Approximately 20% of patients with heart failure have left bundle branch block (LBBB) on surface electrocardiogram (ECG). In this group of patients, detection of right ventricular (RV) dilatation on standard ECG can be of clinical relevance because RV enlargement is an important prognostic marker. Consequently, the aim of this study was to evaluate diagnostic accuracy for several electrocardiographic criteria in determining significant RV dilatation in these patients. Standard 12-lead ECGs were obtained in 173 patients with heart failure and known LBBB. From the ECG, 3 criteria for RV dilatation were defined: presence of terminal positivity in lead aVR (late R wave in lead aVR), low voltage (<0.6 mV) in all extremity leads, and an R/S ratio <1 in lead V-5. In addition, all patients underwent comprehensive echocardlographic evaluation including assessment of RV dimensions. Measurements were performed blinded to electrocardiographic results. Significant RV dilatation was defined as an RV base-to-apex length >= 86 mm or an RV diastolic area >= 33 cm(2). Eighty-six patients (50%) had a late R wave in lead aVR, 36 patients (21%) had low voltage in extremity leads, and 67 patients (39%) had an R/S ratio <1 in lead V5. An RV base-to-apex length >= 86 mm was present in 67 patients (39%), and 62 patients (36%) had an RV diastolic area >= 33 cm(2). Any combination of 2 to 3 positive criteria could predict an RV base-to-apex length >= 86 mm with a positive predictive value of 89% and a negative predictive value of 88%. Similarly, an RV diastolic area >= 33 cm(2) was predicted with a positive predictive value of 80% and a negative predictive value of 88%. In conclusion, combining 2 to 3 distinct electrocardiographic criteria allows for accurate detection of RV dilatation in patients with heart failure and LBBB.