Right-Sided ECG: Understanding Its Importance

Introduction

A right-sided ECG (electrocardiogram) is a special type of ECG performed to assess the electrical activity of the heart with an emphasis on the right ventricle. This test is crucial for diagnosing conditions that primarily affect the right side of the heart, such as right ventricular infarction, pulmonary embolism, and other structural anomalies.

Why Is a Right-Sided ECG Necessary?

A standard 12-lead ECG primarily evaluates the left ventricle. However, there are situations where right ventricular involvement is suspected, and a normal ECG might miss crucial abnormalities. In such cases, repositioning precordial leads to the right side can provide additional diagnostic insights.

Indications for a Right-Sided ECG

• Suspected Right Ventricular Infarction: Commonly seen in patients with inferior myocardial infarction (MI). It is essential because right ventricular infarcts often present with normal or atypical ECG findings in a standard 12-lead ECG.
• Acute Pulmonary Embolism (PE): This can cause right heart strain, leading to ECG changes that might be better visualized in right-sided leads.
• Congenital Heart Diseases: Conditions such as Tetralogy of Fallot or Ebstein’s anomaly may require right ventricular assessment.
• Arrhythmias Originating from the Right Chambers: Particularly ventricular tachycardia (VT) and right bundle branch blocks.

How Is a Right-Sided ECG Performed?

Instead of placing the standard six precordial leads (V1-V6) on the left side of the chest, they are mirrored to the same positions on the right side:

• V1R → placed where V1 would be, but on the right chest
• V2R → placed where V2 would be, but on the right chest
• …
• V6R → placed on the right mid-axillary line, mirroring the usual V6 position

Key ECG Findings in Right Ventricular Infarction

• ST-segment elevation in right-sided leads (especially V4R) → A hallmark of right ventricular infarction.
• Hypotension without pulmonary congestion → Important clinical feature due to impaired right ventricular function.
• Bradycardia & AV Blocks → The right coronary artery supplies the SA and AV node, increasing the risk of electrical conduction abnormalities.

Clinical Implications

Detecting right ventricular infarction is crucial because its management differs from left ventricular infarction: - Patients are preload dependent → Avoid nitrates and diuretics, as they can worsen hypotension. - Adequate IV fluids may be necessary to maintain cardiac output. - Early identification improves prognosis by altering treatment strategies.

Conclusion

A right-sided ECG is a valuable tool in cardiology, particularly for assessing right ventricular pathology. It is easy to perform, but its interpretation requires an understanding of specific ECG changes. Physicians should consider it whenever an inferior MI or right heart stress is suspected.

Source recommendations

1. American Heart Association Guidelines for the Management of ST-Elevation Myocardial Infarction

1. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001309
2. https://professional.heart.org/en/science-news/2021-acc-aha-scai-guideline-for-coronary-artery-revascularization
3. https://www.ahajournals.org/doi/10.1161/01.cir.0000134791.68010.fa
4. https://pubmed.ncbi.nlm.nih.gov/23256914/
5. https://www.ahajournals.org/doi/10.1161/cir.0b013e3182742cf6

2. European Society of Cardiology Guidelines for the Management of Acute Coronary Syndromes

1. https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Coronary-Syndromes-ACS-Guidelines
2. https://academic.oup.com/eurheartj/article/44/38/3720/7243210
3. https://pubmed.ncbi.nlm.nih.gov/37622654/
4. https://academic.oup.com/eurheartj/article/42/14/1289/5898842
5. https://pubmed.ncbi.nlm.nih.gov/21873419/