Poor R Wave Progression (PRWP) ECG Review

Poor R wave progression refers to the absence of the normal increase in size of the R wave in the precordial leads when advancing from lead V1 to V6.

In lead V1, the R wave should be small. The R wave becomes larger throughout the precordial leads, to the point where the R wave is larger than the S wave in lead V4. The S wave then becomes quite small in lead V6.

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Note that an old anterior myocardial infarction can cause poor R wave progression. In this setting, there is no R wave in the anterior precordial leads and instead Q waves are present; see Anterior Myocardial Infarction Topic Review.

The causes of PRWP are as follows:

1. Old anterior myocardial infarction
2. Lead misplacement (frequently in obese women)
3. Left bundle branch block or left anterior fascicular block
4. Left ventricular hypertrophy
5. Wolff-Parkinson-White syndrome
6. Dextrocardia
7. Tension pneumothorax with mediastinal shift
8. Congenital heart disease

References:
1. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric, 6e
2. Surawicz B, et al. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Circulation. 2009; doi:10.1161/CIRCULATIONAHA.108.191095.