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 T waves in V5 and V6 and possible ST depression

4 left axis deviation may also be present

5 QRS may be slightly prolonged

Notes: 1) a systematic review investigating the accuracy of ECGs in the diagnosis of LVH has been undertaken

2) From the study data in primary care, a negative electrocardiogram result would reduce the typical pre-test probability from 33% to 31%. In secondary care the typical pre-test probability of 65% would be reduced to 63% the authors concluded that electrocardiographic criteria should not be used to rule out left ventricular hypertrophy in patients with hypertension

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 segment and/or T waves (Strain pattern ). 3 Left axis deviation (is a supportive finding, not diagnostic). 4 Prolongation of the QT interval (is a supportive finding, not diagnostic). 5 Prolongation of the QT interval (is a supportive finding, not diagnostic). 6 Prolongation of the QRS duration.

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 standard calibration). 2 In women: R in aVL + S in C3 >2.0 mV (>20mm in standard calibration). 3 The reliability of Cornell voltage criteria decreases in the presence of left anterior fascicular block.

Sokolow-Lyon criteria 1 S in V1 + R in C5 (or C6) >3.5mV (>35mm in standard calibration). 2 R in aVL >1.1 mV (>11mm in standard calibration).

Additional voltage criteria proposed for the diagnosis of left ventricular hypertrophy 1  RI + SIII > 25 mm (2.5 mV) (Gubner, 1943). 2  RI > 15 mm (1.5 mV) (Gubner, 1943). 3  In men, S wave in C3 + R wave in aVL > 28mm (2.8mV) (Casale, 1985). 4  In women, S wave in C3 + R wave in aVL > 20mm (2.0mV) (Casale, 1985). 5 R + S > 19mm (1.9 mV) in any extremity lead (Romhilt, 1968). Secondary ST Segment and T wave changes in left ventricular hypertrophy 1 Depression of the J point. 2 Upwardly convex, down sloping ST segment depression. 3 Asymmetric T wave negativity. Bundle branch blocks and the diagnosis of LVH 1  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. 2   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) 1 Left atrial abnormality. 2 QRS width > 160 miliseconds. 3 The sum of the amplitudes of S wave in C2 and R wave in C6 > 45mm (4.5mV). 4 The amplitude of S wave in C2 is at least 30 mm (3mV). 5 The amplitude of S wave in C3 is at least 25 mm (2.5mV). 6 SII > RII.

Some of the criteria that are suggested for the diagnosis of LVH in the presence of right bundle branch block (RBBB) are 1 The amplitude of S wave in C1 > 2mm (0.2 mV). 2  The R wave amplitude in C5 or C6 > 15 mm (1.5mV). 3  QRS axis is left to the -30 degrees. 4  RI > 11mm (1.1mV). 5  Regarding the amplitudes of S wave in lead III and R wave in any precordial lead, the R/S amplitude > 30 mm (3 mV) 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.

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.

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 .

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

ECG 5. The ECG above belongs to a 40 years-old man with hypertension. According to the Sokolow-Lyon voltage criteria, thesum 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.

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.

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).

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.

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

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 .

ECG 11. The ECG above belongs to a 51 years-old woman with hypertension and normal coronary arteries. According to theGubner 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. Echocardiogram confirmed LVH in this patient.

ECG 12. The ECG above belongs to a 56 years-old hypertensive man with normal coronary arteries. Less than 1 mm ST depression , negative T waves and U waves are seen.

ECG 13. The ECG above belongs to a 46 years-old hypertensive man who has echocardiographically confirmed left ventricular hypertrophy. It shows right bundle branch block and left anterior fascicular block. According to Gubner criteria, there is also left ventricular hypertophy pattern.

ECG 14. The ECG above belongs to a chronic hypertensive man with long-standing uncontrolled hypertension. His echocardiogram showed left ventricular septal hypertrophy. According to Gubner criteria, the R amplitude in I is > 15 mm (>1.5 mV) and suggests the presence of left ventricular hypertrophy.

ECG 15. The ECG above belongs to a 77 years-old woman who had never underwent diagnostic coronary angiography. There are no signs of old myocardial infarction. Echocardiography shows left ventricular hypertrophy however the ECG does not give any clues to that. RBBB impairs the ECG diagnosis of left ventricular hypertrophy.

ECG 16. The ECG of a 45 years-old dilated cardiomyopathy patient with normal coronary arteries and prosthetic aortic and mitral valves. In addition to increased voltage the ST segment depression and asymmetrical T wave negativity in lateral leads show left ventricular strain (strain pattern). The rhythm is atrial fibrillation.

ECG 17. The ECG above belongs to a woman with long-standing chronic systemic arterial hypertension. She had experienced syncope 4 days ago due to acute pulmonary embolism. The ECG shows accelerated junctional rhythm. Heart rate (ventricular rate) is about 83/minute. There is also ectopic atrial tachycardia. The atrial rate is about 165/minute. P waves are not related to the QRS complexes: complete AV block. The increased voltage in this ECG suggests left ventricular hypertrophy.

ECG 18. The ECG above belongs to a 49 years-old diabetic man with long-standing (17 years) hypertension. ECHOcardiography showed diffuse left ventricular hypertrophy. This ECG is compatible with left ventricular hypertrophy according to both the Gubner and the Cornell voltage criteria.

ECG 19. The ECG above belongs to a 4 years-old boy who had been operated for AtrioVentricular Canal Defect (AVCD/AVSD). He had also undergone prosthetic mitral valve implantation. His ECHOcardiogram showed a dilated left ventricle. This ECG shows right bundle branch in association with left ventricular hypertrophy.

Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.

ECG 20. The ECG above belongs to an apparently healthy, 8 years-old lean boy. His ECHOcardiogram is normal: no left ventricular hypertrophy. The ECG of a lean person with a low body mass index may show increased voltage as a normal variant.

Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.

ECG 21. The ECG above belongs to an apparently healthy, 11 years-old lean boy. His echocardiogram is normal. The ECG of a lean person with low body mass index may show increased voltage as a normal variant.

Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.