What are the ECG (electrocardiogram) patterns for Left Ventricular Hypertrophy (LVH) and Right Ventricular Hypertrophy (RVH)?

ECG Patterns for Left Ventricular Hypertrophy (LVH) and Right Ventricular Hypertrophy (RVH)

The ECG diagnosis of LVH relies primarily on increased QRS voltage in specific leads, while RVH typically presents with right axis deviation and prominent R waves in right precordial leads, though both patterns have limited sensitivity but good specificity. 1, 2

Left Ventricular Hypertrophy (LVH) ECG Patterns

Voltage Criteria

• Sokolow-Lyon criteria: S in V1 + R in V5 or V6 > 35 mm
• Cornell voltage criteria: R in aVL + S in V3 > 28 mm (men) or > 20 mm (women)
• R in aVL > 11 mm

Non-Voltage Features

• Left axis deviation
• QRS duration prolongation (> 90 ms)
• Delayed intrinsicoid deflection in V5 or V6 (> 50 ms)
• Secondary ST-T abnormalities ("strain pattern"): ST depression and T-wave inversion in leads I, aVL, V5-V6 1
• Left atrial abnormality: P-wave duration ≥ 120 ms or notched P wave with interpeak interval ≥ 40 ms

Right Ventricular Hypertrophy (RVH) ECG Patterns

Key Features

• Right axis deviation (typically > 90° in adults)
• Prominent R waves in right precordial leads (V1, V2)
• R/S ratio > 1 in lead V1
• Deep S waves in left lateral leads (I, aVL, V5, V6)
• Secondary ST-T abnormalities in right precordial leads (V1-V3) 2

Specific RVH Patterns

1. Pressure Overload Pattern:

   • Tall R waves in right precordial leads (Rs, R, or Qr complexes)
   • Right axis deviation
   • Common in pulmonary hypertension 2

2. Volume Overload Pattern:

   • Similar to incomplete RBBB with rSR' pattern in V1
   • Right axis deviation
   • Common in atrial septal defects 2

Validated RVH Criteria

• R in V1 > 6 mm
• R/S ratio in V1 > 1.0
• qR pattern in V1
• R in V1 + S in V5 or V6 > 10.5 mm
• S in I + R in V1 > 10 mm 1, 2

Biventricular Hypertrophy

When both ventricles are hypertrophied, ECG diagnosis becomes challenging due to cancellation of opposing forces. Look for:

• Criteria for both LVH and RVH simultaneously
• Right axis deviation with LVH voltage criteria
• Tall biphasic R/S complexes in multiple leads
• Prominent S waves in V5 or V6 with LVH criteria
• Signs of both right and left atrial abnormalities 1

Special Considerations

Age-Specific Criteria

• Pediatric criteria differ significantly from adult criteria
• For children > 5 years: RV1 > 13 mm, SV6 > 4 mm, and RV1+SV6 > 17 mm suggest RVH 1, 2

Confounding Factors

• Body habitus (obesity decreases voltage)
• Bundle branch blocks (especially LBBB can mask or mimic LVH)
• Race and gender affect normal voltage ranges

Clinical Pitfalls to Avoid

1. Relying solely on ECG for ruling out ventricular hypertrophy (low sensitivity)
2. Ignoring clinical context when interpreting ECG patterns
3. Using adult criteria for pediatric patients
4. Failing to recognize that biventricular hypertrophy may mask typical patterns of either LVH or RVH 1, 3

Remember that while ECG criteria for ventricular hypertrophy have good specificity, they have limited sensitivity. Echocardiography remains the gold standard for definitive diagnosis of ventricular hypertrophy.