Left Ventricular Hypertrophy

There are several criteria out there for left ventricular hypertrophy, and none of them are particularly sensitive. They’re all less than 50% sensitive, but they’re usually quite specific – 85 to 90%. The most cited criteria are the Sokolow-Lyon and the Cornell criteria, which consider voltage amplitude. There are also ST/T wave changes associated with LVH that may increase the specificity when seen. Namely, lateral ST depressions and asymmetric T wave inversions.

Select electrocardiographic criterial for Left ventricular hypertrophy.

Left ventricular hypertrophy is one of the most common reasons for false activations of the catheterization lab. It often causes discordant ST-elevation in the anterior precordial leads. Armstrong, et al., proposed an algorithm for interpreting acute myocardial infarction in the setting of hypertrophy. Specifically in leads V1 through V3, ST-elevation greater than 25% of the R-S amplitude is likely to be an acute myocardial infarction.

Examples

Left Ventricular Hypertrophy

Classic findings of left ventricular hypertrophy including large amplitude QRS complexes and associated repolarization abnormalities (e.g., asymmetric T-wave inversion in V6).

Left Ventricular Hypertrophy

Classic findings of left ventricular hypertrophy including lateral (and inferior) downsloping ST-segment depressions and asymmetric T-wave inversions.

Hypertrophic Cardiomyopathy

This patient has known hypertrophic cardiomyopathy. Notice the large QRS complexes in V5 and V6 with associated repolarization abnormalities. There are also notched P waves in the inferior leads (i.e., P mitrale appearance) representing left atrial enlargement.

Left Ventricular Hypertrophy

Large QRS complexes, ST-segment depressions and asymmetric T wave inversions primarily in the lateral leads (I, aVL, V5, V6) are classic for left ventricular hypertrophy.

Left Ventricular Hypertrophy

A large QRS complex in aVL (greater than 11 mm) indicates left ventricular hypertrophy. The left axis deviation, slight intraventricular conduction delay, and absent R wave progression across the precordium are all likely explained by left ventricular hypertrophy. The large, downward deflected P wave in V1 and wide P wave in lead II (greater than 120 ms) indicates left atrial enlargement.

Left Ventricular Hypertrophy, Left Atrial Enlargement

The large QRS complexes and asymmetric repolarization abnormalities (i.e., T wave inversions) in the lateral leads are consistent with the "strain" pattern of left ventricular hypertrophy. Additionally, notice that the terminal negative deflection of the P wave in V1 is greater than 1 mm deep and > 40 msec in duration, indicating the presence of left atrial enlargement. This patient was discovered to have severe aortic stenosis.

Left Ventricular Hypertrophy Mimic

This ECG is a mimic of left ventricular hypertrophy and right atrial enlargement in a very young, thin individual. Just as increased soft-tissue impedance from adipose or edema can influence the surface ECG by dampening the conduction of electrical impulses, an especially slender body habitus can have the inverse effect. In this case, the various electrocardiographic abnormalities were simply amplifications of normal cardiac activity. One potentially helpful hint is the combination of LVH with RAD – the former when truly representative of ventricular hypertrophy being more commonly associated with leftward axis deviation.

Left Ventricular Hypertrophy

Cornell criteria for left ventricular hypertrophy is met via the large S wave in V3. The discordant ST-segment elevation in leads V2 through V4 is not out of proportion given the amplitude of the R-S complex. One paper by Armtstrong, et al. defines an abnormal amount of ST-segment elevation (in leads V1 through V3 and in the setting of left ventricular hypertrophy) as greater than 25% of the R-S amplitude.

Left Ventricular Hypertrophy, Left Atrial Enlargement

Classic changes of left ventricular hypertrophy including large QRS complexes, repolarization abnormalities (especially in the inferolateral leads), and discordant ST-segment elevation in the anterior precordial leads (V1 through V3). There is also left atrial enlargement with a wide P wave and a "P-mitrale" appearance in lead II.

Left Ventricular Hypertrophy

Cornell criteria for left ventricular hypertrophy is met via the large S wave in V3. The discordant ST-segment elevation in leads V2 through V4 is not out of proportion given the amplitude of the R-S complex. The catheterization laboratory was inappropriately activated for this patient and revealed non-obstructive coronary artery disease.

ECG Showing Anterior ST-elevation Myocardial Infarction

Anterior ST-elevation Myocardial Infarction, Left Ventricular Hypertrophy

Left ventricular hypertrophy is present given the large QRS complexes. The degree of ST-segment elevation in the anterior precordial leads is more than expected for appropriate discordance. Left heart catheterization revealed complete left anterior descending occlusion.

Left Ventricular Hypertrophy

There are large QRS complexes with repolarization abnormalities (i.e., T-wave inversions) in the lateral leads (I, II, aVL, V4, V5, and V6). Despite 4 mm of ST-elevation in V2, this ECG is not consistent with myocardial infarction when compared to the amplitude of the S wave. In fact, this patient had a left heart catheterization that revealed non-obstructive coronary artery disease and percutaneous intervention was not performed.

References

Wagner GS, Macfarlane P, Wellens H, et al. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Part V: Electrocardiogram Changes Associated With Cardiac Chamber Hypertrophy. Circulation. 2009;53(11):1003-1011.
Armstrong EJ, Kulkarni AR, Bhave PD, et al. Electrocardiographic criteria for ST-elevation myocardial infarction in patients with left ventricular hypertrophy. American Journal of Cardiology. 2012;110(7):977-983. doi:10.1016/j.amjcard.2012.05.032.
Larson DM, Menssen KM, Sharkey SW, et al. “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007;298(23):2754-2760. doi:10.1001/JAMA.298.23.2754.