Electrocardiographic detection of left ventricular hypertrophy: Development and prospective validation of improved criteria

To develop improved electrocardiographic criteria of left ventricular hypertrophy, individual electrocardiographic voltage measurements were compared with echocardiographic left ventricular mass in a “learning series” of 414 subjects. The strongest independent relations with left ventricular mass were exhibited by the S wave in lead V3, the R wave in lead aVL and the T wave in lead V, (each p < 0.001), and by age and sex. Better electrocardiographic detection of left ventricular hypertrophy was achieved by new criteria that stratified QRS voltage and repolarization findings in sex and age subsets. For men, at all ages, left ventricular hypertrophy is suggested by QRS voltage alone when the R wave in lead aVL and the S wave in lead V3total more than 35 mm. When this voltage exceeds 22 mm, left ventricular hypertrophy is suggested in men under age 40 years when the T wave in lead V1is positive (≥0 mm), and in men 40 years or older when the T wave in lead V1is at least 2 mm. For women, at all ages, left ventricular hypertrophy is suggested when the R wave in lead aVL and the S wave in lead V3total more than 25 mm. When this voltage exceeds 12 mm; left ventricular hypertrophy is suggested in women under 40 when the T wave in lead V1is positive (≥0 mm), and in women over 40 when the T wave in lead V1is 2 mm or greater. Of note, the two lead QRS voltage criteria for men and women differ by 10 mm (1 mV) with identical age stratification and repolarization criteria.Prospective validation of these criteria in an independent "test" series of 129 additional subjects revealed superior sensitivity (49%), specificity (93%) and overall accuracy (76%), compared with standard electrocardiographic criteria (Romhilt-Estes point score and Sokolow-Lyon voltage). A multiple logistic regression equation, developed in the learning series using the same variables, achieved a sensitivity of 51%, specificity of 90% and overall accuracy of 76% in the test series.It is concluded that 1) voltages of the S wave in lead V3, R wave in lead aVL and T wave in lead V1convey the most independent electrocardiographic information about left ventricular hypertrophy; 2) sex and age stratification improves diagnosis of left ventricular hypertrophy; and 3) criteria based on these observations, as well as a logistic regression equation, readily applicable to electrocardiographic interpretation by widely available microprocessors, can improve recognition of left ventricular hypertrophy by the electrocardiogram