How is left ventricular hypertrophy (LVH) diagnosed on an electrocardiogram (ECG)?

Diagnosing Left Ventricular Hypertrophy on ECG

Left ventricular hypertrophy (LVH) on ECG is primarily diagnosed using voltage criteria, with the Sokolow-Lyon criterion (sum of S wave in V1 and R wave in V5 or V6 > 35 mm) and Cornell voltage criterion (sum of S wave in V3 and R wave in aVL > 28 mm for men and > 20 mm for women) being the most reliable diagnostic tools with high specificity of 85-90%. 1

Primary Voltage-Based Criteria

• The Sokolow-Lyon criterion: Sum of S wave in V1 and R wave in V5 or V6 > 35 mm 1
• The Cornell voltage criterion: Sum of S wave in V3 and R wave in aVL > 28 mm for men and > 20 mm for women 1
• The Cornell voltage-duration product: Cornell voltage × QRS duration > 2440 mm·ms 1
• The Romhilt-Estes point score system: Incorporates QRS amplitude, ST-T abnormalities, left axis deviation, QRS duration, and intrinsicoid deflection - shown to have sensitivity of 86% and specificity of 81% 1, 2

Supporting ECG Findings

• Secondary ST-T wave abnormalities: J-point depression, upwardly convex down-sloping ST segment depression, and asymmetrical T wave inversion (formerly called "strain" pattern) 3
• These ST-T abnormalities provide major support to LVH diagnosis and are associated with larger left ventricular mass and higher cardiovascular risk 3, 1
• P-wave abnormalities suggesting left atrial enlargement can be an early sign of hypertensive heart disease but should only be used as a supporting criterion 3, 1
• Left axis deviation may support the diagnosis of LVH but should not be used alone 3, 1
• QRS duration prolongation often accompanies LVH and can support the diagnosis 3, 1
• Slight QT interval prolongation is consistent with but not diagnostic of LVH 3

Special Considerations in LVH Diagnosis

• In patients with Left Bundle Branch Block (LBBB), the diagnosis of LVH is challenging and standard criteria have decreased performance 1, 4
• In LBBB patients, modified Sokolow-Lyon criteria with voltage ≥3.0mV has shown better performance with specificity of 88.3% 4
• In Right Bundle Branch Block (RBBB), voltage criteria have decreased sensitivity, but criteria such as SV1 > 2 mm and RV5/V6 > 15 mm can be used 1
• In Left Anterior Fascicular Block (LAFB), R-wave amplitude in leads I and aVL are not reliable criteria for LVH 5
• Criteria that include the depth of the S wave in left precordial leads improve detection of LVH when LAFB is present 5

Factors Affecting ECG Diagnosis of LVH

• Age affects ECG diagnosis as QRS voltages decline with increasing age 1
• Gender differences exist, with women having slightly lower upper limits of QRS voltage than men 1
• Body habitus, particularly obesity, can increase left ventricular mass but decrease QRS voltage due to increased distance between the heart and recording electrodes 1
• There is no significant difference in ECG criteria between concentric and eccentric LVH, though concentric LVH shows shorter intrinsicoid deflection and deeper ST-segment and T-wave depression in anterolateral leads 2

Newer Approaches to LVH Diagnosis

• The Seamens' Sign (QRS complexes touching or overlapping in two contiguous precordial leads) has shown high specificity (92%) and good inter-rater agreement (90%) for LVH diagnosis 6
• Artificial intelligence models using ECG signals have shown promising results in detecting LVH with accuracy, precision, sensitivity, and specificity exceeding 95% 7
• For patients with LBBB, parameters based on the amplitude of S wave in V2 or V3 and R wave in leads aVL, V5, V6 have shown the highest clinical value in predicting LVH 8