From the Guidelines
Left ventricular hypertrophy (LVH) on ECG is best diagnosed using the Sokolow-Lyon criteria or the Cornell criteria, and its presence warrants further evaluation with echocardiography for confirmation, as it is associated with increased risk of arrhythmias, heart failure, and sudden cardiac death. The Sokolow-Lyon criteria (S wave in V1 + R wave in V5 or V6 > 35 mm) and the Cornell criteria (R wave in aVL + S wave in V3 > 28 mm for men or > 20 mm for women) are the most reliable ECG criteria for LVH 1. Other findings may include left axis deviation, prolonged QRS duration, ST depression and T wave inversion in leads with tall R waves (strain pattern), and left atrial enlargement.
Diagnosis and Evaluation
The diagnosis of LVH on ECG has moderate sensitivity (around 50%) but good specificity (85-90%) 1. However, the accuracy of ECG criteria can be influenced by various factors such as age, gender, race, and body habitus. Echocardiography or MRI is recommended for confirmation of LVH, especially in adults who are young (≤18 years of age) or have evidence of secondary hypertension, chronic uncontrolled hypertension, or history of symptoms of heart failure 1.
Management and Treatment
Management of LVH focuses on treating the underlying cause, particularly blood pressure control in hypertensive patients, typically with ACE inhibitors, ARBs, or beta-blockers 1. Regular follow-up is essential as LVH is associated with increased risk of arrhythmias, heart failure, and sudden cardiac death. Lifestyle modifications including sodium restriction, regular exercise, and weight management are also important components of treatment.
Key Considerations
Common causes of LVH include hypertension, aortic stenosis, hypertrophic cardiomyopathy, and athletic heart. The presence of LVH on ECG is a secondary manifestation of hypertension and independently predicts future cardiovascular events 1. BP lowering leads to a reduction in LV mass, and beta blockers are inferior to angiotensin receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, and CCBs in reducing LVH 1. Electrocardiographic criteria for LVH correlate weakly with echocardiographic or MRI definitions of LVH and are less strongly related to cardiovascular outcomes 1.
From the Research
Left Ventricular Hypertrophy on ECG
- Left ventricular hypertrophy (LVH) is a condition where the muscle wall of the heart's left ventricle becomes thickened, which can be detected on an electrocardiogram (ECG) 2.
- The ECG criteria for LVH include voltage, repolarization abnormalities, left atrial abnormality, and ventricular conduction time 3.
- Studies have shown that ECG-LVH is independently associated with an increased risk of cardiovascular disease (CVD) events, regardless of left ventricular anatomy 2.
- The association between ECG-LVH and CVD events is not dependent on echo-LVH, suggesting that ECG-LVH is an electrophysiological marker with predictive properties independent of LV anatomy 2.
Diagnosis and Management
- Cardiovascular imaging plays a key role in the assessment of LV hypertrophy, with echocardiography being the first-line imaging technique 4.
- Cardiovascular magnetic resonance provides added value in measuring LV and right ventricular volumes and mass, and characterizing myocardial tissue properties 4.
- The diagnosis and management of LVH involve a comprehensive assessment of LV systolic and diastolic function, as well as the use of antihypertensive therapies to reduce LVH and improve left ventricular filling 5, 6.
Predictive Properties
- ECG-LVH has been shown to be a predictor of CVD events independent of left ventricular anatomy in subjects aged ≥65 years 2.
- The frequency of ECG criteria for LVH increases with increasing left ventricular mass (LVM), with an increase in LVM having a significant effect on all 4 ECG criteria 3.
- An increasing number of criteria on the ECG are associated with a greater mean LVM, suggesting that ECG-LVH is a useful marker for predicting CVD events 3.