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

ECG Criteria for Left Ventricular Hypertrophy

Primary Voltage-Based Criteria

Use the Sokolow-Lyon criterion (SV1 + RV5 or RV6 ≥ 35 mm) or Cornell voltage criterion (SV3 + RaVL > 28 mm for men, > 20 mm for women) as your first-line ECG criteria for diagnosing LVH, recognizing that while specificity is high (85-90%), sensitivity is low (typically <50%). 1, 2

The most commonly validated voltage criteria include:

• Sokolow-Lyon Index: 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 1
• RaVL alone: > 11 mm 3

Romhilt-Estes Point Score System

Apply the Romhilt-Estes scoring system when you need a comprehensive assessment, as it incorporates multiple ECG features beyond voltage alone. 1, 2

Points are assigned as follows:

• Voltage criteria (any of the following): 3 points
  • Limb lead: R wave in aVL > 11 mm, R wave in aVF > 20 mm, or S wave in aVR > 14 mm
  • Precordial: S wave in V1 or V2 ≥ 30 mm, or R wave in V5 or V6 ≥ 30 mm
• ST-T abnormalities: 3 points (without digitalis) or 1 point (with digitalis) 2
• Left atrial abnormality: 3 points 2
• Left axis deviation (≥ -30°): 2 points 2
• QRS duration ≥ 120 ms: 1 point 2
• Intrinsicoid deflection in V5 or V6 ≥ 50 ms: 1 point 2

Interpretation: ≥ 5 points = definite LVH; 4 points = probable LVH 2

Supporting ECG Features That Strengthen the Diagnosis

Beyond voltage criteria, look for these additional findings that increase diagnostic confidence and indicate higher cardiovascular risk:

• ST-T wave abnormalities: Lateral ST depression with T wave inversion ("strain pattern") strongly supports LVH and indicates larger left ventricular mass with worse prognosis 1, 2
• Left atrial abnormality: P wave changes suggesting left atrial enlargement, particularly common in hypertensive heart disease 1, 2
• Left axis deviation: May support diagnosis but should not be used in isolation 1
• QRS duration prolongation: Often accompanies LVH 1

Critical Adjustments for Patient Demographics

Always adjust your interpretation based on age, gender, race, and body habitus, as these factors significantly affect QRS voltages independent of actual left ventricular mass. 1, 2

• Age: Standard criteria apply best to adults over 35 years; QRS voltages decline with increasing age 1, 2
• Gender: Women have lower upper limits of QRS voltage than men, with SV3 showing the largest difference; use gender-specific Cornell criteria 1, 2
• Body habitus: Obesity dramatically decreases ECG sensitivity despite increasing actual left ventricular mass due to increased distance between heart and electrodes 2, 4
• Race: Apply race-specific adjustments when validated adjustments exist 1

Special Circumstances: Bundle Branch Blocks

Complete Left Bundle Branch Block (LBBB)

Generally do NOT attempt to diagnose LVH in the presence of complete LBBB, as the diagnostic accuracy is severely compromised. 1, 2, 5

If diagnosis is absolutely necessary:

• Use QRS duration > 155 ms combined with left atrial abnormality and precordial voltage criteria 1, 2
• In one study of hypertensive patients with CLBBB, Sokolow-Lyon voltage ≥ 30 mm showed the best performance with sensitivity 22.2% and specificity 88.3%, though this remains suboptimal 5
• Research using cardiac MRI suggests SV2 + SV3 + RV5 or RV6 > 40 mm may have diagnostic value, but requires validation 6

Right Bundle Branch Block (RBBB)

In RBBB, voltage criteria sensitivity decreases, but you can still use specific modified criteria. 1, 2

Apply these criteria:

• SV1 > 2 mm 1, 2
• RV5 or RV6 > 15 mm 1, 2
• QRS axis left of -30° with S in lead III > largest R/S in precordial lead > 30 mm 1, 2

Left Anterior Fascicular Block (LAFB)

Do not rely on R wave amplitude in leads I and aVL for LVH diagnosis in LAFB; instead use S wave depth in left precordial leads (V5, V6). 2

Implementation Recommendations

Specify which diagnostic criteria you used and which were abnormal in your ECG interpretation, and apply multiple validated criteria rather than relying on a single criterion. 1

Key principles:

• Use only validated criteria without deviation from validated formulas 1
• Computer interpretation systems should apply all criteria supported by valid evidence 1
• No single criterion is superior; multiple criteria may be additive in diagnostic value 3
• Only 11.2% of patients meeting either Cornell or Sokolow-Lyon criteria meet both, highlighting the complementary nature of different criteria 3

Common Pitfalls and Caveats

Understand that ECG has high specificity (85-90%) but very poor sensitivity (6-50%) for detecting true LVH, meaning many patients with actual LVH will have normal ECGs, while positive findings usually indicate true disease. 4, 7

Critical limitations to recognize:

• In populations where LVH is unlikely, most positive ECG tests are false positives 1
• In hypertensive populations, most negative ECG tests are false negatives 1
• Day-to-day variation in voltage measurements and electrode placement can affect results 4
• Terms like "borderline" and "minimal" have limited diagnostic accuracy and should be used with caution 1, 4
• Diagnosis in highly trained athletes is especially problematic, as physiologic hypertrophy can mimic pathologic LVH 2

When to Confirm with Echocardiography

Obtain echocardiography for confirmation when ECG shows borderline findings and any of the following are present: stage 2 hypertension (BP >160/100 mmHg), signs or symptoms of target-organ damage, family history of premature cardiac death, or age >65 years with hypertension. 4

Echocardiography will distinguish:

• Physiological hypertrophy (athlete's heart): Increased wall thickness with normal chamber size and normal diastolic filling 4
• Pathological LVH (hypertension): Increased wall thickness with impaired diastolic filling and slow isovolumic relaxation 4
• Hypertrophic cardiomyopathy: Wall thickness >13 mm warrants specific evaluation 4