left ventricular hypertrophy (LVH)

introduction

pressure “systolic” overload resulting in concentric LV wall thickening:
- systemic arterial hypertension
- aortic stenosis
- ischaemic heart disease (IHD)
- cardiomyopathy
- congenital heart diseases (CHD) such as:
  - tricuspid atresia
  - moderate to large VSD and atrioventricular canal defects
  - PDA (older child)
  - coarctation of the aorta
  - pulmonary atresia with intact ventricular septum
  - aortic stenosis
  - hypertrophic obstructive cardiomyopathy (HOCM)
volume “diastolic” overload resulting in hypertrophy with dilatation:
- aortic and mitral insufficiency/regurgitation
- cardiomyopathy

exclude Left Bundle Branch Block (LBBB) - if present, cannot make ECG Dx of LVH
the most characteristic ECG finding of LVH is an increase in amplitude of the QRS resulting in tall R waves (and sometimes either tall T waves as well or ST depression with asymmetric T inversion and J point depression - “LVH with strain” pattern) in I, aVL, V5 and V6, with deeper S waves in V1-2.
there is often poor R wave progression in right and mid precordial leads, and indeed potentially an absent R wave in V1-2 creating a QS pattern in these leads.
left axis deviation (LAD)
QRS may widen as with right ventricular hypertrophy (RVH)
LAH is an early ECG sign
most ECG scoring systems for LVH are not sufficiently sensitive (< 42%)

add voltages of S in V3 + R in aVL > 28mm in men or > 20mm in women
- sens. 42%, spec. 96%

LVH is present if scores 5 or more, and is likely if scores 4
Score 3 if any of the following amplitude criteria are present:
- any limb lead R wave or S wave 20mm or more
- S wave in V1 or V2 30mm or more
- R wave in V5 or V6 30mm or more
Score 3 if LVH ST/T changes and patient not on digoxin (score 1 if these are present and patient is on digoxin)
Score 3 if left atrial abnormality:
- terminal negativity of P wave in lead V1 is at least 1mm with a duration of at least 0.04sec
Score 2 if left axis deviation (LAD)
Score 1 if QRS complex duration is 0.09 sec or more
Score 1 if intrinsicoid deflection in V5 or v6 of 0.05sec or more