LVH AND RVH Dr. Mohammed Niyaz

MEM Y2ASTER MIMS

OVERVIEWLVH Definition Types of LVH ECG changes in systolic overload Criteria to diagnose LVH ECG changes in diastolic overload

RVH Definition ECG changes Clinical correlation

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.

THE NORMAL QRS THROUGH THE LEADS

Represents dominant right to left QRS vector

Indirect representation of left free wall activation

Hypertrophy of LV free wall

LEFT VENTRICULAR HYPERTROPHY

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

Abnormalities of

QRS

Abnormalities of U wave

Left atrial abnormali

ty

Abnormalities of QRS & T wave

axes

Abnormalities of ST

segment & T wave

LVH due to

systolic overloa

d

Abnormalities of

QRS complex

Abnormalities of ST

segment & T wave

T wave Assymetric

alShallow proximal

limb

T wave Inverted in I aVL V5 V6Upright in aVR V1 2

ST segmentMinimally depressed with slight

upward convexity in

left oriented

leads

Abnormalities of QRS & T wave axis

Abnormalities of U

wave

• Inverted in left oriented chest leads

• Not specific, more commonly associated with diastolic overload

Left atrial abnormali

ty

•Corroborative evidence •Particularly useful in presence of LBBB where it may be the only sign of LVH

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

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

Romhilt and Estes point score system

ECG finding Points

Increased QRS magnitude 3ST T abnormalities 3P wave of LA abnormality 3Left axis deviation 2Increased VAT 1

≥ 5points LVHMainly applicable for

LVH due to systolic overload

S wave in V1

R wave in in V5 or V6

35 mm

SOKOLOW LYON INDEX

Total QRS voltage of all 12 conventional ECG leads

> 175 mm or 17.5 mV

TOTAL QRS VOLTAGE

CORNELL VOLTAGE CRITERIASum 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

R wave in aVL > 11 mm

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

CLINICAL SIGNIFICANCE OF LVH

Asymmetrical

Blunt

Not very deep

Symmetrical

Pointed

Deep

LV strain T

inversion

Ischemic T

inversion

RIGHT VENTRICULAR HYPERTROPHY

RIGHT VENTRICULAR HYPERTROPHY

1. Paraseptal region

2. Free wall of RV

3. Basal regions

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

Abnormalities of QRS

Abnormalities of P wave

Abnormalities of ST

segment, T wave & U

wave

Right Axis DeviationDominant R

wave in right sided

leadsInitial

“incident” of QRS in

V1

Increased VAT in

V1RS or rS complexes

in left leads

RS complexes in mid

precordial leads

Clockwise

rotation

RBBB

QRS manifestati

ons of basal RVH

QRS manifestati

ons

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

•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

• RVH is frequently associated with right atrial abnormality

• Manifests as a tall & peaked P wave in standard lead II

Abnormalities of P wave

SI SII SIII SYNDROME

CLINICAL CORRELATION

BIVENTRICULAR HYPERTROPHY

Biventricular Hypertrophy

ECG OF LVH associated with

RADdegree 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

TAKE HOME MESSAGE DIAGNOSING LVH

SOKOLOV LYON CRITERIA

VOLTAGE IN aVL

NON VOLTAGE CRITERIA

CLINICAL CORRELATION

DIAGNOSING RVH

Thank you