What are the English criteria for diagnosing left ventricular hypertrophy?

ECG Criteria for Left Ventricular Hypertrophy

The most widely validated ECG criteria for diagnosing left ventricular hypertrophy are the Sokolow-Lyon criterion (SV1 + RV5 or RV6 ≥35 mm) and the Cornell voltage criterion (SV3 + RaVL >28 mm in men, >20 mm in women), both offering high specificity (85-90%) but limited sensitivity (<50%). 1, 2

Primary Voltage-Based Criteria

The following voltage criteria are the most established for LVH diagnosis:

Sokolow-Lyon Criterion

• SV1 + RV5 or RV6 ≥35 mm (≥3.5 mV) is the most widely used criterion, introduced in 1949 and extensively validated across multiple populations 1, 2
• Offers specificity of 85-90% but sensitivity typically <50% 1
• In patients with complete left bundle branch block, a higher threshold of ≥30 mm (≥3.0 mV) provides the best performance with 22.2% sensitivity and 88.3% specificity 3

Cornell Voltage Criterion

• SV3 + RaVL >28 mm in men and >20 mm in women provides gender-adjusted diagnostic accuracy 1, 2
• Demonstrates similar specificity (85-90%) to Sokolow-Lyon with comparable or slightly better sensitivity 1, 2
• The gender adjustment is critical as women have lower upper limits of QRS voltage, particularly for SV3 1

Cornell Voltage-Duration Product

• Cornell voltage × QRS duration >2440 mm·ms improves diagnostic accuracy over simple voltage criteria 2
• Achieves 15-19% sensitivity at 95% specificity, outperforming simple voltage measurements 4, 5

Romhilt-Estes Point Score System

• Score ≥5 points indicates definite LVH; ≥4 points indicates probable LVH 1, 2
• This comprehensive scoring system incorporates:
  • QRS amplitude (3 points for largest limb lead R or S ≥20 mm, or S in V1/V2 ≥30 mm, or R in V5/V6 ≥30 mm)
  • ST-T abnormalities (3 points with digitalis, 1 point without)
  • Left atrial abnormality (3 points)
  • Left axis deviation ≥-30° (2 points)
  • QRS duration ≥0.09 seconds (1 point)
  • Intrinsicoid deflection in V5/V6 ≥0.05 seconds (1 point) 1
• Provides 22-24% sensitivity at 95% specificity, making it one of the most accurate point-scoring systems 4

Supporting ECG Findings

Beyond voltage criteria, additional ECG features strengthen the diagnosis:

ST-T Wave Abnormalities

• Secondary ST-T changes (formerly called "strain pattern") strongly support LVH diagnosis and indicate larger left ventricular mass with higher cardiovascular risk 2
• These repolarization abnormalities have independent prognostic value beyond the voltage criteria alone 1

Left Atrial Abnormality

• P-wave changes suggesting left atrial enlargement serve as an early marker of hypertensive heart disease 2
• Included in the Romhilt-Estes scoring system as a 3-point criterion 1

QRS Duration and Axis

• QRS duration prolongation frequently accompanies LVH and can support the diagnosis 2
• Left axis deviation (≥-30°) may support LVH but should not be used as a standalone criterion 2
• Increased time from QRS onset to R-wave peak in V5 or V6 reflects conduction delay associated with increased ventricular mass 1

Critical Factors Affecting Diagnostic Accuracy

Age Considerations

• Standard voltage criteria apply best to adults >35 years of age 1, 2
• QRS voltages decline with increasing age, reducing sensitivity in older adults 1
• Diagnosis in young adults (16-35 years) and highly trained athletes has particularly low accuracy and should be made with caution 1

Gender Differences

• Women require lower voltage thresholds due to inherently lower QRS voltages 1, 2
• Cornell criteria with gender-specific cutoffs (>20 mm for women vs >28 mm for men) improve diagnostic performance 2
• Women show stronger association between LVH and stroke mortality compared to men 6

Body Habitus

• Obesity increases left ventricular mass but paradoxically decreases QRS voltage due to increased distance between the heart and recording electrodes 1, 2
• This creates a significant limitation in ECG sensitivity for obese patients 1

LVH Diagnosis in Bundle Branch Block

Complete Left Bundle Branch Block (CLBBB)

• LVH diagnosis in the presence of CLBBB is extremely challenging and should generally not be attempted 1, 2
• Standard voltage criteria show dramatically decreased performance with both sensitivity and specificity compromised 3
• If diagnosis is necessary, Sokolow-Lyon with voltage ≥30 mm provides the best available performance, though still limited 3

Right Bundle Branch Block (RBBB)

• Voltage criteria sensitivity is decreased but diagnosis remains more feasible than with LBBB 2
• Supportive criteria include: SV1 >2 mm, RV5/V6 >15 mm, and QRS axis left of -30° with S wave in lead III 2

Performance Characteristics and Clinical Application

Sensitivity vs Specificity Trade-off

• All voltage criteria demonstrate low sensitivity (typically <50%) but high specificity (85-90%) 1
• Only 11.2% of patients meeting either Cornell or Sokolow-Lyon criteria meet both, highlighting the complementary nature of different criteria 1
• Point-scoring systems (Romhilt-Estes, Perugia) achieve slightly better sensitivity (22-24%) while maintaining 95% specificity 4

Recommended Clinical Approach

• Use multiple validated criteria rather than relying on a single criterion 1
• Specify which criteria were used and which were abnormal in the interpretation 1, 2
• Apply only validated criteria without modification from their tested form 1, 2
• Adjust for gender, race, and body habitus when validated adjustments exist 1, 2

Common Pitfalls to Avoid

• Do not use terms "strain," "systolic," or "diastolic" in diagnostic statements related to LVH 1
• Use terms "probable," "possible," and "borderline" with caution as they lack standardized definitions 1
• Recognize that false positives are more common in low-prevalence populations, while false negatives predominate in high-risk groups (e.g., severe hypertension) 1
• Do not diagnose LVH based solely on voltage criteria in young adults or athletes 1
• Avoid attempting LVH diagnosis in complete LBBB except in specific circumstances with appropriate caution 1, 2, 3