Hypertension & LVH

• LVH-Echo
  • Assessment
  • Example
  • LV Geometric Patterns
  • LV Geometric Patterns in the HOT Study
  • Impact on Prognosis
  • Impact of drugs on LVH

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• LVH-ECG
• Which ECG Criterion?
• Impact on Prognosis

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Hypertension and Left Ventricular Hypertrophy on ECG (ECG-LVH)

Detection with ECG

There are a number of different methods of trying to determine if left ventricular hypertrophy (LVH) is present using the standard ECG.

One study assessed the sensitivity of various methods with specificity set at 96%. Echocardiography with calculation of left ventricular (LV) mass was used as the "gold standard" (J Am Coll Cardiol 1995;25:417-23).

• duration of the QRS complex
• amplitude of R wave in lead aVL
• sum of the R wave in lead I and the S wave in lead III
• sum of the S wave in lead V1 and the R wave in lead V5 or V6 (Sokolow-Lyon voltage)
• sum of the R wave in aVL and S wave in lead V3, adjusted by the addition of 800microvolts for women (gender specific Cornell voltage)
• the sum of the QRS complex in all 12 leads
• the Romhilt-Estes score (a complex ECG criterion- see below)
• the Sokolow-Lyon score which not only includes the voltage criteria but also takes into account various degrees of T wave abnormalites
• each simple voltage criteria was also multiplied by the QRS duration

• 12 lead QRS score great than 20.7 mV
• Sokolow-Lyon voltage greater than 3.8 mV
• Cornell product greater than 0.286 mV.s
• 12 lead product greater than 1.995 mV.s
• Sololow-Lyon product greater than 0.371 mV.s

The Cornell voltage had a sensitivity of only 29% but the product (multiplying by QRS duration) improved sensitivity to 41%.

The sensitivity of each method could be improved by reducing the partition value but as expected this mean reduced specificity. Using the "product" (where the voltage was multiplied by the QRS duration) generally improved sensitivity.

Not unexpectedly, different studies may show different results. Another study showed that the Sokolow-Lyon voltage was one of less sensitive methods (J Am Coll Cardiol 1995;26:1022-9). This study showed a negative correlation between BMI and precordial voltages and a positive correlation with limb lead voltages raising the possibility that different methods work better in obese patients. In other words the Sokolov-Lyon voltage criteria underestimates LVH in obese patients, in obese patients the Cornell product is preferred. This would also be consistent with our observations that it is common to observe prominent QRS complex voltages in precordial leads in slim persons.

The diagnostic criteria of the Perugia Score, the newest scoring system for ECG-LVH. ECG-LVH is defined on the basis of one or more of these being positive:

• SV3 + RaVL >2.4 mV (men) or >2.0 mV (women)
• left ventricular strain
• Romhilt-Estes score =5

Romhilt-Estes scoring system for ECG-LVH is a point score system. A score of 5 diagnoses LVH and a score of 4 diagnoses probable LVH. The scoring system is:

• Voltage in any of the following leads is assigned 3 points:
• R or S in limb lead 20 mm or more
• S in V1, V2, or V3 25 mm or more, or
• R in V4, V5 or V6 25 mm or more.
• ST segment and T wave changes (typical strain) without digitalis is assigned 3 points and with digitalis 1 point.
• Left axis deviation >-15 degrees is assigned 2 points.
• QRS duration >0.09 seconds is assigned 1 point.
• LA involvement as identified by P-terminal force in V1 >1 mm depth with a duration greater than 0.04 seconds is given 3 points.
• Intrinsoid deflection in V5 or V6 >0.05 seconds is given 1 point.

Hitesh Patel, Cardiologist
8th August, 2004
Last update: 4th May, 2005