This 53-year-old man with a history of heavy smoking and longstanding obstructive lung disease has been admitted to the medical ICU in severe respiratory distress with reduced air entry and diffuse wheezes bilaterally:

• Sinus rhythm, 98/min.
• Right atrial enlargement
• RBBB and RVH (Right bundle branch block plus right ventricular hypertrophy)

Criteria favoring the diagnosis of RBBB plus RVH:

RBBB with right axis deviation and R or R1 in V1 > 15 mm. Clinical correlation is very important, as this pattern may be due to RBBB and left posterior fascicular block. The unusual lower QRS voltage in V2 is probably due to higher electrode placement (which occurs not infrequently).