Can an Electrocardiogram (EKG) show both Left Axis Deviation (LAD) and Left Ventricular Hypertrophy (LVH)?

Left Axis Deviation and Left Ventricular Hypertrophy Can Coexist on the Same ECG

Yes, it is absolutely possible to have both Left Axis Deviation (LAD) and Left Ventricular Hypertrophy (LVH) on the same ECG. According to the AHA/ACCF/HRS guidelines, left axis deviation may be associated with LVH and can be used as a supporting criterion for the diagnosis of LVH 1.

Relationship Between LAD and LVH

Left axis deviation can occur in patients with LVH through several mechanisms:

• It may result from the hypertrophy process itself
• It could represent a degree of left anterior fascicular block
• It may be related to other factors that cause a leftward shift of the QRS axis with age 1

The guidelines specifically state that left axis deviation should be used to support a diagnosis of LVH rather than to make the diagnosis independently 1.

Clinical Significance of Combined LAD and LVH

The combination of LAD and LVH has important clinical implications:

• Studies have shown that the combination of LAD and LVH was evident in approximately 11% of men and 9% of women with hypertension 2
• The presence of both findings may indicate more advanced cardiac remodeling
• When both are present, there is a higher risk of cardiovascular mortality compared to either finding alone 3

Diagnostic Considerations

When interpreting an ECG with both LAD and LVH:

• Standard voltage criteria for LVH should still be applied (such as Sokolow-Lyon or Cornell criteria)
• The presence of LAD provides supporting evidence for the diagnosis of LVH
• In patients with left anterior fascicular block (a cause of LAD), R-wave amplitude in leads I and aVL are not reliable criteria for LVH 1
• Criteria that include the depth of the S wave in left precordial leads improve detection of LVH in the presence of left anterior fascicular block 1

Additional Supporting Criteria for LVH

Besides LAD, other ECG findings that support the diagnosis of LVH include:

• Left atrial abnormalities (P-wave changes)
• ST-T abnormalities (previously called "strain pattern")
• Slightly prolonged QT interval
• Left axis deviation 1

Common Pitfalls to Avoid

1. Don't rely solely on LAD to diagnose LVH: LAD should be used as a supporting criterion, not as a standalone diagnostic feature 1

2. Be cautious with voltage criteria in LAD: When left anterior fascicular block is present (causing LAD), R-wave amplitude in leads I and aVL becomes less reliable for LVH diagnosis 1

3. Consider other causes of LAD: Left axis deviation can occur due to many factors besides LVH, including left anterior fascicular block, inferior myocardial infarction, and as a normal variant in some individuals

4. Don't ignore other supporting criteria: The presence of ST-T abnormalities and left atrial abnormality along with LAD strengthens the diagnosis of LVH 3

5. Remember that ECG has limited sensitivity for LVH: Even with multiple criteria including LAD, the ECG has moderate sensitivity compared to echocardiography for detecting LVH 4, 5

In conclusion, LAD and LVH commonly coexist on ECGs, with LAD serving as a supporting criterion for the diagnosis of LVH. When both are present, they may indicate a higher risk of cardiovascular events, warranting closer clinical attention and appropriate management of underlying conditions like hypertension.