What EKG findings indicate Left Ventricular Hypertrophy (LVH)?

ECG Findings That Indicate Left Ventricular Hypertrophy (LVH)

The most reliable ECG criteria for diagnosing LVH include voltage-based measurements such as the Sokolow-Lyon criterion (SV1 + RV5 or RV6 > 35 mm) and Cornell voltage criterion (SV3 + RaVL > 28 mm for men, > 20 mm for women), with additional diagnostic accuracy when combined with non-voltage criteria such as ST-T abnormalities. 1

Primary Voltage-Based Criteria

• Sokolow-Lyon criterion: Sum of S wave in V1 and R wave in V5 or V6 > 35 mm (3.5 mV) 1
• Cornell voltage criterion: Sum of S wave in V3 and R wave in aVL > 28 mm (2.8 mV) for men and > 20 mm (2.0 mV) for women 1
• Cornell voltage-duration product: Cornell voltage × QRS duration > 2440 mm·ms 1
• Romhilt-Estes point score system: Incorporates QRS amplitude, ST-T abnormalities, left axis deviation, QRS duration, and intrinsicoid deflection 1

It's important to note that voltage criteria alone have relatively low sensitivity (usually less than 50%) but high specificity (85-90%) for detecting LVH 1. Different criteria often identify different patients with LVH, as only about 11.2% of patients with LVH meet both Cornell and Sokolow-Lyon criteria simultaneously 1.

Supporting ECG Findings

These findings enhance the diagnostic accuracy when combined with voltage criteria:

• ST-T wave abnormalities: Secondary ST-T changes (formerly called "strain pattern") strongly support the diagnosis of LVH and are associated with larger left ventricular mass and higher cardiovascular risk 1
• Left atrial abnormalities: P-wave changes suggesting left atrial enlargement can be an early sign of hypertensive heart disease 1
• Left axis deviation: May support the diagnosis of LVH but should not be used alone 1
• QRS duration prolongation: Increased QRS duration often accompanies LVH 1
• Slightly prolonged QT interval: Consistent with but not diagnostic of LVH 1

LVH Diagnosis in Special Circumstances

With Left Bundle Branch Block (LBBB)

• LVH diagnosis is challenging with LBBB and should generally not be attempted 1
• If needed, consider these criteria which have higher specificity:
  • Left atrial abnormality 1
  • QRS duration > 155 ms 1
  • Precordial lead voltage criteria 1

With Right Bundle Branch Block (RBBB)

• RBBB reduces S wave amplitude in right precordial leads, decreasing sensitivity 1
• Consider these criteria:
  • SV1 > 2 mm (0.2 mV) 1
  • RV5/V6 > 15 mm (1.5 mV) 1
  • QRS axis left of -30° with S in lead III 1
  • Left atrial abnormality and left axis deviation have enhanced diagnostic value 1

With Left Anterior Fascicular Block

• R-wave amplitude in leads I and aVL are less reliable 1
• Criteria that include S wave depth in left precordial leads improve detection 1

Factors Affecting ECG Diagnosis of LVH

• Age: QRS voltages decline with increasing age; standard criteria best apply to adults over 35 years 1
• Gender: Women have slightly lower upper limits of QRS voltage than men 1
• Body habitus: Obesity increases left ventricular mass but decreases QRS voltage due to increased distance between the heart and recording electrodes 1

Recent Developments

Recent research has explored alternative approaches to improve diagnostic accuracy:

• Combined voltage-duration products show improved sensitivity 2
• The deepest S wave in any lead (SD) plus S wave in V4 (SV4) has shown improved sensitivity (62%) while maintaining high specificity (≥90%) 2
• Voltage-independent measurements based on QRS complex timing characteristics may improve detection in patients where voltage criteria are less reliable 3, 4

When interpreting ECGs for LVH, it's advisable to apply multiple criteria and specify which criteria were used in making the diagnosis 1. The presence of ST-T abnormalities substantially increases the likelihood of LVH when voltage criteria are borderline 1.