ECG Criteria for Diagnosing Left Ventricular Hypertrophy

Primary Voltage-Based Criteria

The American College of Cardiology recommends using the Sokolow-Lyon criterion, which is the sum of the S wave in V1 and the R wave in V5 or V6 > 35 mm, for diagnosing left ventricular hypertrophy (LVH) in adults, with a high specificity of 85-90% 1, 2
The American Heart Association suggests using the Cornell voltage criterion, which is the sum of the S wave in V3 and the R wave in aVL > 28 mm for men and > 20 mm for women, for diagnosing LVH, with a high specificity of 85-90% 1, 2
The Cornell voltage-duration product, which is the Cornell voltage × QRS duration > 2440 mm·ms, can also be used to diagnose LVH, with a high specificity of 85-90% 2, 3
The Romhilt-Estes point score system, which incorporates QRS amplitude, ST-T abnormalities, left axis deviation, QRS duration, and intrinsicoid deflection, can be used to diagnose LVH, with a high specificity of 85-90% 1, 2

The presence of ST-T wave abnormalities, such as secondary ST-T changes, can strongly support the diagnosis of LVH and are associated with larger left ventricular mass and higher cardiovascular risk, according to the American College of Cardiology 4, 5
Left atrial abnormalities, such as P-wave changes suggesting left atrial enlargement, can be an early sign of hypertensive heart disease, as suggested by the American Heart Association 6, 7
Left axis deviation may support the diagnosis of LVH, but should not be used alone, according to the American College of Cardiology 6, 8
QRS duration prolongation, which is often accompanied by LVH, can be used to support the diagnosis, as suggested by the American Heart Association 4, 9

In patients with Left Bundle Branch Block (LBBB), the diagnosis of LVH is challenging and should generally not be attempted, according to the American College of Cardiology 8
In patients with Right Bundle Branch Block (RBBB), the sensitivity of voltage criteria is decreased, but criteria such as SV1 > 2 mm, RV5/V6 > 15 mm, and QRS axis left of -30° with S in lead III can be used to support the diagnosis, as suggested by the American Heart Association 8

Age can affect the ECG diagnosis of LVH, as QRS voltages decline with increasing age, and standard criteria best apply to adults over 35 years, according to the American College of Cardiology 1
Gender can also affect the ECG diagnosis of LVH, as women have slightly lower upper limits of QRS voltage than men, as suggested by the American Heart Association 1
Body habitus, such as obesity, can increase left ventricular mass but decrease QRS voltage due to increased distance between the heart and recording electrodes, according to the American College of Cardiology 1

The American College of Cardiology recommends using multiple validated voltage-based criteria when interpreting ECGs for LVH, as no single criterion is superior, and always adjust for patient demographics including gender, race, age, and body habitus 10, 11, 12

The American Heart Association suggests that criteria should be adjusted for race when validated adjustments exist 10, 11, 12

The American College of Cardiology states that diagnosis of LVH should generally NOT be attempted in complete LBBB, but if diagnosis is necessary, use QRS duration >155 ms + left atrial abnormality + precordial voltage criteria 10, 11, 12

The American Heart Association, American College of Cardiology, and Heart Rhythm Society recommend using only validated criteria without deviation from validated formulas, specifying which diagnostic criteria were used and which were abnormal, and computer systems should use all criteria supported by valid evidence 10, 11, 12

The American College of Cardiology notes that accuracy differs based on pre-test probability: In populations where LVH is unlikely, most positive tests are false positives; in hypertensive populations, most negative tests are false negatives 10, 11, 12