Left Ventricular Hypertrophy (LVH) ECG Review

Left ventricular hypertrophy 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; thus the amplitude of the QRS complex, representing ventricular depolarization, is increased.

Likewise, when the myocardium is abnormally thickened, and electrical activity takes longer to traverse throughout the whole heart, 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 that 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, and distinguishing them from those during a myocardial infarction is important, though often difficult. The typical pattern with LVH includes deviation of the ST segment in the opposite direction of the QRS complex (discordance), and a typical T wave inversion pattern is present, as seen in the image here:

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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

ECG Examples:

• Left Ventricular Hypertrophy (LVH) ECG (Example 1)
• Left Ventricular Hypertrophy (LVH) ECG (Example 2)
• Left Ventricular Hypertrophy (LVH) ECG (Example 3)
• Left Ventricular Hypertrophy (LVH) ECG (Example 4)
• Left Ventricular Hypertrophy (LVH) with Strain Pattern ECG (Example 1)
• Left Ventricular Hypertrophy (LVH) with Strain Pattern ECG (Example 2)

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.