What are the most common causes of left ventricular hypertrophy (LVH) on an electrocardiogram (EKG)?

Most Common Causes of Left Ventricular Hypertrophy (LVH) on EKG

Hypertension and aortic valve stenosis are the most common causes of left ventricular hypertrophy detected on electrocardiogram. 1

Primary Causes of LVH

• Pressure Overload Conditions

  • Hypertension - the most frequent cause of LVH in clinical practice 1, 2
  • Aortic valve stenosis - another leading cause of LVH 1
  • Hypertrophic cardiomyopathy - genetic condition causing asymmetric septal hypertrophy 1

• Volume Overload Conditions

  • Valvular regurgitation (aortic, mitral) 1
  • High-output states (anemia, arteriovenous fistula) 1

• Infiltrative/Storage Disorders

  • Cardiac amyloidosis 1, 3
  • Fabry disease 1
  • Sarcoidosis 1

Risk Factors for Developing LVH

• Hypertension - At systolic pressures exceeding 180 mmHg, evidence of electrocardiographic LVH develops in 50% of patients 4
• Age - The prevalence of electrocardiographic LVH increases with age 4, 5
• Obesity - A significant determinant of LVH 2
• Glucose intolerance/Diabetes - Associated with increased risk of developing LVH 2
• Male sex - Slight male predominance in LVH prevalence 4

ECG Patterns and Associated Findings in LVH

• Voltage Criteria - Increased QRS amplitude in specific leads 6
• Secondary ST-T Abnormalities - Previously called "strain pattern," these repolarization abnormalities indicate more severe LVH 6
• QRS Duration - Often increased due to thickened ventricular walls and intramural fibrosis 6
• Left Axis Deviation - May be associated with LVH but not diagnostic on its own 6, 5
• Left Atrial Abnormalities - Frequently associated with LVH and may be the earliest ECG sign of hypertensive heart disease 6
• QT Interval Prolongation - Often associated with LVH but may simply be secondary to QRS prolongation 6

Clinical Significance

• LVH with repolarization abnormalities carries a greater risk than LVH based solely on voltage criteria 4
• Electrocardiographic LVH is associated with an eightfold increase in cardiovascular mortality and a sixfold increase in coronary mortality 4
• The risk of stroke, cardiac failure, and coronary heart disease is substantially increased in patients with LVH 4, 2
• In patients with electrocardiographic LVH, the risk of cardiac failure is three times that of patients with hypertension alone 4

Diagnostic Challenges

• The presence of intraventricular conduction defects can affect the accuracy of ECG criteria for LVH 6
• In left anterior fascicular block, R-wave amplitude in leads I and aVL are not reliable criteria for LVH 6, 5
• The diagnosis of LVH in the presence of complete left bundle-branch block should be made with caution due to conflicting evidence 6
• ECG has limited sensitivity for detecting LVH compared to imaging methods like echocardiography 6, 3

Management Implications

• Regression of LVH has been documented after medical treatment of hypertension and after aortic valve replacement 7
• When LVH is detected, the underlying cause should be identified and treated to prevent cardiovascular events and mortality 1
• Management involves lifestyle changes, medications, surgery, or implantable devices depending on the etiology 1

Understanding the common causes of LVH on ECG is essential for proper diagnosis and management, as early intervention may help prevent the progression to heart failure and reduce cardiovascular mortality.