LVH & RVH on ECG

1. LVH AND RVH
Dr. Mohammed Niyaz
MEM Y2
ASTER MIMS

2. OVERVIEW
LVH
 Definition
 Types of LVH
 ECG changes in systolic overload
 Criteria to diagnose LVH
 ECG changes in diastolic overload
RVH
 Definition
 ECG changes
 Clinical correlation

3. 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.

4. THE NORMAL QRS THROUGH THE LEADS

5.  Represents dominant
right to left QRS vector
 Indirect representation
of left free wall
activation
 Hypertrophy of
LV free wall
LEFT VENTRICULAR HYPERTROPHY

6. 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

7. Abnormalities
of QRS
Abnormalities
of U wave
Left atrial
abnormality
Abnormalities
of QRS & T
wave axes
Abnormalities
of ST segment
& T wave LVH due
to
systolic
overload

8. Abnormalities
of QRS complex
Attenuation
of q wave
in left leads
Increase in
total QRS
duration
Increased
magnitude
of QRS
deflections
Increase in
VAT

10. Abnormalities
of ST segment
& T wave
T wave
Assymetrical
Shallow proximal
limb
T wave
Inverted in I aVL V5
V6
Upright in aVR V1 2
ST segment
Minimally
depressed with
slight upward
convexity in left
oriented leads

11. Abnormalities of QRS & T wave axis

12. • Inverted in left oriented chest leads
• Not specific, more commonly
associated with diastolic overload
Abnormalities
of U wave
• Corroborative evidence
• Particularly useful in presence of LBBB
where it may be the only sign of LVH
Left atrial
abnormality

14. 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

15. 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

16. Romhilt and Estes point score system
ECG finding Points
Increased QRS magnitude 3
ST T abnormalities 3
P wave of LA abnormality 3
Left axis deviation 2
Increased VAT 1
≥ 5points  LVH
Mainly applicable for
LVH due to systolic overload

17. S wave in
V1
R wave in
in V5 or V6
35
mm

19.  Total QRS voltage of all 12 conventional
ECG leads

20. CORNELL VOLTAGE CRITERIA
Sum 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

21.  R wave in aVL > 11 mm

22. 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

24. CLINICAL SIGNIFICANCE OF LVH

25. Asymmetrical
Blunt
Not very deep
Symmetrical
Pointed
Deep
LV strain
T inversion
Ischemic
T inversion

26. RIGHT VENTRICULAR
HYPERTROPHY

27. RIGHT VENTRICULAR HYPERTROPHY
1. Paraseptal region
2. Free wall of RV
3. Basal regions

28. 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

30. Right Axis
Deviation
Dominant R
wave in right
sided leads
Initial
“incident” of
QRS in V1
Increased VAT
in V1
RS or rS
complexes in left
leads
RS complexes in
mid precordial
leads
Clockwise
rotation
RBBB
QRS
manifestations
of basal RVH
QRS
manifestations

32.  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

33. • 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

34. • RVH is frequently associated with
right atrial abnormality
• Manifests as a tall & peaked P wave
in standard lead II
Abnormalities
of P wave

35. SI SII SIII SYNDROME

37. CLINICAL CORRELATION

38. BIVENTRICULAR HYPERTROPHY
Biventricular Hypertrophy
ECG OF LVH
associated with
RAD
degree 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

39. TAKE HOME MESSAGE
 DIAGNOSING LVH
 SOKOLOV LYON CRITERIA
 VOLTAGE IN aVL
 NON VOLTAGE CRITERIA
 CLINICAL CORRELATION
 DIAGNOSING RVH

40. Thank you