How to grade left ventricular hypertrophy on 2D (two-dimensional) echocardiography?

Grading Left Ventricular Hypertrophy on 2D Echocardiography

Left ventricular hypertrophy (LVH) should be assessed and graded using left ventricular mass (LVM) indexed to body surface area (BSA), with specific thresholds for mild, moderate, and severe LVH based on gender. 1, 2

Measurement Technique

• Measurements should be taken at end-diastole using the inner-edge-to-inner-edge method
• Position cursor perpendicular to the long axis of the ventricle
• Measure:
  • Interventricular septal thickness
  • Left ventricular posterior wall thickness
  • Left ventricular internal diameter

LV Mass Calculation

• Calculate LV mass using the ASE-recommended formula:
  • LV mass (g) = 0.8 × {1.04 × [(LVIDd + PWTd + SWTd)³ - (LVIDd)³]} + 0.6
  • Where LVIDd = LV internal diameter in diastole, PWTd = posterior wall thickness in diastole, SWTd = septal wall thickness in diastole

LVH Classification by Indexed LV Mass

LV Mass Indexed to BSA (g/m²)

• Women:

  • Normal: 43-95 g/m²
  • Mild LVH: 96-108 g/m²
  • Moderate LVH: 109-121 g/m²
  • Severe LVH: ≥122 g/m² 1, 2

• Men:

  • Normal: 49-115 g/m²
  • Mild LVH: 116-131 g/m²
  • Moderate LVH: 132-148 g/m²
  • Severe LVH: ≥149 g/m² 1, 2

Alternative Indexing Methods

For overweight/obese patients, consider height-based indexing:

• LV Mass/Height²·⁷ (g/m²·⁷):
  • Normal: ≤44 g/m²·⁷ (women), ≤48 g/m²·⁷ (men)
  • Mild abnormal: 45-51 g/m²·⁷ (women), 49-55 g/m²·⁷ (men)
  • Moderate abnormal: 52-58 g/m²·⁷ (women), 56-63 g/m²·⁷ (men)
  • Severe abnormal: ≥59 g/m²·⁷ (women), ≥64 g/m²·⁷ (men) 1, 2

Geometric Pattern Classification

In addition to LV mass, assess relative wall thickness (RWT):

• RWT = (2 × PWTd) / LVIDd
• Normal RWT: 0.22-0.42 (women), 0.24-0.42 (men) 1, 2

Based on LV mass index and RWT, classify into four geometric patterns:

1. Normal geometry: Normal LV mass index and normal RWT
2. Concentric remodeling: Normal LV mass index and increased RWT (>0.42)
3. Eccentric hypertrophy: Increased LV mass index and normal RWT (≤0.42)
4. Concentric hypertrophy: Increased LV mass index and increased RWT (>0.42) 1, 2

Important Considerations

• LV mass is a more sensitive indicator of LVH than wall thickness alone 3
• 3D echocardiography is preferred for asymmetric or localized hypertrophy and abnormally shaped ventricles 2
• Concentric hypertrophy carries the highest cardiovascular risk among the geometric patterns 1
• Septal morphology and wall hypertrophy localization should be documented in cases of asymmetric hypertrophy 1
• When measuring wall thickness alone, values ≥12 mm are generally considered abnormal, but this approach is less sensitive than LV mass calculation 3

Pitfalls to Avoid

• Relying solely on wall thickness measurements rather than calculated LV mass
• Not indexing LV mass to body size (BSA or height)
• Using BSA indexing in obese patients (height-based indexing is preferred)
• Failing to assess RWT and geometric pattern, which provide additional prognostic information
• Not considering other causes of LVH (hypertension, aortic stenosis, hypertrophic cardiomyopathy)

By following this standardized approach to grading LVH, clinicians can more accurately assess cardiovascular risk and guide therapeutic decisions for patients with suspected or confirmed LVH.