From the Guidelines
Diagnosis of Left Ventricular Hypertrophy (LVH) using ECG Criteria
The most commonly used ECG criteria for diagnosing LVH are based on measurements of QRS voltages, with the Sokolow-Lyon criterion and the Cornell voltage criterion being the most widely used 1.
ECG Criteria for LVH
- The Sokolow-Lyon criterion is based on the sum of SV1 and RV5 or RV6 1.
- The Cornell voltage criterion is based on the sum of SV3 and RaVL, referred to as the “Cornell voltage” 1.
- Other criteria, such as the point score of Romhilt and Estes, incorporate abnormalities in QRS axis and duration, QRS onset-to-peak time, and P and ST-T morphology, in addition to QRS amplitude 1.
Limitations of ECG Criteria
The sensitivity of the various criteria is generally quite low (usually less than 50%), whereas the specificity is quite high (often in the range of 85% to 90%) 1. The accuracy of the criteria is empirical, dependent on correlations between specific ECG measurements and a reference standard, and only ECG criteria that have been formally tested should be used without modification from the tested form 1.
Clinical Application
In clinical practice, interpretations should specify which criteria are used in making a diagnosis, and automated systems should apply multiple criteria 1. The value of multiple criteria may be additive, and patients who meet one set of criteria for LVH commonly do not meet other criteria 1.
Special Considerations
In patients with left bundle-branch block (LBBB), the diagnosis of LVH can be challenging, and estimations of specificity are affected by the relatively high prevalence of anatomic LVH in patients with LBBB 1. Left atrial P-wave abnormality and QRS duration greater than approximately 155 ms, as well as precordial lead voltage criteria, tend to have relatively high sensitivity for LVH in the presence of LBBB 1.
From the Research
ECG Criteria for Diagnosing Left Ventricular Hypertrophy (LVH)
The following ECG criteria are used to diagnose LVH:
- Cornell voltage
- Cornell voltage product
- Sokolow-Lyon voltage
- Sokolow-Lyon product
- RaVL
- RaVL+SV3
- RV6/RV5 ratio
- Strain pattern
- Left atrial enlargement
- QT interval 2
- Dalfó criterion (ECG18. SV3 + RaVL) 3
- Gubner-Ungerleider criterion 4
- RV5 or RV6 > 25 mm criterion 4
- Groningen-LVH criterion for women (QV2 + RI + RV5 + RV6 + SV2 + SV4 + SV5 + SV6) 5
- Groningen-LVH criterion for men ((RI + RV5 + SII + SV2 + SV6) × QRS duration) 5
- SD + SV4 criterion (the deepest S-wave amplitude in any lead plus SV4 amplitude) 6
Performance of ECG Criteria
The performance of these criteria varies:
- In patients without left bundle branch block (LBBB), ECG sensitivity to the presence of LVH varied between 7.6 and 40.9%, and specificity varied between 70.2 and 99.2% 2
- In patients with LBBB, the Sokolow-Lyon criterion with voltage ≥3,0mV had a sensitivity of 22.2% and specificity of 88.3% 2
- The Dalfó criterion had the highest pooled sensitivity of 86% in patients with LBBB 4
- The Gubner-Ungerleider criterion and the RV5 or RV6 > 25 mm criterion had the highest specificities, with values of 99% and 99%, respectively 4
- The Groningen-LVH criteria had sensitivities of 42% in women and 44% in men 5
- The SD + SV4 criterion had higher sensitivity but not higher specificity compared to other criteria 6
Population-Specific Performance
The performance of ECG criteria can vary depending on the population:
- The Dalfó criterion had the best diagnostic performance in a Northern Mexican population, with a sensitivity of 56% and specificity of 71.3% 3
- The VDP Cornell criterion had the best accuracy in patients less than 60 years old, and in patients with non-ischaemic findings by Echo 3
- The Groningen-LVH criteria were strongest associated with change in systolic blood pressure in an independent cohort 5