What are the diagnostic criteria and treatment options for Left Ventricular Hypertrophy (LVH)?

ECG Criteria for Left Ventricular Hypertrophy

Use multiple validated voltage-based criteria when interpreting ECGs for LVH, as no single criterion is superior, and always adjust for patient demographics including gender, race, age, and body habitus. 1

Primary Voltage-Based Diagnostic Criteria

The following validated criteria should be applied systematically:

Sokolow-Lyon Criterion

• S wave in V1 + R wave in V5 or V6 > 35 mm 2, 3
• Specificity: 85-90% but sensitivity typically <50% 3
• Most accurate in younger, male, Black, and non-obese patients 1

Cornell Voltage Criterion

• Men: S wave in V3 + R wave in aVL > 28 mm 2, 3
• Women: S wave in V3 + R wave in aVL > 20 mm 2, 3
• Gender-specific thresholds improve diagnostic performance 3
• Specificity: 85-90% 2

Cornell Voltage-Duration Product

• Cornell voltage × QRS duration > 2440 mm·ms 2
• Specificity: 85-90% 2

Peguero-Lo Presti Criterion

• Deepest S wave in any lead + S wave in V4 4
• Superior sensitivity (62%) compared to Cornell voltage (35%) with maintained specificity ≥90% 4
• Most recent validated criterion showing improved diagnostic accuracy 4

Romhilt-Estes Point Score System

• ≥5 points = definite LVH; 4 points = probable LVH 2, 3
• Incorporates: QRS amplitude, ST-T abnormalities, left axis deviation, QRS duration, and intrinsicoid deflection 2
• Specificity: 85-90% 2

Supporting ECG Findings That Strengthen Diagnosis

ST-T Wave Abnormalities

• Lateral ST depression with T wave inversion ("strain pattern") strongly supports LVH diagnosis 2, 3
• Associated with larger left ventricular mass and higher cardiovascular risk 2
• Can be used to diagnose LVH even when voltage criteria are not met 1

Left Atrial Abnormality

• P wave changes suggesting left atrial enlargement 2, 3
• Early sign of hypertensive heart disease 2
• Frequently accompanies LVH 3

Additional Features

• Left axis deviation may support diagnosis but should not be used alone 2
• QRS duration prolongation can support the diagnosis 2

Critical Diagnostic Adjustments for Patient Demographics

Age Considerations

• Standard criteria apply only to adults >35 years 3
• QRS voltages decline with increasing age 2
• Diagnosis in highly trained athletes is especially problematic 3

Gender Differences

• Women have lower upper limits of QRS voltage than men 2, 3
• SV3 shows the largest gender difference 3
• Always use gender-specific Cornell criteria 2, 3

Body Habitus

• Obesity dramatically decreases ECG sensitivity despite increased left ventricular mass 2, 3
• Increased distance between heart and recording electrodes reduces voltage 2

Race

• Criteria should be adjusted for race when validated adjustments exist 1

Special Circumstances: Bundle Branch Blocks

Complete Left Bundle Branch Block (LBBB)

• Diagnosis of LVH should generally NOT be attempted in complete LBBB 1, 3
• If diagnosis is necessary, use: QRS duration >155 ms + left atrial abnormality + precordial voltage criteria 3, 5
• LBBB is very rare in healthy individuals and strongly suggests underlying structural cardiovascular disease 5

Right Bundle Branch Block (RBBB)

• Sensitivity of voltage criteria is decreased 3
• Use specific criteria: SV1 >2 mm, RV5/V6 >15 mm, and QRS axis left of -30° with S in lead III 2, 3

Left Anterior Fascicular Block (LAFB)

• R wave amplitude in leads I and aVL are NOT reliable for LVH diagnosis 3
• Instead use: S wave depth in left precordial leads (V5, V6) 3

Implementation Recommendations from AHA/ACCF/HRS

Mandatory Practices

• Use only validated criteria without deviation from validated formulas 1
• Specify which diagnostic criteria were used and which were abnormal 1
• Computer systems should use all criteria supported by valid evidence 1

Terms to Avoid

• Do NOT use the terms "strain," "systolic," or "diastolic" in diagnostic statements 1
• Use "probable," "possible," and "borderline" with caution 1

Diagnostic Confirmation and Follow-up

When ECG is Insufficient

• Echocardiography is the primary confirmatory test 6, 7, 8
• Cardiac MRI is the gold standard for diagnosis and assessment of therapy response 7
• ECG remains useful as a low-cost screening tool in settings where echocardiography is not readily accessible 8

Clinical Context Matters

• Accuracy differs based on pre-test probability: In populations where LVH is unlikely, most positive tests are false positives; in hypertensive populations, most negative tests are false negatives 1
• Even asymptomatic LBBB requires cardiology evaluation given strong association with structural disease 5