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Left Ventricular Hypertrophy ECG

Left ventricular hypertrophy (LVH) can be diagnosed on ECG with good specificity. When the myocardium is hypertrophied, there is a larger mass of myocardium for electrical activation to pass through and thus the amplitude of the QRS complex (ventricular depolarization) is increased.

Likewise, when the myocardium as abnormally thickened and electrical activity takes longer to traverse throughout the whole heart, thus the duration of the QRS complex may be widened. This is referred to as "LVH with QRS widening". Also, repolarization may be affected via similar mechanisms which can result in abnormal ST segments or T waves. This is referred to as "LVH with strain" or "LVH with repolarization abnormality".

At times these repolarization abnormalities can mimic ischemic ST changes, so distinguishing them from those during a myocardial infarction is important, though often difficult. The typical pattern with left ventricular hyertrophy includes deviation of the ST segment in the opposite direction of the QRS complex (discordance) and a typical T wave inversion pattern is present (see image below).

LVH-repolarizationECG

Left Ventricular Hypertrophy (LVH) - ECG Criteria

Through many studies, multiple criteria have been developed to diagnose LVH on an ECG which are below.

Cornell criteria: Add the R wave in aVL and the S wave in V3. If the sum is > 28 mm in males or > 20 mm in females, then LVH is present.

Modified Cornell Criteria: Examine the R wave in aVL. If the R wave is > 12 mm in amplitude, then LVH is present.

Sokolow-Lyon Criteria: Add the S wave in V1 plus the R wave in V5 or V6. If the sum is > 35 mm, then LVH is present.

Romhilt-Estes LVH Point Score System:

If score = 4, then LVH present with 30-54% sensitivity. If score > 5, then LVH is present with 83-97% specificity. 

Amplitude of largest R or S in limb leads >20 mm

Amplitude of S in V1 or V2 > 30 mm

Amplitude of R in V5 or V6 > 30 mm

ST and T wave changes opposite QRS without digoxin

ST and T wave changes opposite QRS with digoxin

Left Atrial Enlargement

Left Axis Deviation

QRS duration > 90 milliseconds

Intrinsicoid deflection in V5 or V6 > 50 millisecond

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ECG Examples:

Related Links:

ECG Review: Hypertrophic Obstructive Cardiomyopathy

Topic Review: Hypertrophic Obstructive Cardiomyopathy

References:

1. Surawicz B et al. ACC/AHA recommendations for the standardization and interpretation of the electrocardiogram. Circulation. 2009;119:e235-240.

2. Chou's Electrocardiography in Clinical Practice: Adult and Pediatric, 6e

By Steven Lome

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