ECG changes in left ventricular hypertrophy (LVH)

If there is left ventricular hypertrophy then this will result in :

1 a tall R wave (greater than 25mm in V5 or V6), or R plus S greater than 35 mm (1)
2 a deep S in V1 or V2
3 if there is significant left ventricular strain then there are also inverted ! waves in V5 and V6 and possi"le S! depression
# left a$is deviation ma% also "e present
5 &RS ma% "e slightl% prolonged
'otes( 1) a s%stematic review investigating the accurac% of )*+s in the diagnosis of ,V- has "een underta.en
2) /rom the stud% data in primar% care, a negative electrocardiogram result would reduce the t%pical pre0test pro"a"ilit% from 331 to
3112 3n secondar% care the t%pical pre0test pro"a"ilit% of 651 would "e reduced to 631 the authors concluded that electrocardiographic
criteria should not "e used to rule out left ventricular h%pertroph% in patients with h%pertension
Ventricular Hypertrophy LVH - ECG abnormalities that may be observed in patients with LVH
1 Increased QRS voltage (valid in patients >35 years of age).
2 Secondary changes of the ST segent and!or T "aves (Strain pattern ).
3 #eft a$is deviation (is a s%pportive finding& not diagnostic).
' (rolongation of the QT interval (is a s%pportive finding& not diagnostic).
5 (rolongation of the QT interval (is a s%pportive finding& not diagnostic).
) (rolongation of the QRS d%ration.
Voltage criteria used to diagnose left ventricular hypertrophy
Cornell voltage criteria
1 in men: R in aVL + S in C3 >2.8 mV >28mm in !tan"ar" cali#ration$.
2 %n &omen: R in aVL + S in C3 >2.' mV >2'mm in !tan"ar" cali#ration$.
3 (he relia#ility o) Cornell *olta+e criteria "ecrea!e! in the pre!ence o) le)t
anterior )a!cicular #loc,.
Soolow!Lyon criteria
1 S in V1 + R in C- or C.$ >3.-mV >3-mm in !tan"ar"
cali#ration$.
2 R in aVL >1.1 mV >11mm in !tan"ar" cali#ration$.
"dditional voltage criteria proposed for the diagnosis of left ventricular hypertrophy
1 R% + S%%% > 2- mm 2.- mV$ /u#ner0 1123$.
2 R% > 1- mm 1.- mV$ /u#ner0 1123$.
3 %n men0 S &a*e in C3 + R &a*e in aVL > 28mm 2.8mV$ Ca!ale0 118-$.
2 %n &omen0 S &a*e in C3 + R &a*e in aVL > 2'mm 2.'mV$ Ca!ale0 118-$.
- R + S > 11mm 1.1 mV$ in any e3tremity lea" Romhilt0 11.8$.
Secondary S# Segment and # wave changes in left ventricular hypertrophy
1 4epre!!ion o) the 5 point.
2 6p&ar"ly con*e30 "o&n !lopin+ S( !e+ment "epre!!ion.
3 7!ymmetric ( &a*e ne+ati*ity.
$undle branch blocs and the diagnosis of LVH
1 %n the pre!ence o) ri+ht #un"le #ranch #loc, R888$0 the "ia+no!i! o) LVH #ecome! more "i))icult
!ince the amplitu"e o) S &a*e in ri+ht precor"ial lea"! C10 C20 C3$ "ecrea!e!.
2 (he relia#ility o) Cornell *olta+e criteria "ecrea!e! in the pre!ence o) le)t anterior )a!cicular #loc,.
"lthough not universally accepted% the following criteria are proposed for the diagnosis of LVH
in the presence of left bundle branch bloc &L$$$'
1 Le)t atrial a#normality.
2 9RS &i"th > 1.' mili!econ"!.
3 (he !um o) the amplitu"e! o) S &a*e in C2 an" R &a*e in C. > 2-mm 2.-mV$.
2 (he amplitu"e o) S &a*e in C2 i! at lea!t 3' mm 3mV$.
- (he amplitu"e o) S &a*e in C3 i! at lea!t 2- mm 2.-mV$.
. S%% > R%%.
Some of the criteria that are suggested for the diagnosis of LVH in the presence of right bundle
branch bloc &($$$' are
1 (he amplitu"e o) S &a*e in C1 > 2mm '.2 mV$.
2 (he R &a*e amplitu"e in C- or C. > 1- mm 1.-mV$.
3 9RS a3i! i! le)t to the -3' "e+ree!.
2 R% > 11mm 1.1mV$.
- Re+ar"in+ the amplitu"e! o) S &a*e in lea" %%% an" R &a*e in any precor"ial lea"0 the R:S amplitu"e > 3' mm 3 mV$
(eferences
Circulation )**+%,,+-e).,!e)/,. Chest ,+0,1.+-,02!,00. "m Heart 3 ,+421,*4-.*)!.*/.
3 Electrocardiol ,+421,0-,.0!,/*. "m 3 Cardiol ,+4.1..-,*5!,*/.
ECG ,. #he above ECG belongs to a patient with coarctation of the aorta and hypertension. #he terminal half of the 6 wave in
C, is clearly negative and 6 wave in lead 77 is double peaed suggesting left atrial abnormality. #he left ventricular hypertrophy
due to chronic arterial hypertension has resulted in high amplitude ( waves in lead C2 and deep S waves in lead C5 .
#he S# segment depression and asymmetrical negative # waves in leads C. ve C/ denote to left ventricular strain pattern.
ECG ). #he above ECG belongs to a male patient with systemic hypertension% left ventricular dilatation and hypertrophy.
"ccording to the Soolow!Lyon voltage criteria% the sum of the amplitudes of the S wave in C, and ( wave in C. is 85.. mV
&5. mm' and suggests LVH. 7n addition to the voltage criteria% there is also accompanying S# segment depression and
asymmetrically negative # waves . #he rhythm is atrial fibrillation.
ECG 5. #he above ECG belongs to a patient with systemic hypertension and coronary artery disease.
#he ECG shows left ventricular hypertrophy and left atrial abnormality .
ECG 2. #he ECG above belongs to a man with long!standing systemic arterial hypertension and a recently diagnosed adenoma
in right adrenal gland. He needs 2 different medications to control his blood pressure. Still% no increased voltage is observed
in the precordial leads. 9n the other hand% according to the Gubner e:tremity electrode voltage criteria% the sum of the
amplitudes of ( wave in lead 7 and S wave in lead 777 is 8).. mV &). mm'% suggesting LVH in this patient.
ECG .. #he ECG above belongs to a 2* years!old man with hypertension. "ccording to the Soolow!Lyon voltage criteria% the
sum of the amplitudes of S wave in C, or C) and ( wave in C. or C/ is 85.. mV &5. mm' and suggests the presence of LVH.
#his ECG does not show left ventricular strain pattern.
ECG /. #he ECG above belongs to a patient with hypertension and echocardiographically confirmed LVH.
His coronary arteries are normal. #he asymmetrical # wave negativity in the above ECG is not related to myocardial ischemia.
ECG 0. #he ECG above shows right bundle branch bloc &($$$'. His echocardiogram showed septal LVH. 7n the ECG above%
the criteria that suggest LVH are- amplitude of S wave in C, is 8 )mm &*.) mV'1 amplitude of ( wave in C. 8 ,.mm &,.. mV'.
ECG 4. #he ECG above belongs to a patient with systemic arterial hypertension and mitral stenosis.
His echocardiography showed diffuse LVH. Her ECG also suggests LVH.
ECG +. #he ECG above belongs to a patient with hypertension and coronary artery disease. He had undergone coronary artery
bypass graft surgery. ;espite ($$$ &right bundle branch bloc'% his ECG suggests LVH. His echocardiogram showed
concentric &diffuse' LVH.
ECG ,*. #he ECG above belongs to a hypertensive woman with normal coronary arteries and shows anterolateral # wave
negativity and upsloping S# segment depression in leads V2 to V/ .
ECG ,,. #he ECG above belongs to a ., years!old woman with hypertension and normal coronary arteries. "ccording to the
Gubner e:tremity electrode voltage criteria% the sum of the amplitudes of ( wave in lead 7 and S wave in lead 777 is 8).. mV
&). mm'% suggesting LVH in this patient. Echocardiogram confirmed LVH in this patient.
ECG ,). #he ECG above belongs to a ./ years!old hypertensive man with normal coronary arteries.
Less than , mm S# depression % negative # waves and < waves are seen.
ECG ,5. #he ECG above belongs to a 2/ years!old hypertensive man who has echocardiographically confirmed left ventricular
hypertrophy. 7t shows right bundle branch bloc and left anterior fascicular bloc. "ccording to Gubner criteria% there is also left
ventricular hypertophy pattern.
ECG ,2. #he ECG above belongs to a chronic hypertensive man with long!standing uncontrolled hypertension.
His echocardiogram showed left ventricular septal hypertrophy. "ccording to Gubner criteria% the ( amplitude in 7 is 8 ,. mm
&8,.. mV' and suggests the presence of left ventricular hypertrophy.
ECG ,.. #he ECG above belongs to a 00 years!old woman who had never underwent diagnostic coronary angiography.
#here are no signs of old myocardial infarction. Echocardiography shows left ventricular hypertrophy however the ECG
does not give any clues to that.
($$$ impairs the ECG diagnosis of left ventricular hypertrophy.
ECG ,/. #he ECG of a 2. years!old dilated cardiomyopathy patient with normal coronary arteries and prosthetic aortic and
mitral valves. 7n addition to increased voltage the S# segment depression and asymmetrical # wave negativity in lateral leads
show left ventricular strain &strain pattern'. #he rhythm is atrial fibrillation.
ECG ,0. #he ECG above belongs to a woman with long!standing chronic systemic arterial hypertension.
She had e:perienced syncope 2 days ago due to acute pulmonary embolism.
#he ECG shows accelerated =unctional rhythm. Heart rate &ventricular rate' is about 45>minute. #here is also ectopic atrial
tachycardia. #he atrial rate is about ,/.>minute. 6 waves are not related to the ?(S comple:es- complete "V bloc.
#he increased voltage in this ECG suggests left ventricular hypertrophy.
ECG ,4. #he ECG above belongs to a 2+ years!old diabetic man with long!standing &,0 years' hypertension.
ECH9cardiography showed diffuse left ventricular hypertrophy.
#his ECG is compatible with left ventricular hypertrophy according to both the Gubner and the Cornell voltage criteria.
ECG ,+. #he ECG above belongs to a 2 years!old boy who had been operated for "trioVentricular Canal ;efect &"VC;>"VS;'.
He had also undergone prosthetic mitral valve implantation.
His ECH9cardiogram showed a dilated left ventricle.
#his ECG shows right bundle branch in association with left ventricular hypertrophy.
6ediatric cardiologist ;r. @ahmut Godemir has donated this ECG to our website.
ECG )*. #he ECG above belongs to an apparently healthy% 4 years!old lean boy.
His ECH9cardiogram is normal- no left ventricular hypertrophy.
#he ECG of a lean person with a low body mass inde: may show increased voltage as a normal variant.
6ediatric cardiologist ;r. @ahmut Godemir has donated the above ECG to our website.
ECG ),. #he ECG above belongs to an apparently healthy% ,, years!old lean boy. His echocardiogram is normal.
#he ECG of a lean person with low body mass inde: may show increased voltage as a normal variant.
6ediatric cardiologist ;r. @ahmut Godemir has donated the above ECG to our website.