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ECG Criteria for Hypertrophy and Chamber Enlargement

1. Left atrial overload(LAE)

Points Sensitivity (%) Specificity (%)
Neg. phase of P: V1> 0.04 seconds 83 80
Neg. phase of P V1> 1 mm 60 90
Notched P (interpeak interval)> 0.4s  15 100
P> 0.11s 33 88

2. Criteria for right atrial overload:

›› Tall > 2.5 mm and peaked P-wave that is seen best in leads II, III, and aVF
›› Distinctive peaking of P-wave is fairly specific for right atrial overload, even if the height criteria is not fulfilled.
›› Bifocal P-wave in V1 with dominant positive deflection
›› The P-wave vector tends to be vertical at (+ 60? and +90?), in such a case the P-wave is inverted or flat in aVL

Notes to remember

›› If the P-wave is inverted in lead I, include dextrocardia or lead reversal in your differential
›› If the P-overload is primarily due to congestive heart disease it's called p-Congenital.

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3. Left ventricular hypertrophy

1. Voltage criteria:
- R1 + S3 > 35 mm                                   - SV103 > 35 mm
- R in aVF > 20 mm                                   - SV I + RV 5-6 > 35 mm
- R in aVL > 11 mm (most specific)            - RV 4-6 > 25 mm and RV6 > RV5

2. Left atrial overload.

3. Incomplete LBBB 90% have LVH.

4. Left ventricular strain pattern (down-sloping of ST segment following dominant R-wave often associated with J-point depression and almost always have accompanied T-wave inversion).

5. Left axis deviation beyond 130°

6. Lateral wall strain is a very common association with LVH (seen as ST slope depression in lead I and aVL).

Notes to remember

›› The voltage criteria were constructed from data of while young men over thirty-five years of age, thus to be applied with caution in females or non-whites.
›› The above criteria's are basically for pressure overload ventricular hypertrophy or systolic overload. Diastolic overload or volume overload (AR, MR, VSD, etc.) can be diagnosed by the combination of deep Q-waves and tall T-waves in leads of prominent R-waves.

Criteria for diagnosis of left ventricular hypertrophy in the presence of complete LBBB:

Points Sensitivity (%) Specificity (%)
* RaVL > 11 MM 24 100
* SV1 + RV5 or RV6 > 40 mm 58 97
* AV2 > 30 mm and SV 3> 25 mm 75 90
* Electrical axis < (40) or (S2 > R1) 39 100

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Point score system for diagnosis of LVH

Criteria Points
1. Amplitude of QRS
R in V5 or V6 > 30 mm
S in V1 or V2 > 30 mm
Largest R or S in limb leads > 20 mm
If any of the above is fulfilled
2. ST -T strain pattern
In the absence of digitalis Rx
In the presence of digitalis Rx
LAE present 3
4. Left axis deviation (< 30°) 2
5. QRS duration (> 0.09 sec) 1
6. Intrinsicoid QRS Deflection of > 0.5 in V5 or V6 1

5 points or more definite LVH
4 points or more probable LVH

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4. Right ventricular hypertrophy:

1. Voltage criteria
- RV 1> 7 mm
- RV 1 + V 5-6 > 10 mm
- R/S ratio in V1>1
- R/S ratio V6>1
2. Indications of right ventricular strain are T-wave inversion and ST - segment
Depression in lead V1 to V4.
Right axis deviation of +90? to +50?. 3. Right atrial overload.
4. Incomplete RBBB.

5. Biventricular hypertrophy


1. Left atrial enlargement (LAE) as the sole representative of LVH, plus:
Clues of RVH including
- RAD> + 90?
- R: S in V6> I
- SV5 and sV6 > 7 mm
2. Right axis deviation with evidence of LVH
3. Clockwise rotation with voltage evidence of LVH in the absence of left anterior hemi block.
4. Counter-clockwise rotation with left axis deviation and evidence of RVH.
5. Katz-Wachtel sign - Very high mid precordial voltage, total QRS complex of V2 to V4 is > 60 mm or R/S ratio in V2 to V4 and /or in two or more limp leads of nearly 1.

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