R-wave progression is considerably lower than Figure 1. Pathological R-wave progression is indicative of previous U-wave changes New U-waves (in absence of QTc prolongation The QT (QTc) interval may be prolonged, shortened or unchanged in ischemia. R-wave amplitude Acute transmural ischemia may transiently increase the amplitude of the R-waves. This is believed to be due to delayed (and thus electrically unopposed) depolarization in the ischemic area. FragmentedQRS complex The definition of fragmented QRS complexes ( Figure 2) are as follows: • QRS complex with more than 1 R wave and/or • notch in the descending limb of the R-waveand/or • notch in the descending limb of the S-wave In case of complete/incomplete bundle branch block or pacemaker rhythm, >2 notches are required in the S-wave or R-wave. Fragmented QRS complexes are indications of previous myocardial infarction. There are imaging studies demonstrating that QRS fragmentation is more common than the development of pathological Q-waves after infarction. The sensitivity of fragmented QRS for myocardial infarction was ...

Article: • • • • • • • Images: • • Epidemiology The most common cause has historically been (and unfortunately continues to be) There are however a number of other less common risk factors/etiologies, each with their own demographics. They include: • industrial exposure (e.g. mining) • • • • • Clinical presentation Symptoms of COPD include dyspnea on exertion, wheezing, productive cough, pursed-lip breathing, and use of accessory respiratory muscles. Historically, patients with chronic bronchitis were termed "blue bloaters," while those with emphysema known as "pink puffers". In advanced cases, muscle wasting, ECG • poor R wave progression • requires an R wave in V3 1, usually occurring in V3 or V4, shifts laterally (to V5 or V6) • deep S waves in the lateral leads (I, aVL, V5, V6) • low QRS voltage • amplitude of QRS complexes 7 mm • often associated with "P pulmonale" ( • multifocal atrial tachycardia Pathology In contrast to Emphysema involves the destruction of alveolar septa and pulmonary capillaries, leading to decreased elastic recoil and resultant • centrilobular (centriacinar): associated with smoking and spreads peripherally from bronchioles • panacinar: homozygous AAT 1 deficiency and uniformly destroys alveoli • paraseptal (distal acinar): involves the distal airways Pulmonary function testing (PFT) reveals airflow obstruction, as evidenced by a decreased forced expiratory volume in 1 second to forced vital capacity (FEV 1/FVC) ratio. Administration of bronchod...

~ (C) 2022 ECGcourse.com, Author Vernon R Stanley, MD PhD | C Stanley, PA-C Co-editor | All rights reserved. Please note content is not legal advice and is not a comprehensive or complete discussion of this topic. Question: The presence of Early Transition (R-wave >S-wave between Leads V 1& V 2) may indicate which of the following (answer at bottom of post): A. Normal Variant B. RBBB C. Posterior Infarction D. All of the Above E. None of the Above As you traverse the precordium sampling the voltage (see Pg. 4 of Tracings Manual) V 1V 2V 3V 4V 5V 6you will notice that the R-Wave gets taller and taller and taller (crescendos) then peaks (note Lead V 5) and then declines (decrescendos). You will find this peculiar characteristic in all NORMALECG’s and it is called R-Wave Progression. If this characteristic of R-Wave crescendo — decrescendo does not hold true, but in fact the R-Wave progression is flat,we denote this as Poor R-Wave Progression. Illustration #17: Transition Zone Electrode V trans V trans= Hypothetical point on chest where R=S. Pearl: In the NORMALECG, the Transition Zone will occur in the following range:V 2V 3V 4 (inclusive). If it occurs earlier, it is called EARLY TRANSITION. If it occurs later, it is called LATE TRANSITION. Please study the Illustration below with a focus on the hypothetical LeadV trans It is highlighted in yellow and represents the TRANSITION ZONE LEAD. This indicates the location as you traverse the precordium where the equality R = Soccu...

Table of Contents • • • • • • • • • • Is poor R wave progression bad? Poor R wave progression is used as an interpretative term in clinical electrocardiography to infer that the precordial R wave voltage is abnormal, most often secondary to previous ischemic damage. Specific definition and predictive value of the term are, however, lacking for most clinical settings. Is poor R progression normal? Poor R-wave progression is a common ECG finding that is often inconclusively interpreted as suggestive, but not diagnostic, of anterior myocardial infarction (AMI). What is good R wave progression? The R wave should progress in size across leads V1 to V6. Normally, in lead V1, there is a small R wave with a deep S wave; the R-wave amplitude should increase in size with the transition zone, normally in leads V2 to V4. Can high blood pressure cause poor R wave progression? In their study, poor R‐wave progression was associated with higher age, hypertension, and diabetes. What causes poor R wave progression? Recent studies have shown that poor R-wave progression has the following four distinct major causes: AMI, left ventricular hypertrophy, right ventricular hypertrophy, and a variant of normal with diminished anterior forces. Standard ECG criteria that identify and distinguish these causes have been developed. What does poor R wave progression on ECG mean? Poor R wave progression across the precordium refers to an electrocardiographic finding where the normal increase in R wave amp...

• • Positive QRS complexes (with upright P and T waves) in aVR • Lead I: inversion of all complexes, aka ‘global negativity’ (inverted P wave, negative QRS, inverted T wave) • Absent R-wave progression in the chest leads (dominant S waves throughout) These changes can be reversed by placing the precordial leads in a mirror-image position on the right side of the chest and reversing the left and right arm leads. Chris is an Intensivist and ECMO specialist at the After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education. He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, His one great achievement is being the father of three amazing children. On Twitter, he is |

Article: • • • • • • • Images: • • Epidemiology The most common cause has historically been (and unfortunately continues to be) There are however a number of other less common risk factors/etiologies, each with their own demographics. They include: • industrial exposure (e.g. mining) • • • • • Clinical presentation Symptoms of COPD include dyspnea on exertion, wheezing, productive cough, pursed-lip breathing, and use of accessory respiratory muscles. Historically, patients with chronic bronchitis were termed "blue bloaters," while those with emphysema known as "pink puffers". In advanced cases, muscle wasting, ECG • poor R wave progression • requires an R wave in V3 1, usually occurring in V3 or V4, shifts laterally (to V5 or V6) • deep S waves in the lateral leads (I, aVL, V5, V6) • low QRS voltage • amplitude of QRS complexes 7 mm • often associated with "P pulmonale" ( • multifocal atrial tachycardia Pathology In contrast to Emphysema involves the destruction of alveolar septa and pulmonary capillaries, leading to decreased elastic recoil and resultant • centrilobular (centriacinar): associated with smoking and spreads peripherally from bronchioles • panacinar: homozygous AAT 1 deficiency and uniformly destroys alveoli • paraseptal (distal acinar): involves the distal airways Pulmonary function testing (PFT) reveals airflow obstruction, as evidenced by a decreased forced expiratory volume in 1 second to forced vital capacity (FEV 1/FVC) ratio. Administration of bronchod...

• • Positive QRS complexes (with upright P and T waves) in aVR • Lead I: inversion of all complexes, aka ‘global negativity’ (inverted P wave, negative QRS, inverted T wave) • Absent R-wave progression in the chest leads (dominant S waves throughout) These changes can be reversed by placing the precordial leads in a mirror-image position on the right side of the chest and reversing the left and right arm leads. Chris is an Intensivist and ECMO specialist at the After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education. He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, His one great achievement is being the father of three amazing children. On Twitter, he is |

Table of Contents • • • • • • • • • • Is poor R wave progression bad? Poor R wave progression is used as an interpretative term in clinical electrocardiography to infer that the precordial R wave voltage is abnormal, most often secondary to previous ischemic damage. Specific definition and predictive value of the term are, however, lacking for most clinical settings. Is poor R progression normal? Poor R-wave progression is a common ECG finding that is often inconclusively interpreted as suggestive, but not diagnostic, of anterior myocardial infarction (AMI). What is good R wave progression? The R wave should progress in size across leads V1 to V6. Normally, in lead V1, there is a small R wave with a deep S wave; the R-wave amplitude should increase in size with the transition zone, normally in leads V2 to V4. Can high blood pressure cause poor R wave progression? In their study, poor R‐wave progression was associated with higher age, hypertension, and diabetes. What causes poor R wave progression? Recent studies have shown that poor R-wave progression has the following four distinct major causes: AMI, left ventricular hypertrophy, right ventricular hypertrophy, and a variant of normal with diminished anterior forces. Standard ECG criteria that identify and distinguish these causes have been developed. What does poor R wave progression on ECG mean? Poor R wave progression across the precordium refers to an electrocardiographic finding where the normal increase in R wave amp...

• Home • Podcasts • Main Episodes • EM Quick Hits • Best Case Ever • Journal Jam • Blogs • ECG Cases • Journal Club • EMC GEM • CritCases • Waiting to Be Seen • BEEM Cases • Summaries • EMC Cases Summaries • Résumés EM Cases • Rapid Reviews Videos • EM Cases Digest • Videos • EM Cases Summit • Rapid Reviews • POCUS Cases • EMU 365 • Quiz Vault • About • Our Team • Advisory Board • Experts Bios • Newsletter Sign Up • EM Cases Learning System • Courses & Summit • CME Credits • FOAMed • Feedback • Conflict of Interest Policy • Six patients presented with poor R wave progression. Can you get the diagnosis based on the LATE mnemonic? Case 1: 70yo previously well with one month of fatigue, normal vitals Case 2: 90yo previously well with one month SOBOE and bipedal edema. Old then new ECG: Case 3: 85yo history of HTN and inferior MI with one day of SOB. Old then new ECG Case 4: 70yo with 5 hours of chest pain. Old then new ECG Case 5: 50yo previously well with 2 hours of chest pain. Went to clinic (first ECG) and then ED (second ECG, one hour later) Case 6: 70yo with 2 hours chest pain radiating to arms, with nausea/diaphoresis/SOB Poor R-wave progression and the LATE mnemonic Ventricular depolarization begins in the septum, where it proceeds from left to right. Then the ventricles depolarize simultaneously, but because of the greater mass of the left ventricle the sum of electrical vectors is directed leftwards. So the right sided lead V1 has an rS wave: small positive R wave fr...