A systematic review comparing 6 EKG criteria for LVH (including commonly used Sokolow-Lyon [defined below], Cornell voltage index or product, Gubner, and Romhilt-Estes scores 4 or 5) with echocardiography reported very low median sensitivities; “highest” sensitivity was found using the Sokolow-Lyon criteria (median 21%, 4-52%). Median specificities were 89% (53-100%) and 99% (71-100%) for Sokolow-Lyon and Romhilt-Estes criteria (5 points) (1).
LVH definition of selected EKG indexes
Sokolow-Lyon index: SV1+(RV5 or V6)>35 mm
Cornell voltage index: men, RaVL+SV3>28 mm; women, RaVL+SV3>20 mm
Modified Cornell: RaVL>11mm (>10 mm, ref. 3)
Gubner: RI+SIII>24mm
More recently, MRI has become the gold standard for in-vivo LV mass measurement. In a study involving patients with aortic stenosis undergoing MRI, EKG generally had poor negative predictive value (NPV) (<70% by most criteria), but high positive predictive value (PPV) (>90% by most criteria) for LVH; for Sokolow-Lyon criteria, the NPV and PPV were 46% and 90%, respectively (2).
In another MRI study involving patients with various cardiovascular conditions (eg hypertension, CAD), RaVL alone (>10mm) performed better than Sokolow-Lyon (AUC 0.78, specificity 95.5%) but its sensitivity was still nothing to brag about (36.5%) (3).
So, EKGs are better at ruling in than ruling out LVH!
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References
1.Pewsner D, Juni P, Egger M, et al. Accuracy of electrocardiography in diagnosis of left ventricular hypertrophy in arterial hypertension: systematic review. BMJ 2007. doi:10.1136/bmj.39276.636354.AE https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2001078
2.Buchner S, Debl K, Haimerl J, et al. Electrocardiographic diagnosis of left ventricular hypertrophy in aortic valve disease: evaluation of ECG criteria by cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2009; 11:18. https://jcmr-online.biomedcentral.com/articles/10.1186/1532-429X-11-18
3.Courand P-Y, Grandjean A, Charles P, et al. R wave in aVL lead is a robust index of left ventricular hypertrophy: a cardiac MRI study. Am J Hypertension 2015;28:1038-48. https://www.ncbi.nlm.nih.gov/pubmed/25588700
Contributed in part by Khin-Kyemon Aung, medical student, Harvard Medical School, Boston.
