Right ventricular hypertrophy (RVH)


Right ventricular hypertrophy (RVH) refers to an abnormal enlargement or pathologic increase in muscle mass of the right ventricle in response to pressure overload.

As per echo examination, the right ventricular wall is thicker than 5mm.


  • pulmonary hypertension with or without left ventricular dysfunction
  • conditions that affect the tricuspid valve leading to significant tricuspid regurgitation 
  • congenital heart disease (Transposition of great arteries, pulmonary stenosis, etc.)
  • chronic lung disease

ECG manifestation 

  • right axis deviation (greater than 110°)
  • dominant R in V1 (R> 7mm , R/S ratio is > 1)
  • dominant S in V5/V6 (S > 7 mm, R/S ratio < 1)

Secondary changes:

  • P pulmonale (> 2.5mm) due to right atrium enlargement 
  • right ventricular strain pattern in V1-V3/V4, sometimes II, III, aVF - ST depression/ T wave inversion 
  • SI, S II, S III pattern - dominant S waves in leads I, II, III
  • complete or incomplete RBBB

Other possible causes of an R/S ratio of > 1 in in lead V1:

  • Posterior wall MI (also causes ST depression in V1-V3, but T waves symmetrically inverted and the patient would be presenting with chest pains)
  • Right bundle branch block
  • Wolff-Parkinson-White Type A
  • Lead misplacement (if V1 is placed too high)
  • Isolated posterior wall hypertrophy (occurs in Duchenne's muscular dystrophy) 

  ECG 1  Right ventricular hypertrophy on ECG

 ECG 2  Right ventricular hypertrophy on ECG


  1. Bhattacharya PT, Ellison MB. Right Ventricular Hypertrophy. [Updated 2020 Aug 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499876/
  2. https://litfl.com/right-ventricular-hypertrophy-rvh-ecg-library/
  3. https://ecgwaves.com/topic/right-ventricular-hypertrophy-ecg-ekg-criteria/