VIII. Ventricular Hypertrophy

Frank G. Yanowitz, MD
Professor of Medicine
University of Utah School of Medicine

Topics for study:

1. Introduction
2. Left Ventricular Hypertrophy (LVH)
3. Right Ventricular Hypertrophy (RVH)
4. Biventricular Hypertrophy

1. 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).

2. 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) (lessonVII)



 ESTES Criteria for LVH ("diagnostic", >5 points; "probable", 4 points)



+ECG Criteria	Points
Voltage Criteria (any of): R or S in limb leads >20 mm S in V1 or V2 > 30 mm R in V5 or V6 >30 mm	3 points
ST-T Abnormalities: Without digitalis With digitalis	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)

  click here to view

 Example 2: (ESTES Criteria: 3 points for voltage in V5, 3 points for ST-T changes)

  click here to view

(Note also the left axis deviation of -40 degrees, and left atrial enlargement)

3. 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 > 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)

  click here to view

 Example #2: (more subtle RVH: note RAD +100 degrees; RAE; Qr complex in V1 rather than qR is atypical)

  click here to view

 Example #3: (note: RAD +120 degrees, qR in V1; R/S ratio in V6 <1)

  click here to view

4. 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

Test your knowledge on lessons VII and VIII by clicking here