- Left ventricular hypertrophy (LVH) = pathologic increase in left ventricular mass secondary to conditions that cause pressure overload (e.g. aortic stenosis, hypertension)
- LVH is an independent predictor of cardiovascular morbidity and mortality in hypertensive patients and early recognition and treatment can improve clinical outcomes
- LVH results in corresponding increase in R wave amplitude in the left-sided leads (I, aVL, V4-V6) as well as an increase in S wave depth in the right-sided leads (III, aVR, V1-V3)
- The increase left ventricular wall thickness prolongs depolarization and therefore an increase in R wave peak time in the lateral leads; it also delays repolarization and therefore causes ST and T-wave abnormalities in the lateral leads
- Numerous criteria for diagnosing LVH – all demonstrate high specificity but low sensitivity
- Need voltage + non-voltage criteria met to be considered diagnostic of LVH
- The application of artificial intelligence to the ECG may aid in the use of the ECG as a diagnostic screening tool
Voltage criteria: limb leads
- [R wave in I] + [S wave in III] >25 mm
- R wave in aVL >11 mm
- R wave in aVF >20 mm
- S wave in aVR >14 mm
Voltage criteria: precordial leads
- R wave in V4, V5, or V6 >26 mm
- Sokolow-Lyon criteria: [S wave depth in V1] + [tallest R wave height in V5 or V6] >35 mm
- [Largest R wave in precordial leads] + [largest S wave in precordial leads] >45 mm
- Increased R wave peak time >50 ms in leads V5 or V6
- ST-segment depression and T-wave inversion in the left-sided leads (“left ventricular strain pattern”)
Additional supporting findings
- Left atrial enlargement
- Left axis deviation
- ST-segment elevation in the right precordial leads V1-V3 (“discordant” to the deep S waves)
- Prominent U waves (proportional to increased QRS amplitude)
- Cardiac: hypertension (most common cause), valvular disease (e.g. aortic stenosis, aortic regurgitation, mitral regurgitation), coarctation of the aorta, hypertrophic cardiomyopathy
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