Left ventricular hypertrophy

Associate Editor-In-Chief:

Left ventricular hypertrophy (LVH) is the thickening of the myocardium (muscle) of the left ventricle of the heart. While ventricular hypertrophy can occur naturally as a reaction to aerobic exercise and strength training, it is most frequently referred to as a pathological reaction to cardiovascular disease.

While LVH itself is not a disease, it is usually a marker for disease involving the heart. Disease processes that can cause LVH include any disease that increases the afterload that the heart has to contract against, and some primary diseases of the muscle of the heart.

Causes of increased afterload that can cause LVH include aortic stenosis, aortic insufficiency, and hypertension. Primary disease of the muscle of the heart that cause LVH are known as hypertrophic cardiomyopathies.

Complete Differential Diagnosis of Causes of Left Ventricular Hypertrophy

 * Acromegaly
 * Alcoholic cardiomyopathy
 * Aortic coarctation
 * Aortic regurgitation
 * Aortic stenosis
 * Chronic Renal Failure
 * Familial dilated and hypertrophic cardiomyopathy
 * Hypertrophic cardiomyopathy (HCM)
 * Idiopathic dilated cardiomyopathy
 * Mitral regurgitation
 * Patent Ductus Arteriosus
 * Restrictive cardiomyopathy
 * Thalassemia

Diagnosis
The principal method to diagnose LVH is echocardiography, during which the thickness of the muscle of the heart can be measured. The electrocardiogram (ECG) often shows signs of increased voltage from the heart in individuals with LVH, so this is often used as a screening test to determine who should undergo further testing with an echocardiogram.

Chest x-ray
Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Echocardiography
Two dimensional echocardiography can produce images of the left ventricle. The thickness of the left ventricle as visualized on echocardiography correlates with its actual mass. Normal thickness of the left ventricular myocardium is from 0.6 to 1.1 cm (as measured at the very end of diastole. If the myocardium is more than 1.1 cm thick, the diagnosis of LVH can be made.

ECG criteria for LVH
There are multiple criteria used to diagnose LVH via electrocardiography. None of them are perfect. However, by using multiple different criteria the sensitivity and specificity are increased.

The Sokolow and Lyon criteria
 * S in V1 + R in V5 or V6 (whichever is larger) =/> 35 mm
 * R in aVL =/> 11 mm

The Cornell criteria1 for the ECG diagnosis of LVH involves 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)

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

Additional resources

 * ECGpedia: Course for interpretation of ECG
 * The whole ECG - A basic ECG primer
 * 12-lead ECG library
 * Simulation tool to demonstrate and study the relation between the electric activity of the heart and the ECG
 * ECG information from Children's Hospital Heart Center, Seattle
 * ECG Challenge from the ACC D2B Initiative
 * National Heart, Lung, and Blood Institute, Diseases and Conditions Index
 * A history of electrocardiography
 * EKG Interpretations in infants and children

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