Precordial Leads – The Transition, R-Wave Progression, R/S Ratio in Lead V1

Since we covered the first 6 leads of the 12 lead ECG in the 6-part tutorial on axis determination, a few words about the precordial leads might be in order. These are leads V1-V6, the unipolar leads that are placed directly on the patient’s chest.

The heart is a 3 dimensional object, and calculating the heart’s electrical axis in the frontal plane tells us nothing about whether or not the heart’s electrical axis is anterior or posterior, for example. This 3rd dimension that can be calculated using the precordial leads is sometimes referred to as the Z-axis (think of the Cartesian coordinate system).

I’m never one to say “you don’t need to know that”. The words will never come out of my mouth, at least not in an educational setting. However, I will say that I have not found an exact calculation of the Z-axis to be clinically useful. Maybe it is useful to cardiologists. I really don’t know, and it’s possible that my opinion will change in this matter.

The following image comes from The Textbook of Medical Physiology 9e; © 1996 Guyton AC, Hall JE; WB Saunders.

Here’s what I teach my students.

The QRS complex should start out negative in lead V1. The QRS complex should end up positive in lead V6. Somewhere in between, there should be an equiphasic QRS complex and this is referred to as the transition. This most often occurs in lead V3 but is highly dependent on lead placement. When the transition happens in lead V1 or V2 it is referred to as an early transition. When it happens in leads V4, V5, or V6 it is referred to as a late transition.

In addition, there should be a gradual increase in the amplitude of the R-wave between leads V1-V4. This is referred to as R-wave progression. Lead V1 may or may not have an R wave, but one should show up by lead V2 and get a little taller in lead V3 and reach its maximum height in lead V4 or V5. Again, this is highly dependent on lead placement.

With an early transition, the R wave is sometimes taller than the S wave in lead V1. This is referred to as an R/S ratio > 1, and it could indicate a serious problem. Even when this finding is in lead V2 you should take a second glance. We’ll cover this in more detail on another day, but for now, here is the differential diagnosis of tall R waves in lead V1. This is taken from Mattu, Brady, et al. Prominent R Wave in Lead V1: Electrocardiographic Differential Diagnosis; Am J Emerg Med 2001;19:504-513:

  • Right bundle branch block
  • Left ventricular ectopy
  • Right ventricular hypertrophy
  • Acute right ventricular dilation
  • Wolff-Parkinson-White syndrome Type A
  • Posterior myocardial infarction
  • Hypertrophic cardiomyopathy
  • Progressive muscular dystrophy
  • Dextrocardia
  • Misplaced precordial leads
  • Normal variant

As a side note, for the past 2 consecutive weekends I helped teach ACLS to a group of PA students in Savannah, GA. I taught Asystole, PEA, bradycardia, and ACS. I absolutely despise the new DVD driven format of ACLS. I’m sure the AHA had their reasons, but the class should be re-named “Introduction to ACLS” or “ACLS Awareness” because the DVDs simplify things to a fault. Anyway, I couldn’t help but notice during the ACS video that the “paramedics” placed leads V1 and V2 one intercostal space too high! That’s ironic, because that is by far the most common mistake clinicians make when placing the electrodes for the precordial leads. When they are placed in this manner, the result is often abnormal R-wave progression on the 12 lead ECG.

Poor R-wave progression (or “poor anterior R-wave progression”) is a non-specific finding on the 12 lead ECG. However, it could be an indicator of a more serious problem.

Why is this an issue? Simple. Do we transport every patient to the hospital? No. Do we usually have an old ECG for comparison? No. Do most 80 year old patients have a normal ECG? No. I hear all the time how paramedics don’t need to know how to interpret a 12 lead ECG to a high level. Of course we do! How else can we correctly advise Mrs. Smith of the risk she’s taking when she refuses care?

In addition, it’s impossible to correctly interpret ST segment depression, ST segment elevation, and T wave abnormalities if you don’t understand the various conditions that cause them.

Take for example the ECG used in Part IV of the axis determination tutorial.

This ECG was captured on an emergency call of a 16 year old girl with a congenital heart defect. The call was for “acute shortness of breath” and the family advised dispatch that she was in “heart failure”. Look at the T waves in the right precordial leads. They’re inverted! And the ST segments are depressed! That’s acute coronary ischemia, right? Wrong. It’s a strain pattern from right ventricular hypertrophy. Note the tall R waves in lead V1. It turns out the girl was having a panic attack. Do you see why paramedics need to understand 12 lead ECGs?

Here are some parting words from Chou’s Electrocardiography in Clinical Practice, Fifth Edition, © 2001 Saunders, ISBN: 0-7216-8696-4:

“The widely used term “poor R wave progression” is not helpful. In many cases the abnormally low R amplitude extending from the right into the mid or left precordial leads indicates myocardial infarction of the anterior wall. Such a pattern occurs also in the presence of left ventricular hypertrophy and in normal subjects without cardiac or pulmonary disease. It may be caused by a shift of the transitional zone to the left or by an atypical (abnormally high) placement of the mid-precordial chest electrodes. For this reason it is advisable to report the most likely cause of “poor R wave progression” in each case.”

*** UPDATE ***

Poor anterior R-wave progression can also help differentiate between benign early repolarization (BER) and acute anterior STEMI! R-wave progression tends to remain intact for the former and tends to be disrupted by the latter.

Stephen Smith, M.D. (Dr. Smith’s ECG Blog) has a decision rule that states:

If the mean R-wave amplitude from V2-V4 is less than 5 mm, then it is almost certainly MI. If greater than 5 mm, it is probably BER. A cutoff of 5 mm gives a sensitivity for MI of about 70%, but a specificity of greater than 95%.

See also:

76 year old male CC: Shortness of breath while walking (note the poor R-wave progression that points to acute anterior STEMI rather than benign early repolarization)


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68 y.o. male with weakness: “Treat the monitor, not the patient?”
the bizzare complexes coupled with the fact that the patient takes a potassium sparing diuretic make me think hyperkalemia
2015-04-29 12:31:37
The 12 Leads of Christmas: V2
Thank you for your response. By all means, take your time! As for the source of the first figure, I got it from the book "Essential Cardiology: Principles and Practice - 3rd edition" by Clive Rosendorff - Chapter 7, Figure 7.3 (Page 97). It's one of the rare texts where I found a mention of…
2015-04-27 06:52:25
Vince DiGiulio
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Your questions on this topic are some of the best I've encountered—no need to apologize! It makes me very happy to see this post reaching the right people. I'm working non-stop the next two days but I will get back to you soon with my full response. Two things to start: First, where did you…
2015-04-27 05:14:11
68 y.o. male w/ weakness: conclusion – “Treat the monitor.”
Very informative case! Thank you for sharing..... I will be using it to teach our paramedics and residents (if you allow me to)..... Keep the great working going guys!
2015-04-27 03:05:29
The 12 Leads of Christmas: V2
Thank you so much! I wonder why this information is not found in ECG texts. I have a query though. The critical information seems to be the fact that leads V1 and V2; V3; and V4-V6, each are physically located on a different transverse plane with respect to the theoretical electrical center. (Also mentioned in…
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