From the Guidelines
Left ventricular hypertrophy (LVH) should be diagnosed using validated electrocardiogram (ECG) criteria, such as the Sokolow-Lyon index and Cornell product, with consideration of factors like gender, race, and body habitus, as recommended by the American Heart Association 1. The Sokolow-Lyon index is calculated by adding the S wave in V1 and the R wave in V5 or V6 (whichever is larger); LVH is present if this sum exceeds 35 mm. The Cornell product is calculated by multiplying the sum of the R wave in aVL and the S wave in V3 by the QRS duration; LVH is indicated if this product exceeds 2440 mm·ms. Some key points to consider when diagnosing LVH include:
- The sensitivity of the various criteria is generally quite low (usually less than 50%), whereas the specificity is quite high (often in the range of 85% to 90%) 1.
- The existence of many different criteria for diagnosing LVH makes clinical application more complex, and the diagnostic accuracy will depend on the specific criterion used 1.
- Patients who meet one set of criteria for LVH commonly do not meet other criteria, highlighting the importance of using multiple criteria and considering individual patient factors 1.
- The American Heart Association recommends using only validated criteria for diagnosing LVH, without deviation from the validated formulas, and specifying which diagnostic criteria were used and which were abnormal 1. Management of LVH focuses on treating the underlying cause, typically with antihypertensive medications like ACE inhibitors, ARBs, or beta-blockers if hypertension is present, and regular blood pressure monitoring and follow-up ECGs are essential to track LVH regression with treatment 1. LVH is clinically significant as it increases the risk of arrhythmias, heart failure, and sudden cardiac death, making early detection and management crucial for preventing cardiovascular complications 1.
From the Research
Left Ventricular Hypertrophy Detection and Regression
- Left ventricular hypertrophy (LVH) is a maladaptive response to chronic pressure overload and an important risk factor for atrial fibrillation, diastolic heart failure, systolic heart failure, and sudden death in patients with hypertension 2.
- The detection of LVH can be improved by using different electrocardiographic criteria, such as the Cornell product and Sokolow-Lyon voltage index, which can increase the detection of LVH to 33% and 39.3%, respectively, when combined 3.
- The Cornell product and Sokolow-Lyon product are more sensitive than the Cornell voltage and Sokolow voltage in detecting LVH, with a detection rate of 27.3% and 23.6%, respectively, compared to 12.9% and 12.0% for the voltage criteria 3.
Regression of Left Ventricular Hypertrophy
- Controlling arterial pressure, sodium restriction, and weight loss can facilitate the regression of LVH 2.
- Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, followed by calcium channel antagonists, can most rapidly facilitate the regression of LVH 2.
- Beta blockers, especially the newer cardioselective ones, can also play a role in regressing LVH, although their effect is minor compared to other antihypertensive agents 4.
- The regression of LVH is associated with improved diastolic function and coronary flow reserve, and decreased cardiovascular risk 2.
Risk Prediction and LVH
- Patients with hypertension and ECG LVH have higher cardiovascular morbidity and mortality, and the continued presence or new development of ECG LVH by two criteria can further concentrate risk during blood pressure lowering 5.
- The combination of Cornell product and Sokolow-Lyon voltage criteria can improve risk prediction in patients with hypertension, with a >3-fold increased risk of events in patients with persistent or developed ECG LVH by both criteria 5.