What are the ECG (electrocardiogram) criteria for diagnosing left ventricular hypertrophy (LVH)?

ECG Criteria for Left Ventricular Hypertrophy

Multiple validated voltage and non-voltage criteria exist for diagnosing LVH on ECG, though all have limited sensitivity and should be interpreted in clinical context, with the understanding that no single criterion is definitively superior.

Primary Voltage Criteria

Sokolow-Lyon Index

• S wave in V1 + R wave in V5 or V6 ≥ 3.5 mV (35 mm) is the classic threshold 1
• This criterion has extremely low sensitivity (1.9%) but high specificity in clinical practice 2
• Shows weak correlation with actual left ventricular mass (r = 0.19) 3
• The traditional 3.5 mV cutoff may require recalibration for improved accuracy 3

Cornell Voltage Criteria

• For men: S wave in V3 + R wave in aVL > 2.8 mV 1
• For women: S wave in V3 + R wave in aVL > 2.0 mV 1
• These sex-specific criteria show better correlation with left ventricular mass (r = 0.37) compared to Sokolow-Lyon 3
• Revised internal cutoffs of 2.3 mV for men and 1.9 mV for women may provide better sensitivity (22.5-28%) while maintaining 95% specificity 3
• Cornell criteria demonstrate the highest diagnostic accuracy (AUC 0.621-0.876) among voltage criteria 4

Peguero-Lo Presti Criteria

• Deepest S wave in any lead + S wave in V4 > specific threshold 2, 4
• Shows the highest sensitivity (19.2-45.3%) among commonly used criteria 2, 4
• Demonstrates good diagnostic accuracy comparable to Cornell criteria 4
• May be the most useful screening criterion due to superior sensitivity 4

Additional Voltage Criteria

• R wave in aVL > 1.1 mV (11 mm) 1
• R wave in V5 or V6 > 2.6 mV (26 mm) 1
• Sum of R waves in V5 + V6 > 4.5 mV 1

Romhilt-Estes Point Score System

This scoring system assigns points for multiple ECG features, with ≥5 points indicating definite LVH and 4 points indicating probable LVH 1:

• Voltage criteria (3 points): Any limb lead R or S wave ≥ 2.0 mV, or S wave in V1 or V2 ≥ 3.0 mV, or R wave in V5 or V6 ≥ 3.0 mV 1
• ST-T abnormalities (3 points with digitalis, 1 point without): Typical "strain" pattern of downsloping ST depression with inverted asymmetric T waves in lateral leads 1
• Left atrial abnormality (3 points): Terminal negative portion of P wave in V1 ≥ 0.04 seconds in duration and ≥ 0.1 mV in depth 1
• Left axis deviation (2 points): QRS axis ≤ -30° 1
• QRS duration (1 point): ≥ 0.09 seconds 1
• Intrinsicoid deflection (1 point): Time to peak R wave in V5 or V6 ≥ 0.05 seconds 1

The Romhilt-Estes system shows sensitivity of approximately 10% but incorporates multiple ECG features beyond voltage 2.

Supporting (Non-Diagnostic) Criteria

ST-T Wave Abnormalities

• Lateral ST depression with T wave inversion ("strain pattern") provides major support for LVH diagnosis when voltage criteria are met 1
• ST-T abnormalities are associated with larger left ventricular mass and higher cardiovascular mortality risk compared to voltage criteria alone 1
• These findings alone are insufficient to diagnose LVH without voltage criteria 1

Left Atrial Abnormality

• P wave abnormalities suggesting left atrial enlargement frequently accompany LVH, particularly in hypertensive heart disease 1
• May be the earliest ECG sign of hypertensive heart disease 1
• Should only be used as supporting evidence, not as primary diagnostic criterion 1

Left Axis Deviation

• QRS axis more negative than -30° may accompany LVH 1
• The mechanism is unclear—may reflect hypertrophy itself, subclinical left anterior fascicular block, or age-related changes 1
• Use only to support diagnosis, not as primary criterion 1

QT Interval Prolongation

• Slight QT prolongation often accompanies LVH 1
• May reflect altered ion channel function in hypertrophied myocardium 1
• Consistent with but not diagnostic of LVH 1

Special Situations and Pitfalls

Left Bundle Branch Block (LBBB)

• ECG diagnosis of LVH should generally NOT be attempted in the presence of complete LBBB 1
• If diagnosis is attempted, use QRS duration > 155 ms combined with precordial voltage criteria for reasonable specificity, though sensitivity remains very low 1
• Criteria incorporating S wave in V2 or V3 plus R wave in aVL, V5, or V6 may have value, with suggested thresholds: SV2+SV3+RV5+RV6 > 4 mV, RaVL+SV3 > 3.5 mV (diagnostic accuracy 86-89%) 5

Right Bundle Branch Block (RBBB)

• RBBB reduces S wave amplitude in right precordial leads, decreasing sensitivity of voltage criteria 1
• Specific criteria for RBBB: SV1 > 2 mm, RV5 or V6 > 15 mm, QRS axis left of -30° with SIII > largest R/S in precordial lead > 30 mm 1
• These criteria show sensitivities of 46-68% and specificities of 57-71% 1
• Left atrial abnormality and left axis deviation have enhanced diagnostic value in RBBB 1

Left Anterior Fascicular Block (LAFB)

• R wave amplitude in leads I and aVL are NOT reliable for LVH diagnosis when LAFB is present 1, 6
• LAFB causes larger R waves in I and aVL but deeper S waves in V5 and V6 1, 6
• Use criteria incorporating S wave depth in left precordial leads (V5, V6) for improved detection 1, 6

Critical Clinical Context

Performance Limitations

• All ECG voltage criteria have extremely low sensitivity (1.9-19.2% in most studies) despite high specificity 2
• The prevalence of ECG-detected LVH varies dramatically (1.9-45.3%) depending on which criterion is used 4
• ECG should not be relied upon as the sole method for detecting or excluding LVH 2

Prognostic Value

• Despite poor diagnostic accuracy, ECG-detected LVH is a strong independent predictor of cardiovascular morbidity and mortality 3, 7
• Each 0.1 mV increase in voltage predicts 1.6-3.9% increased CVD mortality risk in women and 1.4-3.0% in men 7
• ST-T abnormalities with voltage criteria confer higher risk than voltage criteria alone 1

Gender Considerations

• Women have different voltage thresholds (Cornell criteria: 2.0 mV vs 2.8 mV for men) 1, 3
• Women with ECG-LVH show particularly high stroke mortality risk 7
• Population attributable fractions for stroke mortality: 15.2% in women vs 12.8% in men 7