Poor R Wave Progression

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: PRWP; poor R wave transition; delayed R wave transition; delayed transition; loss of R wave progression; loss of R waves

Overview

Poor R wave progression across the precordium refers to an electrocardiographic finding where the normal increase in R wave amplitude as one progresses from V1 to V6 is lost. Although non-specific, this finding is consistent with a prior anterior myocardial infarction.

Definition

The definition of poor R wave progression (PRWP) varies in the literature, but a common one is when the R wave is less than 2–4 mm in leads V₃ or V₄ and/or there is presence of a reversed R wave progression, which is defined as R in V₄ < R in V₃ or R in V₃ < R in V₂ or R in V₂ < R in V₁, or any combination of these.

Causes

Poor R wave progression can be observed in the following settings:

• Faulty ECG recording technique
• Left bundle branch block
• Myocardial infarction
• Right and left ventricular hypertrophy
• Wolff–Parkinson–White syndrome

EKG Examples

The EKG below shows sinus bradycardia at 47/min and poor R wave progression in the anterior chest leads with Q waves in leads V2 to V4 which are diagnostic of anterior myocardial infarction. Note that unlike the normal septal Q waves that start later in the progression of the chest leads and at the same time grow larger, the Q waves in this patient are abnormal because they are present in leads V2, V3, and V4 and are larger than those in V5 and V6. The cardiogram also shows abnormal T wave inversion and slight ST elevation in leads V1 to V3.