What are the severe voltage criteria that constitute Left Ventricular Hypertrophy (LVH) on an electrocardiogram (EKG) in pediatric patients?

Pediatric ECG Voltage Criteria for Left Ventricular Hypertrophy

Use the age-specific voltage thresholds from the Davignon criteria, which are the validated North American standard for diagnosing LVH in children based on QRS voltage measurements. 1

Age-Specific Voltage Thresholds for LVH

The following measurements indicate LVH when exceeded (values in millimeters, where 1 mm = 0.1 mV): 1

Primary Voltage Criteria:

RV6 (R wave amplitude in lead V6):

• 0-7 days: >12 mm 1
• 7 days-1 year: >23 mm 1
• 1-3 years: >23 mm 1
• 3-5 years: >25 mm 1

• 5 years: >27 mm 1

SV1 (S wave amplitude in lead V1):

• 0-7 days: >23 mm 1
• 7 days-1 year: >18 mm 1
• 1-3 years: >21 mm 1
• 3-5 years: >22 mm 1

• 5 years: >26 mm 1

SV1 + RV6 (Sokolow-Lyon equivalent):

• 0-7 days: >28 mm 1
• 7 days-1 year: >35 mm 1
• 1-3 years: >38 mm 1
• 3-5 years: >42 mm 1

• 5 years: >47 mm 1

Critical Interpretation Caveats

The ECG has extremely poor sensitivity (13-35%) for detecting true LVH in children, despite high specificity (77-96%). 2, 3 This means:

• A positive ECG finding requires echocardiographic confirmation before making clinical decisions 2, 3
• A negative ECG does not rule out LVH—echocardiography remains necessary if clinical suspicion exists 3, 4
• The positive predictive value is only 29-50%, meaning most "positive" ECGs are false positives 3

Technical Factors Affecting Accuracy

Voltage measurements are significantly influenced by digital sampling rates—higher sampling rates (500-1200 samples/second) yield higher voltage measurements than the original Davignon standards. 1 When modern digital ECG systems are used, the amplitude criteria should be adjusted upward, though specific validated thresholds are not yet established. 1

Gender and racial differences similar to adults exist in children older than 10 years, but validated adjustment criteria are not available. 1

Recommended Clinical Approach

Use ECG voltage criteria only as a screening tool, not a diagnostic tool—always correlate with echocardiographic left ventricular mass measurement when LVH is suspected. 1

• Apply multiple validated criteria rather than relying on a single measurement 1
• Specify which criteria were used and which were abnormal in your interpretation 1
• Avoid terms like "probable," "possible," or "borderline" as they have limited diagnostic accuracy 1
• Do not use the terms "strain," "systolic overload," or "diastolic overload" as they lack accuracy in pediatric populations 1

When Echocardiography is Mandatory

Obtain echocardiography for definitive diagnosis in any child with:

• Positive voltage criteria on ECG 2, 3
• Clinical symptoms suggesting cardiac disease 5
• Hypertension (especially stage 2: BP >160/100 mmHg) 5
• Family history of premature cardiac death or cardiomyopathy 5

Echocardiographic left ventricular mass indexed to body surface area (>51 g/m^2.7) is the gold standard for diagnosing LVH in children. 2, 4