How Left Ventricular Hypertrophy is Diagnosed on EKG
LVH is diagnosed on EKG primarily using QRS voltage criteria, with the Sokolow-Lyon Index (SV1 + RV5 or RV6 ≥ 3.5 mV) and Cornell Voltage Criteria (SV3 + RaVL > 2.8 mV in men, > 2.0 mV in women) being the most widely recommended by the American College of Cardiology. 1
Primary Voltage Criteria
The diagnosis relies on measuring increased QRS voltages across specific leads 2:
- Sokolow-Lyon Index: S wave in V1 + R wave in V5 or V6 ≥ 3.5 mV 1
- Cornell Voltage:
- Additional voltage criteria: R wave in aVL > 1.1 mV, R wave in V5 or V6 > 2.6 mV, or sum of R waves in V5 + V6 > 4.5 mV 1
These voltage criteria have high specificity (85-90%) but low sensitivity (usually <50%), meaning they rarely give false positives but miss many true cases of LVH 2.
Romhilt-Estes Point Score System
This comprehensive 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, S wave in V1 or V2 ≥ 3.0 mV, or R wave in V5 or V6 ≥ 3.0 mV 1
- The system also incorporates QRS axis, QRS duration, QRS onset-to-peak time, and P and ST-T morphology abnormalities 2
Supporting Features (Not Diagnostic Alone)
These findings strengthen the diagnosis when voltage criteria are met but should not be used independently 2:
- ST-T wave abnormalities: Lateral ST depression with T wave inversion (previously called "strain pattern") provides major support and indicates larger left ventricular mass with higher cardiovascular risk 2, 1
- Left atrial abnormality: P wave changes suggesting left atrial enlargement frequently accompany LVH, particularly in hypertensive heart disease 2, 1
- Left axis deviation: QRS axis more negative than -30° may accompany LVH 2, 1
- QT prolongation: Slight QT prolongation often accompanies LVH 2, 1
Critical Diagnostic Pitfalls
Age Considerations
QRS voltages decline with increasing age, and standard voltage criteria apply only to adults older than 35 years 2. In the 16-35 age group, voltage criteria have low accuracy, and diagnosis in highly trained athletes is especially problematic 2.
Gender Differences
Women have slightly lower upper limits of QRS voltage than men, with SV3 showing the largest difference 2. Gender-specific criteria (like Cornell) improve diagnostic performance 2.
Body Habitus
Obesity dramatically decreases ECG sensitivity for LVH detection despite being associated with increased left ventricular mass by echocardiography 2, 3.
Bundle Branch Blocks and Fascicular Blocks
In complete left bundle branch block (LBBB), ECG diagnosis of LVH should generally NOT be attempted 1. If attempted, use QRS duration > 155 ms combined with precordial voltage criteria 1.
In right bundle branch block (RBBB), specific criteria can be used: SV1 > 2 mm, RV5 or V6 > 15 mm, and QRS axis left of -30° with SIII > largest R/S in precordial lead > 30 mm 1.
In left anterior fascicular block (LAFB), R wave amplitude in leads I and aVL are NOT reliable for LVH diagnosis 1, 4. Instead, use criteria incorporating S wave depth in left precordial leads (V5, V6) 1, 4.
Practical Application Strategy
Apply multiple criteria rather than relying on a single criterion, as only 11.2% of patients with LVH by either Cornell or Sokolow-Lyon criteria meet both 2. The data suggest that automated systems should apply multiple criteria and specify which criteria are used in making the diagnosis 2.
When voltage criteria are borderline, the presence of ST-T abnormalities provides strong support for the diagnosis and indicates higher cardiovascular risk 2.