Normally, the amplitude (height) of R wave increases from lead V1 to lead V5. The transition zone where R wave amplitude becomes higher than S wave amplitude is usually the lead V3 or lead V4.

  Generally, if the R wave amplitude in lead V5 is less than that of the S wave it is accepted as "poor R wave progression".

DePace criteria suggested for poor R wave progression

  R wave amplitude in lead V3 is equal to or less than 3mm (at the standard calibration of 10mm/mV) or

  RV1 < RV2     and     RV2 < RV3     and     RV3 < RV4.

Causes of poor R wave progression

  Old anterior myocardial infarction.

  Non-ST elevation myocardial infarction.

  Left ventricular hypertrophy.

  Hypertrophic cardiomyopathy.

  Left bundle branch block.

  Misplacement of the electrodes: placement of mid-precordial electrodes higher than the usual position.



  Tako-tsubo cardiomyopathy.


  Cardiac amyloidosis.

  Congenital absence of the pericardium.

left lung resection.

  May also be observed in healthy individuals as a normal variant.

Observation of the following triad suggests the need for exclusion of pneumothorax

  Isolated low voltage in lead I

  Poor R wave progression in chest leads

  Lead aVF
/ Lead I QRS amplitude ratio is > 2


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ECG 1a. The ECG above belongs to a 65 years old woman who was diagnosed as acute anterior myocardial infarction.
The leads C1 to C6 show ST segment elevation and tall T waves. This ECG was recorded just before stent implantation in LAD.

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ECG 1b. The same patient's ECG, one day after stenting of the LAD coronary artery. ST elevation decreased and widespread
T wave negativity appeared now.

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ECG 1c. The ECG above was recorded 4 days after stenting of the LAD coronary artery. Both ST segment elevation and T wave
negativity have regressed.

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ECG 1d. The same patient's ECG, 2 months after acute anterior myocardial infarction. There is no ST segment elevation, no T
wave negativity and no Q waves. Poor R wave progression in anterior leads is the only evidence that may suggest old anterior
myocardial infarction.

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Figure 1a. The same patient's coronary angiography (spider view) just before
stenting shows
complete occlusion at the proximal LAD .

Figure 1b. Her right coronary arteriography was normal.

Figure 1c. Her left coronary arteriogram after PTCA but before stenting showed
incomplete revascularization of the LAD.

Figure 1d. Her left coronary arteriogram, immeadiately after stenting of the
proximal LAD showed
complete recovery of the distal flow in LAD coronary artery .

ECG 2. The ECG above belongs to a 63 years-old diabetic and hypertensive woman with coronary artery disease.
She has signifcant stenoses in her Left Anterior Descending (LAD) coronary artery.
Poor R wave progression is seen in chest leads.

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