This document outlines ECG criteria for detecting enlargement of the heart chambers, including the left ventricle, right ventricle, and atria. Several voltage-based criteria and point scoring systems are described for identifying left ventricular hypertrophy with sensitivities generally around 35-55% and specificities of 85-95%. Signs of right ventricular hypertrophy and chronic pulmonary disease on ECG are also summarized. Biventricular enlargement can be suggested based on meeting criteria for both left and right ventricular hypertrophy simultaneously. Atrial enlargement of the left or right atria is characterized by abnormalities in the P wave morphology and duration.

1. ECG Criterias for
Chamber Enlargement

2. Left Ventricular Hypertrophy

3. Pressure overload pattern

4. Volume overload pattern

6. • Sokolow-Lyon voltages
• SV1 + R V5,6 > 3.5 mV
Sensitivity 22%
Specificity 100 %
• R aVL > 1.1 mV
• R V5,6 > 2.6 mV

7. • Romhilt-Estes point score system
– Any limb lead R wave or S wave > 2.0 mV (3 points)
or SV1 or SV2 ≥ 3.0 mV (3 points)
or RV5 to RV6 ≥ 3.0 mV (3 points)
– ST-T wave abnormality, no digitalis (3 points)
ST-T wave abnormality, digitalis therapy (1 point)
– Left atrial abnormality (3 points)
– Left axis deviation ≥ −30 degrees (2 points)
– QRS duration ≥ 90 msec (1 point)
– Intrinsicoid deflection in V5 or V6 ≥ 50 msec (1 point)
• Probable =4, Definite > = 5
• Sn 35-55 %, Specificity 85-95 %

8. • Cornel Voltage criteria
–SV3 + R aVL ≥ 2.8 mV (for men)
–SV3 + R aVL >2.0 mV ( women)
–Sensitivity 42%
–Specificity 96%

9. • Cornell voltage duration measurement
– QRS duration X Cornell voltage > 2,436 mm-sec
( + 8mm if female )
– QRS duration X sum of voltages in all leads > 1,742
mm-sec
– Sn 51 % and specificity of 95 %
– Accurate in obese

10. • Cornell Regression equation
– Risk of LVH = 1/(1+ e−exp)
– For subjects in sinus rhythm,
– exp = 4.558 − 0.092 (SV3 + RaVL) − 0.306 TV1 −
0.212 QRS − 0.278 PTFV1 − 0.559 (gender)
– PTF is the area under the P terminal force in lead
V1 (in mm-sec)
– gender = 1 for men and 2 for women.
– LVH is diagnosed present if exp < −1.55

11. • LVH : total QRS voltage in all 12 leads > 175
mm
• LVH : R in V6 = > V5
• Gertsch index : S III + max ( R+S) in any
precardial lead > 3.0 mV . valid even if LAFB
• Lewis score: R I + S III > 17 mm

12. More sensitive : LVH in HTN : sum of the QRS voltage of 12 ECG
leads >120 mm

13. 90 % of LBBB have LVH
A left atrial P-wave abnormality
QRS duration > 155 ms
SOURCE: Hurst 12/e Kafka, Burggraf, Milliken

14. SOURCE : hurst 12/e Gertsch, Theler, Foglia

15. RBBB and LVH
• RBBB decreases sensitivity of precardial voltage criteria
• LAA can be useful
• Point score system can be useful 96 % specific

16. Right Ventricular
hypertrophy

17. R’ > 15 mm in RBBB
Cabrera index > 0.5
R in V1/(R v1 + s v1)

19. Sokolow Lyon criteria for RVH:
– R V1 + S V5, V6 > 10.5 mm
– R V1 > 7 mm
– R in aVR > 5mm
– S V1 < 2mm

20. • Butler leggett formula :
RVH : Anterior (R or R’ in v1 or v2) + Right
(deepest S in I or v6) – Posterolateral
( S in V1) => 0.7mV ( Sn 34% and Sp 95%)

21. RVH Morphology
1. Precardial Voltage changes
2. ST T changes over RV
3. Delayed onset of intrinsicoid deflection
4. normal QRS duration
5. RAD

22. CHOU Types of RVH
• Type A: Typical RVH
tall R in V1 , Prominent S in V5, V6
• Type B: Incomplete RBBB pattern( ASD, RHD )
R in V1 >0.5 mV with R/S >1, Normal
QRS in V5, V6
• Type C: Chronic Lung Disease
(rS V1, V2 and RS in V5, V6 precardial
leads)
– ECG changes due to both RVH + anatomical shift
of heart

23. • RAD and Clockwise rotation is very common
in Type A RVH compared to B & C

24. The signs of acute RV overload :
• Change in the ÂQRS (>30° to the right)
• Transient negative T waves
• SI, QIII TIII pattern (McGinn-White pattern) in
the frontal plane and an RS or rS pattern in V6
• Appearance of a complete right bundle-branch
block morphology often with ST-segment
elevation
• S1Q3T3 pattern occurs in only about 10% PE
PPV 23- 69%

25. Chronic Obstructive Pulmonary Disease
• reduced amplitude of the QRS complex
• right axis deviation in the frontal plane
• delayed transition in the precordial leads
• Evidence of true RVH
– (1) RAD > 110 degrees
– (2) deep S waves in the lateral precordial leads
– (3) an S1Q3T3 pattern

26. Biventricular hypertrophy
• Diagnostic voltage criteria for both ventricles
• Delayed intrinsicoid delection over both
ventricles
• Repolarization changes over both
• LVH with RAD of QRS
• LVH with RAE
• Deep S in LVH
• LVH with clock wise rotation of precardial
morphology

27. Biventricular hypertrophy
• LAD with counterclockwise rotation in RVH
• Large equiphasic QRS in midprecardial leads
>6mm( Katz wachtel sign)
• Tall R in Left precardial leads + small s in V1 or
inverted t waves in right precardial leads

28. Atrial Enlargement

31. RAA
• Q waves (especially qR patterns) in the right
precordial leads (100 % specific)
• low-amplitude QRS complexes (<0.6 mV) in
lead V1 with a threefold or greater increase in
lead V2 (90 % specific)
• Severe RAE  prominent terminal negativity
in V1 ( Pseudo LAE pattern )
• Early terminal negativity of P V1 (< 0.03 s)

32. AF – LAE present if f wave > 1mm in V1

33. LAE Criteria Sensitivity specificity
Prolonged P wave duration > 120 msec in lead II 33 88
Prominent notching of P wave, usually most obvious in
lead II, with interval between notches of 0.40 msec (P
mitrale)
15 100
Ratio between the duration of the P wave in lead II and
duration of the PR segment > 1.6 Macruz index
31 64
Increased duration and depth of terminal- negative
portion of P wave in lead V1 (P terminal force) so that
area subtended by it > 0.04 mm-sec Morris index
69 93
Terminal negative deflection in V1 > 0.1 mV 60 93
duration > 0.04 s 83 80
Leftward shift of mean P wave axis to between −30 and
−45 degrees

34. Biatrial Enlargement