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

ECG Criteria for Left Ventricular Hypertrophy

The most widely used and validated ECG criteria for diagnosing LVH 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 low sensitivity (typically <50%). 1, 2

Primary Voltage-Based Criteria

The AHA/ACCF/HRS guidelines establish several validated voltage criteria for LVH diagnosis 1:

Most Common Criteria

• Sokolow-Lyon criterion: SV1 + RV5 or RV6 >35 mm (>3.5 mV) 1, 2
• Cornell voltage: SV3 + RaVL >28 mm in men, >20 mm in women 1, 2
• Cornell voltage-duration product: Cornell voltage × QRS duration >2440 mm·ms 2, 3
• RaVL alone: >11 mm (>1.1 mV) 3

Additional Voltage Criteria

• R wave in aVL + S wave in V3 (alternative Cornell formulation) 1
• R or S wave in any limb lead >20 mm 1
• S wave in V1 or V2 >30 mm 1
• R wave in V5 or V6 >30 mm 1

Romhilt-Estes Point Score System

This comprehensive scoring system incorporates multiple ECG features beyond voltage 1, 2:

• QRS amplitude criteria (3 points if met)
• ST-T wave abnormalities (secondary ST-T changes: 3 points without digitalis, 1 point with digitalis) 1, 2
• Left atrial abnormality (3 points) 1, 2
• Left axis deviation (≥-30°: 2 points) 1, 2
• QRS duration (≥0.09 seconds: 1 point) 1, 2
• Intrinsicoid deflection in V5 or V6 (≥0.05 seconds: 1 point) 1, 2

A score of ≥5 points indicates definite LVH; 4 points indicates probable LVH. 1, 2

Supporting ECG Findings That Strengthen LVH Diagnosis

Beyond voltage criteria alone, these findings significantly support LVH diagnosis 1, 2:

• ST-T wave abnormalities (ST depression and T wave inversion in lateral leads) indicate more severe LVH, larger left ventricular mass, and higher cardiovascular risk 1, 2
• Left atrial enlargement (P wave duration >0.12 seconds in lead II, or biphasic P in V1 with negative terminal portion >0.04 seconds) may be the earliest ECG sign of hypertensive heart disease, appearing even before voltage criteria are met 2, 3
• QRS duration prolongation (often with incomplete left bundle branch block pattern) reflects increased ventricular wall thickness and intramural fibrosis 1
• Left axis deviation (QRS axis ≥-30°) supports but should not be used alone for diagnosis 1, 2

Critical Performance Characteristics

Understanding the limitations of ECG criteria is essential for proper interpretation 1:

• Sensitivity is generally poor: 6-50% across all criteria, meaning ECG misses most cases of true LVH 1, 4
• Specificity is high: 85-90%, meaning positive findings are usually reliable 1
• Different criteria rarely agree: Only 11.2% of hypertensive patients with LVH by either Cornell or Sokolow-Lyon criteria meet both criteria simultaneously 1
• Multiple criteria should be applied: Automated systems should evaluate several criteria because their diagnostic value may be additive 1

Factors That Significantly Affect ECG Voltage Measurements

Age Effects

• QRS voltages decline with increasing age 1, 2
• Standard criteria apply best to adults >35 years old 1, 2
• Diagnosis in ages 16-35 years has particularly low accuracy 1
• Sensitivity increases with age (p<0.001) 4

Gender Effects

• Women have slightly lower upper limits of QRS voltage than men 1, 2
• SV3 shows the largest gender difference 1
• Gender-specific thresholds improve diagnostic performance 1, 2
• ECG sensitivity for LVH is marginally lower in women (5.6%) than men (9.0%) 4

Body Habitus Effects

• Obesity paradoxically decreases QRS voltage despite increasing actual left ventricular mass, due to increased distance between heart and chest wall electrodes 1, 5
• Obesity is inversely associated with ECG sensitivity (p<0.05) 4
• In severe obesity (BMI >50), voltage criteria become particularly unreliable and may appear falsely "borderline" 5
• ECG criteria should not be relied upon alone in severely obese patients 5

Race Effects

• QRS voltages are influenced by race, though specific adjustments are not well-standardized 1
• ECG sensitivity for LVH in hypertensive Caucasians is particularly low (10-20%) 3

Smoking Effects

• Smoking is inversely related to ECG sensitivity for LVH (p=0.001) 4

LVH Diagnosis in Specific Clinical Scenarios

With Left Bundle Branch Block (LBBB)

• Complete LBBB makes LVH diagnosis extremely difficult and should generally not be attempted 1, 2
• The evidence is conflicting, and diagnosis should be made with caution 1
• In hypertensive patients with complete LBBB, standard ECG criteria show significant decrease in both sensitivity and specificity 6

With Right Bundle Branch Block (RBBB)

• Incomplete RBBB reduces sensitivity of voltage criteria by decreasing S-wave amplitude in right precordial leads 5, 2
• Criteria that may still be useful include: SV1 >2 mm, RV5/V6 >15 mm, and QRS axis left of -30° with S wave in lead III 2
• Incomplete RBBB in isolation is generally benign and does not require specific workup 5

In Hypertensive Patients

• ECG should be part of routine evaluation of all hypertensive patients 3
• Sokolow-Lyon index (SV1 + RV5 or RV6 >3.5 mV or >38 mm) is commonly used 3
• Marked repolarization abnormalities (ST depression, T wave inversion) indicate more severe LVH and higher cardiovascular risk 3
• LVH detected by ECG is an independent predictor of cardiovascular events, particularly in patients >55 years old 3

In Athletes

• Diagnosis of LVH in highly trained athletes is especially problematic due to physiologic hypertrophy 1
• Echocardiography distinguishes physiological hypertrophy (normal chamber size, normal diastolic filling) from pathological LVH (impaired diastolic filling, slow isovolumic relaxation) 5

Common Pitfalls and How to Avoid Them

Day-to-Day Variability

• Voltage measurements vary from day to day and with electrode placement 1, 5
• A single borderline reading often doesn't warrant concern 5
• Terms like "borderline" and "minimal" should be used with caution as they have limited diagnostic accuracy 5, 2

When to Proceed to Echocardiography

Echocardiography is indicated if ANY of the following are present 5:

• Stage 2 hypertension (BP >160/100 mmHg)
• Signs or symptoms suggesting target-organ damage
• Positive family history for premature cardiac death
• Age >65 years with hypertension
• Borderline ECG findings with stage 1 hypertension (140-159/90-99 mmHg)

Distinguishing Hypertension from Hypertrophic Cardiomyopathy

• ECG findings favoring simple hypertension (not HCM): normal ECG or isolated voltage increase without repolarization abnormality 3
• Wall thickness >13 mm on echocardiography warrants evaluation for hypertrophic cardiomyopathy 5
• Regression of LVH with strict blood pressure control (<130 mmHg) for 6-12 months favors simple hypertension 3

Prognostic Significance

• LVH detected by ECG independently predicts cardiovascular events in observational studies and clinical trials 3
• Regression of left ventricular mass assessed by ECG predicts lower risk of major cardiovascular events 3
• ST-T abnormalities with LVH indicate larger left ventricular mass and higher cardiovascular risk 1, 2, 3
• Left atrial enlargement is associated with increased risk of atrial fibrillation, cardiovascular disease, and death 3