A Practical Approach to the Investigation of an rSr' Pattern in Leads V1-V2

The differential diagnosis of an rSr' pattern in leads V1-V2 on electrocardiogram is a frequently encountered entity in clinical cardiology. This finding often presents itself in asymptomatic and healthy individuals. The causes might vary from benign and nonpathological, to severe and life-threatening diseases, such as Brugada syndrome or arrhythmogenic right ventricular dysplasia. Workup of these patients involves a history and physical examination to screen for underlying cardiac disease and potential triggers. Routine investigation involves blood work and a thorough electrocardiographic examination. Echocardiography has a role in evaluating patients in whom structural heart disease is suspected. Pulmonary testing using computed tomography can be conducted if right ventricular enlargement is identified. More advanced testing is not warranted if these initial investigations are reassuring. Referral to an arrhythmia specialist should be considered for patients in whom this finding is due to Brugada syndrome, arrhythmogenic right ventricular dysplasia, or Wolf-Parkinson-White syndrome. We propose a clinical and electrocardiographic algorithm that will assist clinicians in narrowing their differential diagnosis.