Is the aVR lead useful for diagnosing left ventricular hypertrophy on an electrocardiogram?

aVR Lead in Left Ventricular Hypertrophy Diagnosis

The aVR lead is NOT included in standard ECG criteria for diagnosing left ventricular hypertrophy and should not be used for this purpose. 1

Standard ECG Criteria for LVH (Without aVR)

The established voltage criteria for LVH diagnosis do not incorporate the aVR lead 1:

Primary Voltage Criteria

• Sokolow-Lyon Index: S wave in V1 + R wave in V5 or V6 ≥ 3.5 mV 1
• Cornell Voltage Criteria:
  • Men: S wave in V3 + R wave in aVL > 2.8 mV 1
  • Women: S wave in V3 + R wave in aVL > 2.0 mV 1
• R wave in aVL > 1.1 mV is a standalone criterion with excellent specificity (98.3%) though modest sensitivity (19.6%) 2
• R wave in V5 or V6 > 2.6 mV 1

Why aVR Is Not Used for LVH

The aVR lead has a unique spatial orientation that points toward the right shoulder and away from the left ventricle 3. While inverted aVR (–aVR) has proven useful for detecting exercise-induced ischemia and left main coronary disease because it aligns with the LV axis 3, it has never been validated or incorporated into diagnostic criteria for LVH.

Clinical Algorithm for LVH Diagnosis

Use this stepwise approach 1, 2:

1. First, measure R wave in aVL:

   • If < 0.5 mV: LVH excluded 2
   • If > 1.0 mV: LVH confirmed 2
   • If 0.5-1.0 mV: Proceed to step 2 2

2. Apply Cornell Voltage or Sokolow-Lyon criteria 1, 4

3. Consider Romhilt-Estes point system (≥5 points = definite LVH, 4 points = probable LVH) 1

Supporting Features (Not Diagnostic Alone)

• Lateral ST depression with T wave inversion 1
• Left atrial abnormality 1, 5
• Left axis deviation (QRS axis more negative than -30°) 1
• QT interval prolongation 1

Critical Pitfalls

In Left Anterior Fascicular Block (LAFB): R-wave amplitude in leads I and aVL are NOT reliable for LVH diagnosis 1, 6. The superior and posterior QRS vector shift in LAFB artificially increases R waves in aVL 6, 7. Instead, use criteria incorporating S-wave depth in left precordial leads (V5, V6) 1, 6.

In Complete LBBB: ECG diagnosis of LVH should generally NOT be attempted, but if necessary, use QRS duration > 155 ms combined with precordial voltage criteria 1

In RBBB: Use specific modified criteria: SV1 > 2 mm, RV5 or V6 > 15 mm, and QRS axis left of -30° 1

Performance Characteristics

Among all criteria, Cornell voltage and Cornell product demonstrate the best overall diagnostic accuracy (AUC 0.678-0.71) 4, 8. The R wave in aVL alone performs remarkably well in women, Caucasians, and with right bundle branch block, but decreases in myocardial infarction 2. Traditional criteria have high specificity (78-100%) but poor sensitivity (9-60%) 4, 8, 9.