What are the voltage criteria for left ventricular hypertrophy (LVH) on an electrocardiogram (EKG)?

From the Guidelines

Left ventricular hypertrophy (LVH) on an electrocardiogram (EKG) is diagnosed using several voltage criteria, with the most commonly used being 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) 1. The voltage criteria for LVH are based on measurements of QRS voltages, which reflect the increased electrical forces generated by a thickened left ventricular wall.

• The Sokolow-Lyon criteria are widely used and consider the sum of the S wave in V1 and the R wave in V5 or V6 to be ≥ 35 mm.
• The Cornell criteria consider the sum of the R wave in aVL and the S wave in V3 to be > 28 mm for men or > 20 mm for women.
• Other criteria, such as the Romhilt-Estes point score system and the Cornell product, can also be used to diagnose LVH. It's essential to note that while these criteria are specific, they have limited sensitivity, meaning a normal ECG doesn't rule out LVH 1.
• Clinical correlation with imaging studies like echocardiography is often necessary for definitive diagnosis.
• Age, body habitus, and race can affect these voltage measurements, with younger, thinner individuals and Black patients often showing higher voltages even without true LVH. The American Heart Association recommends using only validated criteria for diagnosing LVH and adjusting for factors known to alter accuracy, such as gender, race, and body habitus 1.

From the Research

Voltage Criteria for Left Ventricular Hypertrophy (LVH) on EKG

The voltage criteria for LVH on an electrocardiogram (EKG) are used to detect increased left ventricular mass. The following are some of the key points related to voltage criteria for LVH:

• The Sokolow-Lyon voltage criterion is one of the most commonly used criteria, which measures the sum of the S wave in lead V1 and the R wave in lead V5 or V6 [ 2 ].
• The Cornell voltage criterion is another commonly used criterion, which measures the sum of the R wave in lead aVL and the S wave in lead V3 [ 3 ].
• The 12-lead sum of QRS voltage is also used as a criterion for LVH [ 4 ].
• The product of QRS voltage and duration, as an approximation of the time-voltage integral of the QRS complex, can improve the electrocardiographic identification of LVH [ 3 ].
• The total 12-lead QRS voltage is a useful indicator of LV hypertrophy and is more sensitive than other commonly employed criteria [ 5 ].

Sensitivity of Voltage Criteria

The sensitivity of voltage criteria for LVH varies:

• The Sokolow-Lyon voltage criterion has a sensitivity of 39% [ 5 ].
• The Cornell voltage criterion has a sensitivity of 40.8% [ 6 ].
• The 12-lead sum of QRS voltage has a sensitivity of 54% [ 4 ].
• The product of QRS voltage and duration has a sensitivity of 51% [ 3 ].
• The total 12-lead QRS voltage has a sensitivity of 53% [ 5 ].

Limitations of Voltage Criteria

The voltage criteria for LVH have some limitations:

• They have poor sensitivity at acceptable levels of specificity [ 2 ].
• They are not accurate in patients with systemic hypertension or aortic stenosis [ 6 ].
• They do not distinguish between eccentric and concentric LVH [ 2 ].