d o
t o r e g . c o m
Dr. Mete ALPASLAN
Left Ventricular Hypertrophy - LVH
ECG abnormalities that may be observed in patients with LVH
Increased QRS voltage (valid in patients >35 years of age).
Secondary ST segment and/or T wave changes ( strain pattern ).
Left axis deviation (is a supportive finding, not diagnostic).
QT interval prolongation (is a supportive finding, not diagnostic).
Prolongation of QRS duration.
Voltage criteria used to diagnose left ventricular hypertrophy
Cornell
voltage criteria.
Sokolow-Lyon
criteria.
Cornell voltage criteria
In men: R in aVL + S in C3 >2.8 mV (>28 mm in standard calibration).
In women: R in aVL + S in C3 >2.0 mV (>20 mm in standard calibration).
The reliability of Cornell voltage criteria decreases in the presence of left anterior fascicular block.
Sokolow-Lyon criteria (valid above the age of 30)
S in V1 + R in C5 (or C6) >3.5 mV ( >35 mm in standard calibration).
R in aVL >1.1 mV ( >11 mm in standard calibration).
In persons younger than 30 years of age, Sokolow-Lyon criteria is frequently seen despite the absence of left ventricular hypertrophy. Therefore, it is not suitable for ages below 30.
Additional voltage criteria proposed for the diagnosis of left ventricular hypertrophy
RI + SIII > 25 mm (2.5 mV) (Gubner, 1943).
RI > 15 mm (1.5 mV) (Gubner, 1943).
In men, S wave in C3 + R wave in aVL > 28mm (2.8mV) (Casale, 1985).
In women, S wave in C3 + R wave in aVL > 20mm (2.0mV) (Casale, 1985).
R + S > 19mm (1.9 mV) in any extremity lead (Romhilt, 1968).
Secondary ST segment and T wave changes in left ventricular hypertrophy
Depression of J point.
Upwardly convex, downsloping ST segment depression.
Asymmetric T wave negativity.
Bundle branch blocks and the diagnosis of LVH
In the presence of right bundle branch block (RBBB), the diagnosis of LVH becomes more difficult since the amplitude of S wave in right precordial leads (C1, C2, C3) decreases.
The reliability of Cornell voltage criteria decreases in the presence of left anterior fascicular block.
Although not universally accepted, the following criteria are proposed for the diagnosis of LVH
in the presence of left bundle branch block (LBBB)
Left atrial abnormality.
QRS width > 160 miliseconds.
The sum of amplitudes of S wave in C2 and R wave in C6 > 45mm (4.5mV).
The amplitude of S wave in C2 is at least 30 mm (3mV).
The amplitude of S wave in C3 is at least 25 mm (2.5mV).
SII > RII.
Some of the criteria that are suggested for the diagnosis of LVH
in the presence of right bundle branch block (RBBB) are
The amplitude of S wave in C1 > 2mm (0.2 mV).
The R wave amplitude in C5 or C6 > 15 mm (1.5mV).
QRS axis is left to the -30 degrees.
RI > 11mm (1.1mV).
Regarding the amplitudes of S wave in lead III and R wave in any precordial lead, the R/S amplitude > 30 mm (3 mV)
Click here for hypertrophic cardiomyopathy.
References
Circulation 2009,119:e251-e261.
Chest 1971;59:174-177.
Am Heart J 1984;108:502-506.
J Electrocardiol 1984;17:157-160.
Am J Cardiol 1985;55:103-106.
ECG 1. The above ECG belongs to a patient with coarctation of the aorta and hypertension. The terminal half of the P wave in
C1 is clearly negative and P wave in lead II is double peaked suggesting left atrial abnormality. The left ventricular hypertrophy
due to chronic arterial hypertension has resulted in high amplitude R waves in lead C4 and deep S waves in lead C3 .
The ST segment depression and asymmetrical negative T waves in leads C5 ve C6 denote to left ventricular strain pattern.
Click here for a more detailed ECG
ECG 2. The above ECG belongs to a male patient with systemic hypertension, left ventricular dilatation and hypertrophy.
According to the Sokolow-Lyon voltage criteria, the sum of the amplitudes of the S wave in C1 and R wave in C5 is >3.5 mV
(35 mm) and suggests LVH. In addition to the voltage criteria, there is also accompanying ST segment depression and
asymmetrically negative T waves . The rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 3. The above ECG belongs to a patient with systemic hypertension and coronary artery disease.
The ECG shows left ventricular hypertrophy and left atrial abnormality .
Click here for a more detailed ECG
ECG 4. The ECG above belongs to a man with long-standing systemic arterial hypertension and a recently diagnosed adenoma
in right adrenal gland. He needs 4 different medications to control his blood pressure. Still, no increased voltage is observed
in the precordial leads. On the other hand, according to the Gubner extremity electrode voltage criteria, the sum of the
amplitudes of R wave in lead I and S wave in lead III is >2.5 mV (25 mm), suggesting LVH in this patient.
Click here for a more detailed ECG
ECG 5. The ECG above belongs to a 40 years-old man with hypertension. According to the Sokolow-Lyon voltage criteria, the
sum of the amplitudes of S wave in C1 or C2 and R wave in C5 or C6 is >3.5 mV (35 mm) and suggests the presence of LVH.
This ECG does not show left ventricular strain pattern.
Click here for a more detailed ECG
ECG 6. The ECG above belongs to a patient with hypertension and echocardiographically confirmed LVH.
His coronary arteries are normal. The asymmetrical T wave negativity in the above ECG is not related to myocardial ischemia.
Click here for a more detailed ECG
ECG 7. The ECG above shows right bundle branch block (RBBB). His echocardiogram showed septal LVH. In the ECG above,
the criteria that suggest LVH are: amplitude of S wave in C1 is > 2mm (0.2 mV); amplitude of R wave in C5 > 15mm (1.5 mV).
Click here for a more detailed ECG
ECG 8. The ECG above belongs to a patient with systemic arterial hypertension and mitral stenosis.
His echocardiography showed diffuse LVH. Her ECG also suggests LVH.
Click here for a more detailed ECG
ECG 9. The ECG above belongs to a patient with hypertension and coronary artery disease. He had undergone coronary artery
bypass graft surgery. Despite RBBB (right bundle branch block), his ECG suggests LVH. His echocardiogram showed
concentric (diffuse) LVH.
Click here for a more detailed ECG
ECG 10. The ECG above belongs to a hypertensive woman with normal coronary arteries and shows anterolateral T wave
negativity and upsloping ST segment depression in leads V4 to V6 .
Click here for a more detailed ECG
ECG 11. The ECG above belongs to a 51 years-old woman with hypertension and normal coronary arteries. According to the
Gubner extremity electrode voltage criteria, the sum of the amplitudes of R wave in lead I and S wave in lead III is >2.5 mV
(25 mm), suggesting LVH in this patient. Echocardiogram confirmed LVH in this patient.
Click here for a more detailed ECG
ECG 12. The ECG above belongs to a 56 years-old hypertensive man with normal coronary arteries.
Less than 1 mm ST depression , negative T waves and U waves are seen.
Click here for a more detailed ECG
ECG 13. The ECG above belongs to a 46 years-old hypertensive man who has echocardiographically confirmed left ventricular
hypertrophy. It shows right bundle branch block and left anterior fascicular block.
According to Gubner criteria, there is also left ventricular hypertophy pattern.
Click here for a more detailed ECG
ECG 14. The ECG above belongs to a chronic hypertensive man with long-standing uncontrolled hypertension.
His echocardiogram showed left ventricular septal hypertrophy. According to Gubner criteria, the R amplitude in I is > 15 mm
(>1.5 mV) and suggests the presence of left ventricular hypertrophy.
Click here for a more detailed ECG
ECG 15. The ECG above belongs to a 77 years-old woman who had never underwent diagnostic coronary angiography.
There are no signs of old myocardial infarction. Echocardiography shows left ventricular hypertrophy however the ECG
does not give any clues to that.
RBBB impairs the ECG diagnosis of left ventricular hypertrophy.
Click here for a more detailed ECG
ECG 16. The ECG of a 45 years-old dilated cardiomyopathy patient with normal coronary arteries and prosthetic aortic and
mitral valves. In addition to increased voltage the ST segment depression and asymmetrical T wave negativity in lateral leads
show left ventricular strain (strain pattern). The rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 17. The ECG above belongs to a woman with long-standing chronic systemic arterial hypertension.
She had experienced syncope 4 days ago due to acute pulmonary embolism.
The ECG shows accelerated junctional rhythm. Heart rate (ventricular rate) is about 83/minute. There is also ectopic atrial
tachycardia. The atrial rate is about 165/minute. P waves are not related to the QRS complexes: complete AV block.
The increased voltage in this ECG suggests left ventricular hypertrophy.
Click here for a more detailed ECG
ECG 18. The ECG above belongs to a 49 years-old diabetic man with long-standing (17 years) hypertension.
ECHOcardiography showed diffuse left ventricular hypertrophy.
This ECG is compatible with left ventricular hypertrophy according to both the Gubner and the Cornell voltage criteria.
Click here for a more detailed ECG
ECG 19. The ECG above belongs to a 4 years-old boy who had been operated for AtrioVentricular Canal Defect (AVCD/AVSD).
He had also undergone prosthetic mitral valve implantation.
His ECHOcardiogram showed a dilated left ventricle.
This ECG shows right bundle branch in association with left ventricular hypertrophy.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 20. The ECG above belongs to an apparently healthy, 8 years-old lean boy.
His ECHOcardiogram is normal: no left ventricular hypertrophy.
The ECG of a lean person with a low body mass index may show increased voltage as a normal variant.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 21. The ECG above belongs to an apparently healthy, 11 years-old lean boy. His echocardiogram is normal.
The ECG of a lean person with low body mass index may show increased voltage as a normal variant.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 22. The compact ECG above belongs to a 14 years-old male with a normal ECHOcardiogram (no left ventricular
hypertrophy). Sokolow-Lyon criteria is frequently present in adults younger than 30 years of age.
As seen in the above example, there is no left ventricular hypertrophy despite the presence of Sokolow-Lyon criteria.
ECG 23. The ECG above belongs to a 51 years-old man with long-standing untreated hypertension.
This ECG was recorded in the emergency room when he was experiencing intracranial hemorrhage.
ECHOcardiography showed significant left ventricular hypertrophy (interventricular septum:1.9 cm, posterior wall:1.4 cm)
Acccording to Gubner criteria, increased QRS voltage is present.
The QRS width is also increased (124 miliseconds).
Click here for a more detailed ECG
ECG 24. The ECG above belongs to a 76 years-old woman with long-standing hypertension.
ECHOcardiography showed normal left ventricular systolic function with only mild mitral valve insufficiency.
Many ECG signs of left ventricular hypertrophy are seen in the above ECG.
Click here for a more detailed ECG
ECG 25. The compact ECG above belongs to a woman with chronic systemic hypertension.
It shows left ventricular hypertrophy according to Gubner criteria:
The R amplitude in lead I + the S wave amplitude in lead III is larger than 25 mm (2.5 mV).
The R amplitude in lead I is larger than 15 mm (1.5 mV).
ECHOcardiography confirmed left ventricular hypertrophy in this patient.
ECG 26. The ECG above belongs to a 40 years-old man with untreated hypertension.
He says that he has high blood pressure for the last year.
There is no classic ECG pattern for left ventricular hypertrophy (LVH), but the Romhilt criteria is positive in this ECG.
Lead II is compatible with the Romhilt criteria: R + S > 19mm (1.9 mV) in any extremity lead (Romhilt 1968).
The above ECG shows LVH criteria but ECHOcardiography does not. He has normal left ventricular wall thickness.
In patients with hypertension, ECG criteria of LVH may be seen before the development of increased wall thickness
on ECHOcardiography.
Click here for a more detailed ECG
ECG 27. The ECG above belongs to a 60 years-old woman with effort angina, hypertension, diabetes mellitus,
chronic renal failure and morbid obesity. She was offered diagnostic coronary angiography but she refused.
This ECG shows left anterior fascicular block. It has been reported that the reliability of Cornell voltage criteria decreases
in the presence of left anterior fascicular block. In the above ECG, the Cornell voltage criteria is just satisfied:
R in aVL + S in C3 >2.0 mV (in women).
Also Gubner criteria is just satisfied: RI + SIII > 25 mm (2.5 mV).
ECHOcardiography showed thickened interventricular septum (1.4 cm) in this patient.
Click here for a more detailed ECG
ECG 28. The ECG above belongs to a 56 years-old woman with chronic hypertension.
ECHOcardiography showed left ventricular hypertrophy.
Gubner criteria for left ventricular hypertrophy is present.
ST depression and T wave negativity are also seen but coronary angiography did not show significant stenosis.
Click here for a more detailed ECG
ECG 29. The above ECG is from a 45 years-old woman with a permanent cardiac pacemaker.
ECHOcardiography showed dilated right atrium and right ventricle.
Leads I and V4 show giant pacemaker spikes which must not be confused with increased QRS voltage.
There is no ECG sign of left ventricular hypertrophy.
Click here for a more detailed ECG
ECG 30. The above ECG is from a 41 years-old man with systemic hypertension and significant valvular heart disease.
He has severe aortic insufficiency, moderate aortic stenosis and moderate mitral stenosis.
ECHOcardiography showed left ventricular hypertrophy and dilation of all cardiac chambers
The amplitudes of R and S waves in either lead II or lead III is > 19mm (1.9 mV) (Romhilt criteria).
Click here for a more detailed ECG
ECG 31. The above ECG is from a 67 years-old woman with systemic hypertension and left ventricular hypertrophy.
The amplitudes of R and S waves in lead III is > 19mm (1.9 mV) (Romhilt criteria).
The ECG shows extensive T wave negativity. However, coronary angiography showed normal coronary arteries.
She also does not complain of typical chest pain.
Click here for a more detailed ECG
ECG 32. The above ECG is from a 29 years-old man with systemic hypertension.
ECHOcardiography did NOT show left ventricular hypertrophy.
The amplitudes of R (and S) waves in lead II is 24 mm (>19 mm or >1.9 mV) (Romhilt criteria).
ECG signs of left ventricular hypertrophy arises long before detection by ECHOcardiography.
Sokolow-Lyon criteria is also positive in this patient but under 30 years of age, the reliability of Sokolow-Lyon criteria is low.
When I saw this ECG on his initial visit to my outpatient clinic, I said "you have high blood pressure", but he said "No".
I measured his blood pressure high, but he said "it may be due to hospital anxiety" (white-coat hypertension).
To persuade him, I used ABPM (Ambulatory Blood Pressure Monitoring) for 24 hours.
ABPM showed that more than half of the measurements were above normal limits.
Click here for a more detailed ECG
ECG 33. Above ECG is from a 54 years-old woman with hypertension, mild to moderate aortic valve stenosis
and chronic renal failure.
Leads I, aVL, V5 and V6 show ST segment depression and negative T waves.
However, her coronary angiography showed normal coronary arteries.
ECHOcardiography showed left ventricular hypertrophy.
Despite the presence of bundle branch block, this ECG shows left ventricular hypertrophy.
Click here for a more detailed ECG
ECG abnormalities that may be observed in patients with LVH
Increased QRS voltage (valid in patients >35 years of age).
Secondary ST segment and/or T wave changes ( strain pattern ).
Left axis deviation (is a supportive finding, not diagnostic).
QT interval prolongation (is a supportive finding, not diagnostic).
Prolongation of QRS duration.
Voltage criteria used to diagnose left ventricular hypertrophy
Cornell
voltage criteria.
Sokolow-Lyon
criteria.
Cornell voltage criteria
In men: R in aVL + S in C3 >2.8 mV (>28 mm in standard calibration).
In women: R in aVL + S in C3 >2.0 mV (>20 mm in standard calibration).
The reliability of Cornell voltage criteria decreases in the presence of left anterior fascicular block.
Sokolow-Lyon criteria (valid above the age of 30)
S in V1 + R in C5 (or C6) >3.5 mV ( >35 mm in standard calibration).
R in aVL >1.1 mV ( >11 mm in standard calibration).
In persons younger than 30 years of age, Sokolow-Lyon criteria is frequently seen despite the absence of left ventricular hypertrophy. Therefore, it is not suitable for ages below 30.
Additional voltage criteria proposed for the diagnosis of left ventricular hypertrophy
RI + SIII > 25 mm (2.5 mV) (Gubner, 1943).
RI > 15 mm (1.5 mV) (Gubner, 1943).
In men, S wave in C3 + R wave in aVL > 28mm (2.8mV) (Casale, 1985).
In women, S wave in C3 + R wave in aVL > 20mm (2.0mV) (Casale, 1985).
R + S > 19mm (1.9 mV) in any extremity lead (Romhilt, 1968).
Secondary ST segment and T wave changes in left ventricular hypertrophy
Depression of J point.
Upwardly convex, downsloping ST segment depression.
Asymmetric T wave negativity.
Bundle branch blocks and the diagnosis of LVH
In the presence of right bundle branch block (RBBB), the diagnosis of LVH becomes more difficult since the amplitude of S wave in right precordial leads (C1, C2, C3) decreases.
The reliability of Cornell voltage criteria decreases in the presence of left anterior fascicular block.
Although not universally accepted, the following criteria are proposed for the diagnosis of LVH
in the presence of left bundle branch block (LBBB)
Left atrial abnormality.
QRS width > 160 miliseconds.
The sum of amplitudes of S wave in C2 and R wave in C6 > 45mm (4.5mV).
The amplitude of S wave in C2 is at least 30 mm (3mV).
The amplitude of S wave in C3 is at least 25 mm (2.5mV).
SII > RII.
Some of the criteria that are suggested for the diagnosis of LVH
in the presence of right bundle branch block (RBBB) are
The amplitude of S wave in C1 > 2mm (0.2 mV).
The R wave amplitude in C5 or C6 > 15 mm (1.5mV).
QRS axis is left to the -30 degrees.
RI > 11mm (1.1mV).
Regarding the amplitudes of S wave in lead III and R wave in any precordial lead, the R/S amplitude > 30 mm (3 mV)
Click here for hypertrophic cardiomyopathy.
References
Circulation 2009,119:e251-e261.
Chest 1971;59:174-177.
Am Heart J 1984;108:502-506.
J Electrocardiol 1984;17:157-160.
Am J Cardiol 1985;55:103-106.
ECG 1. The above ECG belongs to a patient with coarctation of the aorta and hypertension. The terminal half of the P wave in
C1 is clearly negative and P wave in lead II is double peaked suggesting left atrial abnormality. The left ventricular hypertrophy
due to chronic arterial hypertension has resulted in high amplitude R waves in lead C4 and deep S waves in lead C3 .
The ST segment depression and asymmetrical negative T waves in leads C5 ve C6 denote to left ventricular strain pattern.
Click here for a more detailed ECG
ECG 2. The above ECG belongs to a male patient with systemic hypertension, left ventricular dilatation and hypertrophy.
According to the Sokolow-Lyon voltage criteria, the sum of the amplitudes of the S wave in C1 and R wave in C5 is >3.5 mV
(35 mm) and suggests LVH. In addition to the voltage criteria, there is also accompanying ST segment depression and
asymmetrically negative T waves . The rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 3. The above ECG belongs to a patient with systemic hypertension and coronary artery disease.
The ECG shows left ventricular hypertrophy and left atrial abnormality .
Click here for a more detailed ECG
ECG 4. The ECG above belongs to a man with long-standing systemic arterial hypertension and a recently diagnosed adenoma
in right adrenal gland. He needs 4 different medications to control his blood pressure. Still, no increased voltage is observed
in the precordial leads. On the other hand, according to the Gubner extremity electrode voltage criteria, the sum of the
amplitudes of R wave in lead I and S wave in lead III is >2.5 mV (25 mm), suggesting LVH in this patient.
Click here for a more detailed ECG
ECG 5. The ECG above belongs to a 40 years-old man with hypertension. According to the Sokolow-Lyon voltage criteria, the
sum of the amplitudes of S wave in C1 or C2 and R wave in C5 or C6 is >3.5 mV (35 mm) and suggests the presence of LVH.
This ECG does not show left ventricular strain pattern.
Click here for a more detailed ECG
ECG 6. The ECG above belongs to a patient with hypertension and echocardiographically confirmed LVH.
His coronary arteries are normal. The asymmetrical T wave negativity in the above ECG is not related to myocardial ischemia.
Click here for a more detailed ECG
ECG 7. The ECG above shows right bundle branch block (RBBB). His echocardiogram showed septal LVH. In the ECG above,
the criteria that suggest LVH are: amplitude of S wave in C1 is > 2mm (0.2 mV); amplitude of R wave in C5 > 15mm (1.5 mV).
Click here for a more detailed ECG
ECG 8. The ECG above belongs to a patient with systemic arterial hypertension and mitral stenosis.
His echocardiography showed diffuse LVH. Her ECG also suggests LVH.
Click here for a more detailed ECG
ECG 9. The ECG above belongs to a patient with hypertension and coronary artery disease. He had undergone coronary artery
bypass graft surgery. Despite RBBB (right bundle branch block), his ECG suggests LVH. His echocardiogram showed
concentric (diffuse) LVH.
Click here for a more detailed ECG
ECG 10. The ECG above belongs to a hypertensive woman with normal coronary arteries and shows anterolateral T wave
negativity and upsloping ST segment depression in leads V4 to V6 .
Click here for a more detailed ECG
ECG 11. The ECG above belongs to a 51 years-old woman with hypertension and normal coronary arteries. According to the
Gubner extremity electrode voltage criteria, the sum of the amplitudes of R wave in lead I and S wave in lead III is >2.5 mV
(25 mm), suggesting LVH in this patient. Echocardiogram confirmed LVH in this patient.
Click here for a more detailed ECG
ECG 12. The ECG above belongs to a 56 years-old hypertensive man with normal coronary arteries.
Less than 1 mm ST depression , negative T waves and U waves are seen.
Click here for a more detailed ECG
ECG 13. The ECG above belongs to a 46 years-old hypertensive man who has echocardiographically confirmed left ventricular
hypertrophy. It shows right bundle branch block and left anterior fascicular block.
According to Gubner criteria, there is also left ventricular hypertophy pattern.
Click here for a more detailed ECG
ECG 14. The ECG above belongs to a chronic hypertensive man with long-standing uncontrolled hypertension.
His echocardiogram showed left ventricular septal hypertrophy. According to Gubner criteria, the R amplitude in I is > 15 mm
(>1.5 mV) and suggests the presence of left ventricular hypertrophy.
Click here for a more detailed ECG
ECG 15. The ECG above belongs to a 77 years-old woman who had never underwent diagnostic coronary angiography.
There are no signs of old myocardial infarction. Echocardiography shows left ventricular hypertrophy however the ECG
does not give any clues to that.
RBBB impairs the ECG diagnosis of left ventricular hypertrophy.
Click here for a more detailed ECG
ECG 16. The ECG of a 45 years-old dilated cardiomyopathy patient with normal coronary arteries and prosthetic aortic and
mitral valves. In addition to increased voltage the ST segment depression and asymmetrical T wave negativity in lateral leads
show left ventricular strain (strain pattern). The rhythm is atrial fibrillation.
Click here for a more detailed ECG
ECG 17. The ECG above belongs to a woman with long-standing chronic systemic arterial hypertension.
She had experienced syncope 4 days ago due to acute pulmonary embolism.
The ECG shows accelerated junctional rhythm. Heart rate (ventricular rate) is about 83/minute. There is also ectopic atrial
tachycardia. The atrial rate is about 165/minute. P waves are not related to the QRS complexes: complete AV block.
The increased voltage in this ECG suggests left ventricular hypertrophy.
Click here for a more detailed ECG
ECG 18. The ECG above belongs to a 49 years-old diabetic man with long-standing (17 years) hypertension.
ECHOcardiography showed diffuse left ventricular hypertrophy.
This ECG is compatible with left ventricular hypertrophy according to both the Gubner and the Cornell voltage criteria.
Click here for a more detailed ECG
ECG 19. The ECG above belongs to a 4 years-old boy who had been operated for AtrioVentricular Canal Defect (AVCD/AVSD).
He had also undergone prosthetic mitral valve implantation.
His ECHOcardiogram showed a dilated left ventricle.
This ECG shows right bundle branch in association with left ventricular hypertrophy.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 20. The ECG above belongs to an apparently healthy, 8 years-old lean boy.
His ECHOcardiogram is normal: no left ventricular hypertrophy.
The ECG of a lean person with a low body mass index may show increased voltage as a normal variant.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 21. The ECG above belongs to an apparently healthy, 11 years-old lean boy. His echocardiogram is normal.
The ECG of a lean person with low body mass index may show increased voltage as a normal variant.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 22. The compact ECG above belongs to a 14 years-old male with a normal ECHOcardiogram (no left ventricular
hypertrophy). Sokolow-Lyon criteria is frequently present in adults younger than 30 years of age.
As seen in the above example, there is no left ventricular hypertrophy despite the presence of Sokolow-Lyon criteria.
ECG 23. The ECG above belongs to a 51 years-old man with long-standing untreated hypertension.
This ECG was recorded in the emergency room when he was experiencing intracranial hemorrhage.
ECHOcardiography showed significant left ventricular hypertrophy (interventricular septum:1.9 cm, posterior wall:1.4 cm)
Acccording to Gubner criteria, increased QRS voltage is present.
The QRS width is also increased (124 miliseconds).
Click here for a more detailed ECG
ECG 24. The ECG above belongs to a 76 years-old woman with long-standing hypertension.
ECHOcardiography showed normal left ventricular systolic function with only mild mitral valve insufficiency.
Many ECG signs of left ventricular hypertrophy are seen in the above ECG.
Click here for a more detailed ECG
ECG 25. The compact ECG above belongs to a woman with chronic systemic hypertension.
It shows left ventricular hypertrophy according to Gubner criteria:
The R amplitude in lead I + the S wave amplitude in lead III is larger than 25 mm (2.5 mV).
The R amplitude in lead I is larger than 15 mm (1.5 mV).
ECHOcardiography confirmed left ventricular hypertrophy in this patient.
ECG 26. The ECG above belongs to a 40 years-old man with untreated hypertension.
He says that he has high blood pressure for the last year.
There is no classic ECG pattern for left ventricular hypertrophy (LVH), but the Romhilt criteria is positive in this ECG.
Lead II is compatible with the Romhilt criteria: R + S > 19mm (1.9 mV) in any extremity lead (Romhilt 1968).
The above ECG shows LVH criteria but ECHOcardiography does not. He has normal left ventricular wall thickness.
In patients with hypertension, ECG criteria of LVH may be seen before the development of increased wall thickness
on ECHOcardiography.
Click here for a more detailed ECG
ECG 27. The ECG above belongs to a 60 years-old woman with effort angina, hypertension, diabetes mellitus,
chronic renal failure and morbid obesity. She was offered diagnostic coronary angiography but she refused.
This ECG shows left anterior fascicular block. It has been reported that the reliability of Cornell voltage criteria decreases
in the presence of left anterior fascicular block. In the above ECG, the Cornell voltage criteria is just satisfied:
R in aVL + S in C3 >2.0 mV (in women).
Also Gubner criteria is just satisfied: RI + SIII > 25 mm (2.5 mV).
ECHOcardiography showed thickened interventricular septum (1.4 cm) in this patient.
Click here for a more detailed ECG
ECG 28. The ECG above belongs to a 56 years-old woman with chronic hypertension.
ECHOcardiography showed left ventricular hypertrophy.
Gubner criteria for left ventricular hypertrophy is present.
ST depression and T wave negativity are also seen but coronary angiography did not show significant stenosis.
Click here for a more detailed ECG
ECG 29. The above ECG is from a 45 years-old woman with a permanent cardiac pacemaker.
ECHOcardiography showed dilated right atrium and right ventricle.
Leads I and V4 show giant pacemaker spikes which must not be confused with increased QRS voltage.
There is no ECG sign of left ventricular hypertrophy.
Click here for a more detailed ECG
ECG 30. The above ECG is from a 41 years-old man with systemic hypertension and significant valvular heart disease.
He has severe aortic insufficiency, moderate aortic stenosis and moderate mitral stenosis.
ECHOcardiography showed left ventricular hypertrophy and dilation of all cardiac chambers
The amplitudes of R and S waves in either lead II or lead III is > 19mm (1.9 mV) (Romhilt criteria).
Click here for a more detailed ECG
ECG 31. The above ECG is from a 67 years-old woman with systemic hypertension and left ventricular hypertrophy.
The amplitudes of R and S waves in lead III is > 19mm (1.9 mV) (Romhilt criteria).
The ECG shows extensive T wave negativity. However, coronary angiography showed normal coronary arteries.
She also does not complain of typical chest pain.
Click here for a more detailed ECG
ECG 32. The above ECG is from a 29 years-old man with systemic hypertension.
ECHOcardiography did NOT show left ventricular hypertrophy.
The amplitudes of R (and S) waves in lead II is 24 mm (>19 mm or >1.9 mV) (Romhilt criteria).
ECG signs of left ventricular hypertrophy arises long before detection by ECHOcardiography.
Sokolow-Lyon criteria is also positive in this patient but under 30 years of age, the reliability of Sokolow-Lyon criteria is low.
When I saw this ECG on his initial visit to my outpatient clinic, I said "you have high blood pressure", but he said "No".
I measured his blood pressure high, but he said "it may be due to hospital anxiety" (white-coat hypertension).
To persuade him, I used ABPM (Ambulatory Blood Pressure Monitoring) for 24 hours.
ABPM showed that more than half of the measurements were above normal limits.
Click here for a more detailed ECG
ECG 33. Above ECG is from a 54 years-old woman with hypertension, mild to moderate aortic valve stenosis
and chronic renal failure.
Leads I, aVL, V5 and V6 show ST segment depression and negative T waves.
However, her coronary angiography showed normal coronary arteries.
ECHOcardiography showed left ventricular hypertrophy.
Despite the presence of bundle branch block, this ECG shows left ventricular hypertrophy.
Click here for a more detailed ECG