Voltage criteria for left ventricular hypertrophy means

8. Ventricular Hypertrophy

Topics for study:

1. Introduction
2. Left Ventricular Hypertrophy (LVH)
3. Right Ventricular Hypertrophy (RVH)
4. Biventricular Hypertrophy

Introductory Information:

The ECG criteria for diagnosing right or left ventricular hypertrophy are very insensitive (i.e., sensitivity ~50%, which means that ~50% of patients with ventricular hypertrophy cannot be recognized by ECG criteria). However, the criteria are very specific (i.e., specificity >90%, which means if the criteria are met, it is very likely that ventricular hypertrophy is present).

Left Ventricular Hypertrophy (LVH)

General ECG features include:

• ≥ QRS amplitude (voltage criteria; i.e., tall R-waves in LV leads, deep S-waves in RV leads)
• Delayed intrinsicoid deflection in V6 (i.e., time from QRS onset to peak R is ≥ 0.05 sec)
• Widened QRS/T angle (i.e., left ventricular strain pattern, or ST-T oriented opposite to QRS direction)
• Leftward shift in frontal plane QRS axis
• Evidence for left atrial enlargement (LAE) (lesson 7)

ESTES Criteria for LVH

("diagnostic", ≥ 5 points; "probable", 4 points)

CORNELL Voltage Criteria for LVH

(sensitivity = 22%, specificity = 95%)

• S in V3 + R in aVL > 24 mm (men)
• S in V3 + R in aVL > 20 mm (women)

Other Voltage Criteria for LVH:

• Limb-lead voltage criteria:
  • R in aVL ≥ 11 mm or, if left axis deviation, R in aVL ≥ 13 mm plus S in III ≥ 15 mm
  • R in I + S in III > 25 mm
• Chest-lead voltage criteria:
  • S in V1 + R in V5 or V6 ≥ 35 mm
• Example 1: (Limb-lead Voltage Criteria; e.g., R in aVL >11 mm; note wide QRS/T angle)
  

• Example 2: (ESTES Criteria: 3 points for voltage in V5, 3 points for ST-T changes)
  

Right Ventricular Hypertrophy

General ECG features include:

• Right axis deviation (> 90 degrees)
• Tall R-waves in RV leads; deep S-waves in LV leads
• Slight increase in QRS duration
• ST-T changes directed opposite to QRS direction (i.e., wide QRS/T angle)
• May see incomplete RBBB pattern or qR pattern in V1
• Evidence of right atrial enlargement (RAE) (lessonVII)

Specific ECG features (assumes normal calibration of 1 mV = 10 mm):

• Any one or more of the following (if QRS duration < 0.12 sec):
  • Right axis deviation (> 90 degrees) in presence of disease capable of causing RVH
  • R in aVR ≥ 5 mm, or
  • R in aVR > Q in aVR
• Any one of the following in lead V1:
  • R/S ratio > 1 and negative T wave
  • qR pattern
  • R gt; 6 mm, or S < 2mm, or rSR' with R' > 10 mm
• Other chest lead criteria:
  • R in V1 + S in V5 (or V6) 10 mm
  • R/S ratio in V5 or V6 < 1
  • R in V5 or V6 < 5 mm
  • S in V5 or V6 > 7 mm
• ST segment depression and T wave inversion in right precordial leads is usually seen in severe RVH such as in pulmonary stenosis and pulmonary hypertension.

Example #1: (note RAD +105 degrees; RAE; R in V1 > 6 mm; R in aVR > 5 mm)

Example #2: (more subtle RVH: note RAD +100 degrees; RAE; Qr complex in V1 rather than qR is atypical)

Example #3: (note: RAD +120 degrees, qR in V1; R/S ratio in V6 < 1)

Biventricular Hypertrophy (difficult ECG diagnosis to make)

In the presence of LAE any one of the following suggests this diagnosis:

• R/S ratio in V5 or V6 < 1
• S in V5 or V6 > 6 mm
• RAD (> 90 degrees)

Other suggestive ECG findings:

• Criteria for LVH and RVH both met
• LVH criteria met and RAD or RAE present

Test your knowledge on lessons 7 and 8!

What is voltage criteria for left ventricular hypertrophy?

What does left ventricular hypertrophy by voltage only mean?

How serious is left ventricular hypertrophy?

Is left ventricular hypertrophy normal?