Kriteria LVH

Left Ventricular Hypertrophy ECG Criteria

Through many studies, multiple criteria have been developed to diagnose LVH on an ECG; they are listed below.
Cornell criteria: Add the R wave in aVL and the S wave in V3. If the sum is greater than 28 millimeters in males or greater than 20 mm in females, LVH is present.
Modified Cornell Criteria: Examine the R wave in aVL. If the R wave is greater than 12 mm in amplitude, LVH is present.
Sokolow-Lyon Criteria: Add the S wave in V1 plus the R wave in V5 or V6. If the sum is greater than 35 mm, LVH is present.
Romhilt-Estes LVH Point Score System: If the score equals 4, LVH is present with 30% to 54% sensitivity. If the score is greater than 5, LVH is present with 83% to 97% specificity.

• Amplitude of largest R or S in limb leads ≥ 20 mm = 3 points
• Amplitude of S in V1 or V2 ≥ 30 mm = 3 points
• Amplitude of R in V5 or V6 ≥ 30 mm = 3 points
• ST and T wave changes opposite QRS without digoxin = 3 points
• ST and T wave changes opposite QRS with digoxin = 1 point
• Left Atrial Enlargement = 3 points
• Left Axis Deviation = 2 points
• QRS duration ≥ 90 ms = 1 point
• Intrinsicoid deflection in V5 or V6 > 50 ms = 1 point

References:
1. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric, 6e
2. Surawicz B, et al. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Circulation. 2009;doi:10.1161/CIRCULATIONAHA.108.191095.

 Original from life in the fast lane

Left Ventricular Hypertrophy

Background

• The left ventricle hypertrophies in response to pressure overload secondary to conditions such as aortic stenosis and hypertension.
• This results in increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) and increased S wave depth in the right-sided leads (III, aVR, V1-3).
• The thickened LV wall leads to prolonged depolarisation (increased R wave peak time) and delayed repolarisation (ST and T-wave abnormalities) in the lateral leads.

Criteria for Diagnosing LVH

• There are numerous criteria for diagnosing LVH, some of which are summarised below.
• The most commonly used are the Sokolov-Lyon criteria (S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm).
• Voltage criteria must be accompanied by non-voltage criteria to be considered diagnostic of LVH.

Voltage Criteria

Limb Leads

• R wave in lead I + S wave in lead III > 25 mm
• R wave in aVL > 11 mm
• R wave in aVF > 20 mm
• S wave in aVR > 14 mm

Precordial Leads

• R wave in V4, V5 or V6  > 26 mm
• R wave in V5 or V6 plus S wave in V1 > 35 mm
• Largest R wave plus largest S wave in precordial leads > 45 mm

Non Voltage Criteria

• Increased R wave peak time > 50 ms in leads V5 or V6
• ST segment depression and T wave inversion in the left-sided leads: AKA the left ventricular ‘strain’ pattern

Additional ECG changes seen in LVH

• Left atrial enlargement.
• Left axis deviation.
• ST elevation in the right precordial leads V1-3 (“discordant” to the deep S waves).
• Prominent U waves (proportional to increased QRS amplitude).

LVH by voltage criteria: S wave in V2 + R wave in V5 > 35 mm

LV strain pattern: ST depression and T wave inversion in the lateral leads

Causes of LVH

• Hypertension (most common cause)
• Aortic stenosis
• Aortic regurgitation
• Mitral regurgitation
• Coarctation of the aorta
• Hypertrophic cardiomyopathy

Handy Tips

• Voltage criteria alone are not diagnostic of LVH
• ECG changes are an insensitive means of detecting LVH (patients with clinically significant left ventricular hypertrophy seen on echocardiography may still have a relatively normal ECG)

ECG Examples

Example

Good example of LVH:

• Markedly increased LV voltages: huge precordial R and S waves that overlap with the adjacent leads (SV2 + RV6 >> 35 mm).
• R-wave peak time > 50 ms in V5-6 with associated QRS broadening.
• LV strain pattern with ST depression and T-wave inversions in I, aVL and V5-6.
• ST elevation in V1-3.
• Prominent U waves in V1-3.
• Left axis deviation.

Severe LVH such as this appears almost identical to left bundle branch block — the main clue to the presence of LVH is the excessively high LV voltages. 

Example 2

• There are massively increased QRS voltages — the S waves in V3 are so deep they are literally falling off the page!
• The ST elevation in V1-3 is simply in proportion to the very deep S waves (“appropriate discordance”).
• The LV strain pattern is seen in all leads with a positive R wave (V5-6, I, II, III, aVF).

This ECG was reproduced from Dr Smith’s ECG blog — Dr Smith blog

References

• Edhouse J, Thakur RK, Khalil JM. ABC of clinical electrocardiography. Conditions affecting the left side of the heart. BMJ. 2002 May 25;324(7348):1264-7. Review. PMID: 12028984.

Advanced Reading

• Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography
• Hampton, JR. The ECG In Practice, 6e
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric, 6e
• Wagner, GS. Marriott’s Practical Electrocardiography 12e
• Chan, TC. ECG in Emergency Medicine and Acute Care
• Mattu, A. ECG’s for the Emergency Physician