ECG criteria for LVH

There are several sets of criteria used to diagnose LVH via electrocardiography.[3] None of them is perfect, though by using multiple criteria sets, the sensitivity and specificity are increased. The Sokolow-Lyon index[4][5]: S in V1 + R in V5 or V6 (whichever is larger) 35 mm ( 7 large squares) R in aVL 11 mm The Cornell voltage criteria[6] for the ECG diagnosis of LVH involve measurement of the sum of the R wave in lead aVL and the S wave in lead V3. The Cornell criteria for LVH are:

S in V3 + R in aVL > 28 mm (men) S in V3 + R in aVL > 20 mm (women) The Romhilt-Estes point score system ("diagnostic" >5 points; "probable" 4 points):

ECG Criteria Voltage Criteria (any of): 1. R or S in limb leads 20 mm 2. S in V1 or V2 30 mm 3. R in V5 or V6 30 mm ST-T Abnormalities:

Points

ST-T vector opposite to QRS without digitalis

3 1 3 2 1

ST-T vector opposite to QRS with digitalis Negative terminal P mode in V1 1 mm in depth and 0.04 sec in duration (indicates left atrial enlargement) Left axis deviation (QRS of -30 or more) QRS duration 0.09 sec

Delayed intrinsicoid deflection in V5 or V6 (>0.05 sec)

Other voltage-based criteria for LVH include:

Lead I: R wave > 14 mm Lead aVR: S wave > 15 mm Lead aVL: R wave > 12 mm Lead aVF: R wave > 21 mm Lead V5: R wave > 26 mm Lead V6: R wave > 20 mm

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If there is left ventricular hypertrophy then this will result in :

a tall R wave (greater than 25mm in V5 or V6), or R plus S greater than 35 mm (1) a deep S in V1 or V2 if there is significant left ventricular 'strain' then there are also inverted T waves in V5 and V6 and possible ST depression left axis deviation may also be present QRS may be slightly prolonged

Notes:

a systematic review investigating the accuracy of ECGs in the diagnosis of LVH has been undertaken (2) o from the study data in primary care, a negative electrocardiogram result would reduce the typical pre-test probability from 33% to 31%. In secondary care the typical pre-test probability of 65% would be reduced to 63% o the authors concluded that electrocardiographic criteria should not be used to rule out left ventricular hypertrophy in patients with hypertension

Normal ecg

Diagnosis of myocardial infarction

ST elevation is measured at the junctional or J-point

The diagnosis of acute myocardial infarction is not only based on the ECG. A myocardial infarction is defined as:[2]

Elevated blood levels of cardiac enzymes (CKMB or Troponin T) AND One of the following criteria are met:

The patient has typical complaints, The ECG shows ST elevation or depression. pathological Q waves develop on the ECG A coronary intervention had been performed (such as stent placement)

So detection of elevated serum heartenzymes is more important than ECG changes. However, the cardiac enzymes can only be detected in the serum 5-7 hours after the onset of the myocardial infarction. So, especially in the first few hours after the myocardial infarction, the ECG can be crucial. ECG Manifestations of Acute Myocardial Ischaemia (in Absence of LVH and LBBB)are [3]:
ST elevation New ST elevation at the J-point in two contiguous leads with the cut-off points: 0.2 mV in men or 0.15 mV in women in leads V2V3 and/or 0.1 mV in other leads. ST depression and T-wave changes. New horizontal or down-sloping ST depression >0.05 mV in two contiguous leads; and/or T inversion 0.1 mVin two contiguous leads with prominent R-wave or R/S ratio 1

A study using MRI to diagnose myocardial infarction has shown that more emphasis on ST segment depression could greatly improve the yield of the ECG in the diagnosis of myocardial infarction (sensitivity increase from 50% to 84%).[4] Myocardial infarction diagnosis in left or right bundle branch block can be difficult, but it is explained in these seperate chapters:

Electrocardiogram

ECG of atrial fibrillation (top) and normal sinus rhythm (bottom). The purple arrow indicates a P wave, which is lost in atrial fibrillation.

Atrial fibrillation is diagnosed on an electrocardiogram (ECG), an investigation performed routinely whenever an irregular heart beat is suspected. Characteristic findings are the absence of P waves, with unorganized electrical activity in their place, and irregular R-R intervals due to irregular conduction of impulses to the ventricles.[5] However, irregular R-R intervals may be difficult to determine if the rate is extremely rapid.[10] QRS complexes should be narrow, signifying that they are initiated by normal conduction of atrial electrical activity through the intraventricular conduction system. Wide QRS complexes are worrisome for ventricular tachycardia, although in cases where there is disease of the conduction system, wide complexes may be present in AFib with rapid ventricular response. If paroxysmal AF is suspected but an ECG during an office visit only shows a regular rhythm, AF episodes may be detected and documented with the use of ambulatory Holter monitoring (e.g. for a day). If the episodes are too infrequent to be detected by Holter monitoring with reasonable probability, then the patient can be monitored for longer periods (e.g. a month) with an ambulatory event monitor.[5]