This 69-year-old man with a long history of chronic obstructive lung disease and asthma is admitted because of worsening of his respiratory failure:

• Sinus tachycardia with occasional premature supraventricular complexes
• Right atrial enlargement
• Right bundle branch block
• Right ventricular hypertrophy

Comment: This patient was in the terminal stage of chronic obstructive lung disease, with acute exacerbation of his chest infection, severe respiratory insufficiency, evidence of pulmonary hypertension and right heart failure. He expired 10 days after the recording of this ECG tracing. The criteria for right ventricular hypertrophy in the setting of right bundle branch block include right axis deviation and amplitude of R or R’ in the right chest leads( V1, V2) of 15 mm. or greater. The presence of right axis deviation in very important, as a tall R or R’ in the right chest leads is not uncommon in patients with RBBB with no evidence of right ventricular hypertrophy.

References:

• Minor WR and al. The electrocardiogram and vectorcardiogram in Right Ventricular Hypertrophy and Right Bundle Branch Block. Circulation 16:348-367, 1957
• Booth RW, Chou TC, Scott RC: Electrocardiographic evidence of ventricular hypertrophy in the presence of Right Bundle Branch Block. Circulation 18, 169-176, 1958