ECG Criteria for Left Ventricular Hypertrophy
Use multiple validated voltage-based criteria simultaneously when diagnosing LVH on ECG, as no single criterion is superior and their diagnostic value is additive. 1, 2
Primary Voltage Criteria
The most commonly used and validated criteria include:
- Sokolow-Lyon Index: SV1 + RV5 or RV6 ≥ 35 mm (≥3.5 mV) 1, 2
- Cornell Voltage Criteria:
- RaVL alone: > 11 mm 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. 3, 2 Importantly, only 11.2% of patients meeting either Cornell or Sokolow-Lyon criteria will meet both, highlighting why multiple criteria should be applied. 3, 1
Enhanced Criteria Using QRS Duration
Cornell Product (Cornell voltage × QRS duration > 2440 mm·ms) significantly improves diagnostic accuracy over voltage alone and has the highest overall accuracy among ECG criteria. 2, 4, 5
Romhilt-Estes Point Score System
This scoring system incorporates multiple ECG features beyond voltage: 1, 2
The system includes QRS amplitude, ST-T abnormalities, left axis deviation, QRS duration, intrinsicoid deflection, and P-wave changes. 3, 2
Critical Supporting Features
- ST-T wave abnormalities (lateral ST depression with T wave inversion) strongly support LVH diagnosis and indicate larger left ventricular mass with higher cardiovascular risk 1, 2, 6
- Left atrial abnormality (P-wave changes) frequently accompanies LVH and may be the earliest ECG sign of hypertensive heart disease 1, 2, 6
- QRS duration prolongation supports the diagnosis 2
Age, Gender, and Body Habitus Adjustments
Age considerations: Standard voltage criteria apply only to adults >35 years old; diagnosis in younger patients (16-35 years) and highly trained athletes has low accuracy. 3, 1
Gender-specific thresholds are essential: Women have lower upper limits of QRS voltage than men, particularly for SV3, and gender-adjusted criteria improve diagnostic performance. 3, 1, 2
Obesity dramatically decreases ECG sensitivity for LVH despite increasing actual left ventricular mass, due to the insulating effect of adipose tissue. 3, 2
Special Circumstances: Bundle Branch Blocks
Complete Left Bundle Branch Block (LBBB)
ECG diagnosis of LVH should generally NOT be attempted in complete LBBB. 1, 2 If diagnosis is necessary, use: QRS duration >155 ms combined with left atrial abnormality and precordial voltage criteria. 1, 2
Right Bundle Branch Block (RBBB)
Voltage criteria sensitivity is decreased, but use: 1, 2
- SV1 > 2 mm
- RV5 or V6 > 15 mm
- QRS axis left of -30° with SIII > largest R/S in precordial lead > 30 mm
Left Anterior Fascicular Block (LAFB)
R wave amplitude in leads I and aVL are unreliable; instead use criteria incorporating S wave depth in left precordial leads (V5, V6). 1
Implementation Algorithm
- Measure all validated voltage criteria (Sokolow-Lyon, Cornell, RaVL) and specify which criteria are used 3, 1
- Calculate Cornell Product for highest diagnostic accuracy 2, 4
- Assess for supporting features: ST-T abnormalities, left atrial abnormality, QRS prolongation 1, 2
- Apply gender-specific cutoffs 1, 2
- Consider age and body habitus when interpreting results 3, 1
- Use only validated criteria without modification from tested formulas 3, 2
Critical Pitfalls to Avoid
- Do not rely on a single criterion: Different criteria identify different patient subsets 3, 1
- Do not use standard criteria in patients <35 years without recognizing the high false-positive rate 3, 1
- Do not ignore gender differences: Using male cutoffs in women reduces specificity 3, 1
- Recognize that negative ECG does not exclude LVH: In hypertensive populations, most negative tests are false negatives due to low sensitivity 2
- In populations where LVH is unlikely, most positive tests are false positives despite high specificity 2