ECG abnormalities that may be observed in patients with LVH

  Increased QRS voltage (valid in patients >35 years of age).

  Secondary changes of the ST segment and/or T waves ( Strain pattern ).

  Left axis deviation (is a supportive finding, not diagnostic).

  Prolongation of the QT interval (is a supportive finding, not diagnostic).

  Prolongation of the QT interval (is a supportive finding, not diagnostic).

  Prolongation of the QRS duration.




Voltage criteria used to diagnose left ventricular hypertrophy

  Cornell voltage criteria.

 
Sokolow-Lyon criteria.



Cornell voltage criteria

  In men: R in aVL + S in C3 >2.8 mV (>28 mm in standard calibration).

  In women: R in aVL + S in C3 >2.0 mV (>20 mm in standard calibration).

  The reliability of Cornell voltage criteria decreases in the presence of left anterior fascicular block.




Sokolow-Lyon criteria (valid above the age of 30)

  S in V1 + R in C5 (or C6) >3.5 mV ( >35 mm in standard calibration).

  R in aVL >1.1 mV ( >11 mm in standard calibration).

  In persons younger than 30 years of age, Sokolow-Lyon criteria is frequently seen despite the absence of

      left ventricular hypertrophy. Therefore, it is not suitable for ages below 30.




Additional voltage criteria proposed for the diagnosis of left ventricular hypertrophy

  RI + SIII > 25 mm (2.5 mV) (Gubner, 1943).

  RI > 15 mm (1.5 mV) (
Gubner, 1943).

  In men, S wave in C3 + R wave in aVL > 28mm (2.8mV) (
Casale, 1985).

  In women, S wave in C3 + R wave in aVL > 20mm (2.0mV) (
Casale, 1985).

  R + S > 19mm (1.9 mV) in any extremity lead (
Romhilt, 1968).



Secondary ST segment and T wave changes in left ventricular hypertrophy

  Depression of the J point.

  Upwardly convex, downsloping ST segment depression.

  Asymmetric T wave negativity.




Bundle branch blocks and the diagnosis of LVH

  In the presence of right bundle branch block (RBBB), the diagnosis of LVH becomes more difficult

      since the amplitude of S wave in right precordial leads (C1, C2, C3) decreases.

  The reliability of Cornell voltage criteria decreases in the presence of left anterior fascicular block.




Although not universally accepted, the following criteria are proposed for the diagnosis of LVH
in the presence of left bundle branch block (LBBB)


  Left atrial abnormality.

  QRS width > 160 miliseconds.

  The sum of the amplitudes of S wave in C2 and R wave in C6 > 45mm (4.5mV).

  The amplitude of S wave in C2 is at least 30 mm (3mV).

  The amplitude of S wave in C3 is at least 25 mm (2.5mV).

  SII > RII.




Some of the criteria that are suggested for the diagnosis of LVH
in the presence of right bundle branch block (RBBB) are


  The amplitude of S wave in C1 > 2mm (0.2 mV).

  The R wave amplitude in C5 or C6 > 15 mm (1.5mV).

  QRS axis is left to the -30 degrees.

  RI > 11mm (1.1mV).

  Regarding the amplitudes of S wave in lead III and R wave in any precordial lead,

      the R/S amplitude > 30 mm (3 mV)


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References

  Circulation 2009,119:e251-e261.

  Chest 1971;59:174-177.

  Am Heart J 1984;108:502-506.

  J Electrocardiol 1984;17:157-160.

  Am J Cardiol 1985;55:103-106.





ECG 1. The above ECG belongs to a patient with coarctation of the aorta and hypertension.
The terminal half of the P wave in
C1
is clearly negative and P wave in lead II is double peaked suggesting left atrial abnormality. The left ventricular hypertrophy
due to chronic arterial hypertension has resulted in
high amplitude R waves in lead C4 and deep S waves in lead C3 .
The ST segment depression and asymmetrical negative T waves in leads C5 ve C6 denote to left ventricular strain pattern.


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ECG 2. The above ECG belongs to a male patient with systemic hypertension, left ventricular dilatation and hypertrophy.
According to the Sokolow-Lyon voltage criteria, the sum of the amplitudes of
the S wave in C1 and R wave in C5 is >3.5 mV
(35 mm) and suggests LVH. In addition to the voltage criteria, there is also accompanying
ST segment depression and
asymmetrically negative T waves
. The rhythm is atrial fibrillation.

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ECG 3. The above ECG belongs to a patient with systemic hypertension and coronary artery disease.
The ECG shows left ventricular hypertrophy and left atrial abnormality .


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ECG 4. The ECG above belongs to a man with long-standing systemic arterial hypertension and a recently diagnosed adenoma
in right adrenal gland. He needs 4 different medications to control his blood pressure. Still, no increased voltage is observed
in the precordial leads. On the other hand, according to the Gubner extremity electrode voltage criteria, the sum of the
amplitudes of
R wave in lead I and S wave in lead III is >2.5 mV (25 mm), suggesting LVH in this patient.

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ECG 5. The ECG above belongs to a 40 years-old man with hypertension. According to the Sokolow-Lyon voltage criteria, the
sum of the amplitudes of
S wave in C1 or C2 and R wave in C5 or C6 is >3.5 mV (35 mm) and suggests the presence of LVH.
This ECG does not show left ventricular strain pattern.


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ECG 6. The ECG above belongs to a patient with hypertension and echocardiographically confirmed LVH.
His coronary arteries are normal. The
asymmetrical T wave negativity in the above ECG is not related to myocardial ischemia.

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ECG 7. The ECG above shows right bundle branch block (RBBB). His echocardiogram showed septal LVH. In the ECG above,
the criteria that suggest LVH are: amplitude of S wave in C1 is > 2mm (0.2 mV); amplitude of R wave in C5 > 15mm (1.5 mV).


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ECG 8. The ECG above belongs to a patient with systemic arterial hypertension and mitral stenosis.
His echocardiography showed diffuse LVH. Her ECG also suggests LVH.


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ECG 9. The ECG above belongs to a patient with hypertension and coronary artery disease. He had undergone coronary artery
bypass graft surgery. Despite RBBB (right bundle branch block), his ECG suggests LVH. His echocardiogram showed
concentric (diffuse) LVH.


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ECG 10. The ECG above belongs to a hypertensive woman with normal coronary arteries and shows
anterolateral T wave
negativity
and upsloping ST segment depression in leads V4 to V6 .

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