Poor (slow) R Wave Progression

CARDIOLOGY, ECG

Poor R wave progression (PRWP) refers to the absence of the normal increase in the size of the R wave in the precordial leads from lead V1 to V6.

Normal or expected pattern

As you go from V1 to V6, the height of R wave normally becomes progressively taller from leads V1 through V6. In V1 to V3, there is an R wave of low amplitude and an S wave that is larger (R/S <1); between leads V3 to V4, there is a transition to an R wave that has a greater amplitude than the S wave (R/S >1).

In other words, In lead V1, the R wave should be small. The R wave becomes larger throughout the precordial leads, to the point where the R wave is larger than the S wave in lead V4. The S wave then becomes quite small in lead V6.

Poor R Wave Progression

Slow or poor R wave progression (PRWP) is said to be present when the R wave height does not become progressively taller from leads V1 to V3 or V4, or even remains at low amplitude across the entire precordium.

In PRWP, the R wave height ≤ 3 mm in V3.

Causes of Poor R Wave Progression (PRWP)

Note that an old anterior myocardial infarction can cause poor R wave progression. In this setting, there is no R wave in the anterior precordial leads and instead, Q waves are present.

  1. Lead misplacement (especially in obese women)
  2. Old Anteroseptal or anterior wall myocardial infarction
  3. Left ventricular hypertrophy (LVH)
  4. Right ventricular hypertrophy (RVH)
  5. Left anterior fascicular block
  6. Left bundle branch block (LBBB)
  7. Infiltrative or dilated cardiomyopathy
  8. Wolff-Parkinson-White (WPW) patterns due to right-sided or anteroseptal bypass tracts
  9. Chronic lung disease e.g. COPD (which may also have right atrial abnormality, right axis deviation)
  10. Physiologic late transition or clockwise rotation of the heart (Congenital heart disease)
  11. Dextrocardia (right rotation of the heart)
  12. Tension pneumothorax with mediastinal shift.

 

“Poor R wave progression may be more frequently seen in females. Because there are so many different causes of PRWP, this finding alone is not useful in identifying patients with a prior anterior myocardial infarction.”

R-wave Progression Video

 

Reference

Circulation. 2009 Nov 24;120(21):2122. https://www.ncbi.nlm.nih.gov/pubmed/19933951

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