Left ventricular hypertrophy

Introduction

Left ventricular hypertrophy (LVH) refers to an increase in the size of myocardial fibers in the main cardiac pumping chamber. 

While ventricular hypertrophy occurs naturally as a reaction to aerobic exercise and strength training, it is most frequently referred to as a pathological reaction to cardiovascular disease, or high blood pressure.

Such hypertrophy is usually the response to a chronic pressure or volume load. 

The principal method to diagnose LVH is echocardiography, left ventricular wall is usually considered thickened when it is  > 12mm; LVH is defined as an increase in left ventricular mass (LVM) > 115 g/m2 in men and > 95 g/m2 in women.

Etiology

  • pressure overload states
    - aortic stenosis
    - systemic hypertension 
  • hypertrophic cardiomyopathy
  • physiologic changes associated with intense athletic training
  • aortic or mitral valve regurgitation 

ECG manifestation 

Sokolow-Lyon index (specificity > 85%, sensitivity 20%)

  • R wave in V5/V6 + S wave in V1/V2 > 35 mm
  • R wave in aVL > 11 mm

Cornell voltage criteria

  • men: S wave in V3 + R wave in aVL > 28 mm
  • women: S wave in V3 + R wave in aVL > 20 mm

Modified Cornell criteria 

  • R wave in aVL  > 12 mm

Other voltage criteria 

  • R wave in I + S wave in III > 25 mm
  • R wave in aVF > 20 mm
  • S wave in aVR > 14 mm

 Precordial Leads

  • R wave in V4, V5 or V6  > 26 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 depression and T wave inversion in the left-sided leads

 Romhilt-Estes LVH Point Score System
  - If the score equals 4, LVH is present with 30% to 54% sensitivity. If the score is greater than 5, LVH is     present with 83% to 97% specificity.

 Other ECG changes that may be seen in LVH

  • left atrial enlargement
  • left axis deviation
  • ST elevation in the right precordial leads V1-3 
  • ST depression in left sided leads (V4-V6) with T wave inversion

 

ECG 1 Signs of LV hypertrophy

 

ECG 2 Positive modified Cornell criteria in a patient with HOCM after unsuccessful septal alcohol ablation (RBBB, LAH)

 

References 

  1. Ary L Goldberger, David M Mirvis, Todd F Dardas. Left ventricular hypertrophy: Clinical findings and ECG diagnosis:  https://www.uptodate.com/contents/left-ventricular-hypertrophy-clinical-findings-and-ecg-diagnosis
  2. https://ecgwaves.com/topic/ecg-left-ventricular-hypertrophy-lvh-clinical-characteristics/
  3. https://litfl.com/left-ventricular-hypertrophy-lvh-ecg-library/