- Ed Burns and Robert Buttner
ECG Diagnostic criteria
- There are numerous voltage criteria for diagnosing LVH, summarised below
- The most commonly used are the Sokolov-Lyoncriteria: S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm
- Voltage criteria must be accompanied by non-voltage criteria to be considered diagnostic of LVH
Voltage Criteria
Limb Leads
- R wave in lead I + S wave in lead III > 25 mm
- R wave in aVL > 11 mm
- R wave in aVF > 20 mm
- S wave in aVR > 14 mm
Precordial Leads
- R wave in V4, V5 or V6 > 26 mm
- R wave in V5 or V6 plus S wave in V1 > 35 mm
- Largest R wave plus largest S wave in precordial leads > 45 mm
Non Voltage Criteria
- Increased R wave peak time > 50 ms in leads V5 or V6
- ST segment depression and T wave inversion in the left-sided leads:AKA the left ventricular ‘strain’ pattern
Pathophysiology
- The left ventricle hypertrophies in response to pressure overload secondary to conditions such as aortic stenosis and hypertension
- This results in increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) and increased S wave depth in the right-sided leads (III, aVR, V1-3)
- The thickened LV wall leads to prolonged depolarisation (increased R wave peak time) and delayed repolarisation (ST and T-wave abnormalities) in the lateral leads
Additional ECG changes seen in LVH
- Left atrial enlargement
- Left axis deviation
- ST elevation in the right precordial leads V1-3 (“discordant” to the deep S waves)
- ProminentU waves(proportional to increased QRS amplitude)
Causes of LVH
- Hypertension (most common cause)
- Aortic stenosis
- Aortic regurgitation
- Mitral regurgitation
- Coarctation of the aorta
- Hypertrophic cardiomyopathy
Handy Tips
- Voltage criteria alone are not diagnostic of LVH
- ECG changes are an insensitive means of detecting LVH (patients with clinically significant left ventricular hypertrophy seen on echocardiography may still have a relatively normal ECG)
ECG Examples
Example 1
Left ventricular hypertrophy (LVH):
- Markedly increased LV voltages: huge precordial R and S waves that overlap with the adjacent leads (SV2 + RV6 >> 35 mm).
- R-wave peak time > 50 ms in V5-6 with associated QRS broadening.
- LV strain pattern with ST depression and T-wave inversions in I, aVL and V5-6.
- ST elevation in V1-3.
- Prominent U waves in V1-3.
- Left axis deviation.
Severe LVH such as this appears almost identical to left bundle branch block — the main clue to the presence of LVH is the excessively high LV voltages.
Example 2
- There are massively increased QRS voltages — the S waves in V3 are so deep they are literally falling off the page!
- The ST elevation in V1-3 is simply in proportion to the very deep S waves (“appropriate discordance”).
- The LV strain pattern is seen in all leads with a positive R wave (V5-6, I, II, III, aVF).
Related Topics
- Right ventricular hypertrophy
- Left atrial enlargement
- Left bundle branch block
References
- Edhouse J, Thakur RK, Khalil JM. ABC of clinical electrocardiography. Conditions affecting the left side of the heart. BMJ. 2002 May 25;324(7348):1264-7
Advanced Reading
Online
- Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
- Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
- Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
- Rawshani A. Clinical ECG Interpretation ECG Waves
- Smith SW. Dr Smith’s ECG blog.
Textbooks
- Zimmerman FH. ECG Core Curriculum. 2023
- Mattu A, Berberian J, Brady WJ. Emergency ECGs: Case-Based Review and Interpretations, 2022
- Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
- Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
- Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
- Hampton J, Adlam D. The ECG Made Practical 7e, 2019
- Kühn P, Lang C, Wiesbauer F. ECG Mastery: The Simplest Way to Learn the ECG. 2015
- Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
- Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004
LITFL Further Reading
- ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
- ECG A to Z by diagnosis – ECG interpretation in clinical context
- ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
- 100 ECG Quiz – Self-assessment tool for examination practice
- ECG Reference SITES and BOOKS – the best of the rest
ECG LIBRARY
Ed Burns
Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |
Robert Buttner
MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner
5 Comments
does the LVH with strain pattern carry any pathologic significance? Or does it just further confirm patient has LVH.
The strain pattern just further confirms LVH. It´s presence is associated with a poor prognosis.
“…(patients with clinically significant left ventricular hypertrophy seen on echocardiography may still have a relatively normal ECG)”
–> If you see this. Think of infiltrative restrictive cardiomyopathy disease like amyloid.
Or low voltage on ECG
Just want to say that this site is the best, and you’ve helped someone start from zero with ECGs, something that scared me for a long time, much love from Egypt!
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