ECG Diagnostic Criteria for Right Ventricular Hypertrophy (RVH)

Most commonly used criteria

R in V1 > 7 mm

R/S ratio in V1 > 1

S in V1 < 2 mm (supportive)

S in V5 or V6 > 7 mm

R/S ratio in V5 or V6 < 1

Right axis deviation (RAD): QRS axis > +90°

R in V1 + S in V5 or V6 > 10.5 mm (Sokolow-Lyon RVH criterion)

R in aVR > 5 mm or R/S ratio in aVR > 1

qR pattern in V1 (especially with severe RVH)

Supporting features

Right atrial enlargement (P pulmonale)

Right ventricular strain pattern: ST depression and T-wave inversion in V1–V3/V4

Delayed R-wave transition (late transition to R > S)

Key exam point

The most important ECG combination suggestive of RVH is: RAD + dominant R wave in V1 (R/S >1) + RV strain pattern.

Note: ECG has low sensitivity for RVH; a normal ECG does not exclude RV hypertrophy. Echo or cardiac MRI is preferred for confirmation.

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