8. Ventricular Hypertrophy
Topics for study:
- Introduction
- Left Ventricular Hypertrophy (LVH)
- Right Ventricular Hypertrophy (RVH)
- 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)
+ECG Criteria | Points |
---|---|
Voltage Criteria (any of):
|
3 points |
ST-T Abnormalities:
|
3 points 1 point |
Left Atrial Enlargement in V1 | 3 points |
Left axis deviation | 2 points |
QRS duration 0.09 sec | 1 point |
Delayed intrinsicoid deflection in V5 or V6 (>0.05 sec) | 1 point |
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