2. OVERVIEW
LVH
Definition
Types of LVH
ECG changes in systolic overload
Criteria to diagnose LVH
ECG changes in diastolic overload
RVH
Definition
ECG changes
Clinical correlation
3. DEFINITION OF LVH
Increase in the mass of the left ventricle, which
can be secondary to an increase in wall thickness,
an increase in cavity size, or both.
5. Represents dominant
right to left QRS vector
Indirect representation
of left free wall
activation
Hypertrophy of
LV free wall
LEFT VENTRICULAR HYPERTROPHY
6. Systolic overload
aka Pressure overload
Resistance to LV systolic
outflow
LV compromise occurs in
systole
AS, HTN, HCM,
Coarctation of aorta
Diastolic overload
aka Volume overload
Overfilling of the LV in
diastole
LV compromise occurs in
diastole
PDA, VSD ( moderate to large
L R shunts), AR, MR
LEFT VENTRICULAR HYPERTROPHY
7. Abnormalities
of QRS
Abnormalities
of U wave
Left atrial
abnormality
Abnormalities
of QRS & T
wave axes
Abnormalities
of ST segment
& T wave LVH due
to
systolic
overload
10. Abnormalities
of ST segment
& T wave
T wave
Assymetrical
Shallow proximal
limb
T wave
Inverted in I aVL V5
V6
Upright in aVR V1 2
ST segment
Minimally
depressed with
slight upward
convexity in left
oriented leads
12. • Inverted in left oriented chest leads
• Not specific, more commonly
associated with diastolic overload
Abnormalities
of U wave
• Corroborative evidence
• Particularly useful in presence of LBBB
where it may be the only sign of LVH
Left atrial
abnormality
13.
14. QRS T WAVE AXIS
Early stage – no change in axis
Due to symmetric increase in bulk
Late stage- Left Axis deviation
Due to left anterior hemiblock
15. Progressive
widening of
QRS T angle
beyond the
normal 45
degree
T wave
tends to be
flat in lead I
Longstanding
hypertension
T wave is
maximally to
the right(+-
180 degree)
Wide frontal
and
horizontal
plane QRS –T
angles
16. Romhilt and Estes point score system
ECG finding Points
Increased QRS magnitude 3
ST T abnormalities 3
P wave of LA abnormality 3
Left axis deviation 2
Increased VAT 1
≥ 5points LVH
Mainly applicable for
LVH due to systolic overload
19. Total QRS voltage of all 12 conventional
ECG leads
20. CORNELL VOLTAGE CRITERIA
Sum of S wave in V3 and R wave in aVL>
28 mm in men and > 20 mm in women
Sensitivity is increased by multiplying with
QRS duration- CORNELL VOLTAGE
PRODUCT
> 2440 mm ms indicates LVH
22. Tall R waves
Relatively tall,
symmetrical
T wave
Inverted U
waves
Minimal ST
segment
elevation
Deep,
prominent,
narrow Q
waves
LVH due
to
diastolic
overload
28. Right free wall
• Tall R waves in
right precordial
leads
• Mean frontal QRS
axis to the
region of 120
Right Para septal
wall
• Tall R waves of
RS complexes in
mid precordial
leads
• 90 to 120
Right basal region
• rS complexes in
v1 to v6with
deep s waves v5
v6
• qR complexes in
aVR
• Terminal S waves
in all 3 standard
leads- SI SII SIII
syndrome
• Mean frontal QRS
is directed to the
right superior
quadrant
29.
30. Right Axis
Deviation
Dominant R
wave in right
sided leads
Initial
“incident” of
QRS in V1
Increased VAT
in V1
RS or rS
complexes in left
leads
RS complexes in
mid precordial
leads
Clockwise
rotation
RBBB
QRS
manifestations
of basal RVH
QRS
manifestations
31.
32. Right axis deviation
R in V1 > 6 mm
qR complex in V1
(R in V1) + (S in V5 or
V6) >10.5 mm
R/S ratio in V1 >1
S/R ratio in V6 >1
Increased VAT in V1
Right bundle branch
block
ST-T wave
abnormalities ("strain")
in right precordial leads
Right atrial abnormality
S1S2S3 pattern
S1Q3T3 pattern
33. • Minimally depressed
• Slight upward convexity
Abnormalities
of ST segment
• T wave inversion in right oriented leads (V1 to
V4)
• Most marked in V1 V2 & diminishes
progressively in amplitude
Abnormalities
of T wave
• Decreased in amplitude or even inverted in
right precordial leads &/or inferior leads
Abnormalities of
U wave
34. • RVH is frequently associated with
right atrial abnormality
• Manifests as a tall & peaked P wave
in standard lead II
Abnormalities
of P wave
38. BIVENTRICULAR HYPERTROPHY
Biventricular Hypertrophy
ECG OF LVH
associated with
RAD
degree of
clock wise
rotation (
particularly
seen in RVH
with RV
dilatation
Relatively
tall R wave
in V1 (R/S
>1)
When P wave of
LAA is seen with
Right Axis
deviation of
QRS to right
of 90
degree
S wave in
lead V5 or
lead V6
equal to or
greater
than 0.7
mV
R/S ratio in
lead V5 or
V6 equal to
or less than
1
39. TAKE HOME MESSAGE
DIAGNOSING LVH
SOKOLOV LYON CRITERIA
VOLTAGE IN aVL
NON VOLTAGE CRITERIA
CLINICAL CORRELATION
DIAGNOSING RVH
LVH as a consequence of hypertension usually presents with an increase in wall thickness, with or without an increase in cavity size..
R wave progression
Standard lead I-left oriented lead – qR complex similar to V6
rS in right oriented leads (V1 V2)
RS Rs in v3 v4
qR in the left oriented leads (I aVL V4 V5 V6)
What does S wave in right leads & R wave in left leads represent?
In LVH, LV is under strain, probably d/t relative LV ischemia, so T wave vector runs away towards the right… bad friend !!!!!
T wave has a relatively blunt apex or nadir
ST segment has opposite changes in right oriented leads (Minimally elevated with slight upward concavity in left oriented leads)
QRS & T wave axis in frontal & horizontal planes; In longstanding LVH, axis deviates to left bcz of fibrosis which affects the anterosuperior division of LBB l/t LAHB (initially incomplete & progressively becomes more advanced).
When LVH is complicated by AR or cardiac failure, LAD maybe even more marked; indicates an adverse prognosis
Inverted U wave: reason unknown; sensitive sign of impaired LV, but rarely sought
In early stage mean QRS vector is increased in amplitude but no change in axis ( 50 to 60 degree)
Commonly directed to the direction of 0 in the hemiaxial referrance system
When LVH of systolic overload is complicated by aortic incompetence or cardiac failure the
left axis deviation is more marked.
This is an adverse prognostic sign
Cornell voltage sensitivity is increased by multiplying with QRS; For calculating CV Product, a correction factor of mm is added to cornell voltage
Cornell Voltage Product overestimates LVH in the presence of obesity whereas Sokolow Lyon criteria underestimates it
QRS voltages are affected by many factors including age, gender, body habitus, race etc. The common criteria best apply to adults >35yrs of normal built
Sum of S wave in V1 and R wave in V5 or V6 exceeds 3.5 mV ( 35 mm with normal standardisation)
Sensitivity 22%
The common criteria is best applied for adults >35 years of age and moderate build
Correction factor of 8 mm is added for women for cornell voltage pdt
All above manifestations are in left oriented leads
RVH results in generation of increased QRS forces that directed anteriorly & to the right. (??? so positive QRS in V1 , V2 & aVR)
In basal region hypertrophy, QRS forces are directed superiorly, somewhat posteriorly & to the right
RAD: most common manifestation; if hypertrophy of basal region is involved,it goes further to the right & in extreme cases may cause NWAD
If RVH + NWAD is present, it indicates the presence of additional complicating factors like IV conduction defects like LAHB (seen in TOF, noonans syndrm)
2) Dominant R wave in right sided leads: due to combined effect of R paraseptal & R free wall vectors, but principally the RV free wall vector
3) Initial “incident” of QRS in V1: small initial slurring of QRS or rR’ deflections (in ASD) or qR complex (indicates RVH + RAA Eg: TR)
4) Increased VAT: corroborative evidence of right free wall ventricular hypertrophy, provided there is no RBBB
5) RS or rS complexes in I aVL V5 V6: rS complex in V6 is particularly indicative of RVH
6) RS complexes in mid precordial leads:
7) Clockwise electrical rotation in longitudinal axis: transition zone shifted to left (V4,V5 or V5,V6)
8) QRS manifestations of basal RVH: uncommon;
V1 V2 dominantly negative or rS complex V5 V6 deep S waves of rS complexes aVR tall R waves of qR complex
Frontal plane QRS axis may be deviated to the NW axis
there may be terminal S waves in all 3 standard leads SI SII SIII syndrome
T wave runs away from the area of mischeif.
Katz Wachtel phenomenon: VSD in newborns & infants shows tall biphasic QRS complexes in midprecordial leads (R + S >40mm)
3. R/S >1 seen in eisenmenger syndrome(VSD with PAH)