Author + information
- Thomas J. Betjeman, MD∗ (, )
- Luis Rigales, MD and
- Irwin Hoffman, MD
- ↵∗Christus St. Vincent Regional Medical Center, 455 St. Michaels Drive, Santa Fe, New Mexico 87505
Simple new voltage criteria for the electrocardiograhic (ECG) diagnosis of left ventricular hypertrophy (LVH) have been proposed by Peguero et al. (1). When the sum of the maximum S-wave in any ECG lead plus the S-wave in V4 exceeds 28 mm in men or 23 mm in women, LVH may be diagnosed.
Left anterior hemiblock (LAHB) is a well defined vectorcardiographic (VCG) and ECG entity since 1970 (2). The VCG and ECG criteria were refined by Warner et al. (3) in 1983. The frontal plane VCG loop is left and superior, with counterclockwise rotation. The resulting scalar leads aVL and aVR both exhibit terminal R waves, but the R-wave peak in aVR occurs later than the terminal R-wave in aVL. The abnormal left axis is superior to –30°, resulting in prominent R waves in leads I and aVL, with corresponding deep S waves in leads III and aVF. These increased R-wave amplitudes in LAHB commonly match published criteria for LVH, resulting in well recognized false positive LVH diagnoses (4). In addition, the corresponding deep S waves in leads III and aVF when added to S-wave V4 may satisfy the proposed new LVH criteria.
We have observed several cases of intermittent LAHB in which these new LVH criteria are met only when LAHB is present. Figure 1A is an ECG from a 39-year-old man at a heart rate of 68 beats/min.
Figure 1B was recorded on the same patient 13 h later at a heart rate of 99 beats/min. The QRS complexes in Figure 1B exhibit classic LAHB. The axis has shifted to –41 degrees, and the R-wave peak in aVL precedes the R-wave peak in aVR. A high S-wave amplitude is seen in lead III. Applying the proposed new LVH criteria, the sum of S-wave III (19 mm) when added to S-wave V4 (10 mm) is 29 mm, meeting the new LVH criteria. However, the corresponding QRS amplitudes in Figure 1A at a slower rate are normal, indicating that the enhanced amplitudes in Figure 1B are LAHB dependent.
Electrocardiographers should be aware of this possible pitfall in LVH diagnosis with the proposed new ECG criteria when LAHB is present. LVH confirmation by echocardiography is usually necessary.
Please note: The authors acknowledge the valuable assistance of Ms. Ebler, Medical Librarian, Christus St. Vincent Regional Medical Center. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. P. K. Shah, MD, served as Guest Editor-in-Chief for this paper. Kalyanam Shivkumar, MD, PhD, served as Guest Editor for this paper.
- 2017 American College of Cardiology Foundation
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