Lesson 2: LVH/RVH and Strain

Summary Of Learning Points

• LVH increases the amplitude of the normal vector generated by the left ventricle. 

  • This results in a deeper S wave in earlier septal leads and a taller R wave in later septal leads and lateral leads

• There are many criteria for LVH (you don’t need to memorize these!), some of the most common include

  • Cornell Criteria: S wave in V3 + R wave aVL >28mm in males​ >20mm in females​

  • Sokolow-Lyon Criteria: S in V1 or V2+ R in V5 or V6 >35mm

  • Any precordial lead is ≥ 45 mm

  • The R wave in aVL is ≥ 11 mm

  • The R wave in lead I is ≥ 12 mm

  • The R wave in lead aVF is ≥ 20 mm

• LVH with strain is characterized by

  • ST depression with downward concavity and asymmetric T wave inversions in V4-V6

  • ST elevation with upward concavity and upright, asymmetric T wave in V1-V3

  • With abnormal depolarization there is often abnormal discordant repolarization.

• RVH increases amplitude of the normal vector generated by the Right ventricles

  • This manifests as an R:S ratio >1 in leads V1 and V2

• RVH criteria: R:S ratio >1 in leads V1 and V2 AND 1 of the following

  • Right atrial enlargement

  • Right axis deviation

  • RVH strain

  • S1Q3T3

• RVH is a challenging diagnosis! R:S >1 alone is not diagnostic of RVH, differential includes

  • Right ventricular hypertrophy

  • Right bundle branch block

  • Posterior wall AMI

  • WPW type A

  • Young kids and adolescents

Practice ECG

Take a look at this practice ECG. What do you think about the ST/T segments here? (Scroll down for the answers)

Answer

Rate: 60 BPM

Rhythm: Sinus

Axis: Normal

P waves: upright in II, predominantly negative in V1 consistent with left atrial abnormality

PR interval: Normal

QRS: Narrow, meets LVH criteria (R in avL+ S in V3 >28 m, R wave in aVL> 11mm)

ST/T changes: ST depression with T wave inversions in aVL. Additionally, there is prominent horizontal or down-sloping ST depression in leads (I, II, aVF, V5, V6) which suggest ischemia superimposed on LVH, especially with concomitant elevation in aVR

Q waves: aVL

QT: <500ms