By Ken Grauer, MD

Professor Emeritus in Family Medicine, College of Medicine, University of Florida

Dr. Grauer reports no financial relationships relevant to this field of study.

The ECG in the figure below was obtained from a 40-year-old man. Without the benefit of any history, how might one interpret this tracing? Is there evidence of an acute coronary syndrome? Is there a common diagnosis that potentially explains all the findings?

There is baseline artifact that is most marked in lead V1. The rhythm is sinus at a rate just under 100/minute. The PR, QRS, and QT intervals are normal. Additional relevant findings include marked right axis deviation (RAD), marked right atrial abnormality (RAA), a small Q wave and predominant R wave in lead V1, persistence of S waves across the precordium, and ST-T wave depression in multiple leads.

Although one might be tempted to ascribe the diffuse ST-T wave depression in the figure to ischemia, it is far more likely to reflect marked right ventricular hypertrophy (RVH) with pulmonary hypertension. That is because this unifying diagnosis potentially could explain all the important ECG findings noted so far. One might find it easiest to think of the ECG diagnosis of RVH as a “detective diagnosis.” This is because no single finding reveals the diagnosis. Instead, just like a detective, the provider must evaluate a combination of findings occurring in the right clinical context to make a diagnosis.

This 40-year-old man has uncorrected Tetralogy of Fallot. This explains the findings of right atrial and right ventricular enlargement with pulmonary shunting and pulmonary hypertension.

For more information about and further discussion on this case, please visit:

ECG Review