Poor R wave progression (PRWP) and reversed R wave progression (RRWP) in the electrocardiogram (ECG) have been recognized since the 1970s as potential markers for the presence of fibrosis in the anterior wall of the heart [[1], [2], [3]] and have inconsistent definitions in literature (Fig. 1). The proposed mechanism by which PRWP/RRWP could indicate such a condition is that anterior myocardial necrosis results in a decrease in the magnitude and duration of anterior electromotive force in the horizontal plane VCG, which would be reflected on the ECG by diminution of the R-wave magnitude in V1-V4 [2].

This concept, widely taught and disseminated across medical education and clinical practice, remains without solid evidence backing its clinical implications and diagnostic value. Physicians are also aware of other differential diagnoses for these findings, such as lead displacement, left anterior hemiblock, and variants of normal [2]. However, as a past myocardial infarction is among the more serious of these diagnoses, in many cases, reporting PRWP/RRWP may lead to unnecessary escalation of healthcare costs [4], overdiagnosis, and overtreatment. Despite its prevalence in clinical discussions, medical reports and textbooks, the evidence base supporting the link between PRWP/RRWP and anterior wall fibrosis, and its significance in the prognosis of chronic coronary artery disease, has not been comprehensively evaluated or summarized.

Scoping reviews are designed to assess the extent, range, and nature of evidence on a specific topic or question [[5], [6], [7]]. These reviews are particularly useful for clarifying key concepts in the literature, exploring how research is carried out on certain topics, and identifying gaps where future studies could be directed. Following PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines [8], the aim of this review is to map the evidence available on PRWP, identify the main themes and findings and highlight areas where further research is needed, thus contributing to a better understanding of the clinical relevance of PRWP and its potential diagnostic value.