The ECG criteria for diagnosing right or left ventricular hypertrophy are highly specific but carry a low sensitivity. In other words, if the criteria are present it is very likely that ventricular hypertrophy is present. It also means that ECG may miss the presence of hypertrophy.
Left Ventricular Hypertrophy (LVH)
ECG features include:
1) > QRS amplitude (voltage criteria; i.e., tall R-waves in LV leads, deep S-waves in RV leads)
2) Delayed intrinsicoid deflection in V6 (i.e., time from QRS onset to peak R is > 0.05 sec)
3) Widened QRS/T angle (i.e., left ventricular strain pattern, or ST-T oriented opposite to QRS direction)
4) Leftward shift in frontal plane QRS axis
5) Evidence for left atrial enlargement
6) ESTES Criteria for LVH (“diagnostic”, > 5 points; “probable”, 4 points)
7) CORNELL Voltage Criteria for LVH (sensitivity = 22 per cent, specificity per cent)
-S in V3 + R in aVL > 24 mm (men)
-S in V3 + R in aVL > 20 mm (women)
8) Other Voltage Criteria for LVH
a) 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
b) Chest-lead voltage criteria:
-S in V1 + R in V5 or V6 > 35 mm
Right Ventricular Hypertrophy
ECG features include:
1) Right axis deviation (> 90 degrees)
2) Tall R-waves in RV leads; deep S-waves in LV leads
3) Slight increase in QRS duration
4) ST-T changes directed opposite to QRS direction (i.e., wide QRS/T angle)
5) May see incomplete RBBB pattern or qR pattern in V1
6) Evidence of right atrial enlargement Specific ECG features (assumes normal calibration of 1 mV = 10 mm):
Any one or more of the following (if QRS duration < 0.12 sec):
a) Right axis deviation (>90 degrees) in presence of disease capable of causing RVH
b) R in aVR > 5 mm, or
c) R in aVR > Q in aVR
Any one of the following in lead V1:
a) R/S ratio > 1 and negative T-wave qR pattern
b) R > 6 mm, or S < 2mm, or rSR’ with R’ >10 mm
Other Chest Lead Criteria
a) R in V1 + S in V5 (or V6) 10 mm
b) R/S ratio in V5 or V6 < 1
c) R in V5 or V6 < 5 mm
d) 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.
Left Ventricular Hypertrophy (LVH)
ECG features include:
1) > QRS amplitude (voltage criteria; i.e., tall R-waves in LV leads, deep S-waves in RV leads)
2) Delayed intrinsicoid deflection in V6 (i.e., time from QRS onset to peak R is > 0.05 sec)
3) Widened QRS/T angle (i.e., left ventricular strain pattern, or ST-T oriented opposite to QRS direction)
4) Leftward shift in frontal plane QRS axis
5) Evidence for left atrial enlargement
6) ESTES Criteria for LVH (“diagnostic”, > 5 points; “probable”, 4 points)
7) CORNELL Voltage Criteria for LVH (sensitivity = 22 per cent, specificity per cent)
-S in V3 + R in aVL > 24 mm (men)
-S in V3 + R in aVL > 20 mm (women)
8) Other Voltage Criteria for LVH
a) 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
b) Chest-lead voltage criteria:
-S in V1 + R in V5 or V6 > 35 mm
Right Ventricular Hypertrophy
ECG features include:
1) Right axis deviation (> 90 degrees)
2) Tall R-waves in RV leads; deep S-waves in LV leads
3) Slight increase in QRS duration
4) ST-T changes directed opposite to QRS direction (i.e., wide QRS/T angle)
5) May see incomplete RBBB pattern or qR pattern in V1
6) Evidence of right atrial enlargement Specific ECG features (assumes normal calibration of 1 mV = 10 mm):
Any one or more of the following (if QRS duration < 0.12 sec):
a) Right axis deviation (>90 degrees) in presence of disease capable of causing RVH
b) R in aVR > 5 mm, or
c) R in aVR > Q in aVR
Any one of the following in lead V1:
a) R/S ratio > 1 and negative T-wave qR pattern
b) R > 6 mm, or S < 2mm, or rSR’ with R’ >10 mm
Other Chest Lead Criteria
a) R in V1 + S in V5 (or V6) 10 mm
b) R/S ratio in V5 or V6 < 1
c) R in V5 or V6 < 5 mm
d) 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.
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