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LVH AND RVH Dr. Mohammed Niyaz
MEM Y2ASTER MIMS
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OVERVIEWLVH Definition Types of LVH ECG changes in systolic overload Criteria to diagnose LVH ECG changes in diastolic overload
RVH Definition ECG changes Clinical correlation
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DEFINITION OF LVH
Increase in the mass of the left ventricle, which can be secondary to an increase in wall thickness, an increase in cavity size, or both.
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THE NORMAL QRS THROUGH THE LEADS
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Represents dominant right to left QRS vector
Indirect representation of left free wall activation
Hypertrophy of LV free wall
LEFT VENTRICULAR HYPERTROPHY
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Systolic overload
aka Pressure overload
Resistance to LV systolic outflow
LV compromise occurs in systole
AS, HTN, HCM, Coarctation of aorta
Diastolic overload
aka Volume overload
Overfilling of the LV in diastole
LV compromise occurs in diastole
PDA, VSD ( moderate to large L R shunts), AR, MR
LEFT VENTRICULAR HYPERTROPHY
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Abnormalities of
QRS
Abnormalities of U wave
Left atrial abnormali
ty
Abnormalities of QRS & T wave
axes
Abnormalities of ST
segment & T wave
LVH due to
systolic overloa
d
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Abnormalities of
QRS complex
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Abnormalities of ST
segment & T wave
T wave Assymetric
alShallow proximal
limb
T wave Inverted in I aVL V5 V6Upright in aVR V1 2
ST segmentMinimally depressed with slight
upward convexity in
left oriented
leads
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Abnormalities of QRS & T wave axis
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Abnormalities of U
wave
• Inverted in left oriented chest leads
• Not specific, more commonly associated with diastolic overload
Left atrial abnormali
ty
•Corroborative evidence •Particularly useful in presence of LBBB where it may be the only sign of LVH
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QRS T WAVE AXIS
Early stage – no change in axis
Due to symmetric increase in bulk
Late stage- Left Axis deviation
Due to left anterior hemiblock
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Progressive widening of QRS T angle beyond the normal 45
degree
T wave tends to be flat in
lead I
Longstanding
hypertension T wave is
maximally to the right(+- 180 degree)
Wide frontal and
horizontal plane QRS –T
angles
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Romhilt and Estes point score system
ECG finding Points
Increased QRS magnitude 3ST T abnormalities 3P wave of LA abnormality 3Left axis deviation 2Increased VAT 1
≥ 5points LVHMainly applicable for
LVH due to systolic overload
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S wave in V1
R wave in in V5 or V6
35 mm
SOKOLOW LYON INDEX
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Total QRS voltage of all 12 conventional ECG leads
> 175 mm or 17.5 mV
TOTAL QRS VOLTAGE
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CORNELL VOLTAGE CRITERIASum of S wave in V3 and R wave in aVL> 28 mm in men and > 20 mm in women
Sensitivity is increased by multiplying with QRS duration- CORNELL VOLTAGE PRODUCT
> 2440 mm ms indicates LVH
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R wave in aVL > 11 mm
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Tall R waves
Relatively tall,
symmetrical T wave
Inverted U waves
Minimal ST segment elevation
Deep, prominent, narrow Q waves
LVH due to
diastolic
overload
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CLINICAL SIGNIFICANCE OF LVH
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Asymmetrical
Blunt
Not very deep
Symmetrical
Pointed
Deep
LV strain T
inversion
Ischemic T
inversion
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RIGHT VENTRICULAR HYPERTROPHY
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RIGHT VENTRICULAR HYPERTROPHY
1. Paraseptal region
2. Free wall of RV
3. Basal regions
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Right free
wall•Tall R waves in right precordial leads•Mean frontal QRS axis to the region of 120
Right Para septal wall•Tall R waves of RS complexes in mid precordial leads•90 to 120
Right basal region
•rS complexes in v1 to v6with deep s waves v5 v6•qR complexes in aVR•Terminal S waves in all 3 standard leads- SI SII SIII syndrome•Mean frontal QRS is directed to the right superior quadrant
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Abnormalities of QRS
Abnormalities of P wave
Abnormalities of ST
segment, T wave & U
wave
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Right Axis DeviationDominant R
wave in right sided
leadsInitial
“incident” of QRS in
V1
Increased VAT in
V1RS or rS complexes
in left leads
RS complexes in mid
precordial leads
Clockwise
rotation
RBBB
QRS manifestati
ons of basal RVH
QRS manifestati
ons
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Right axis deviation
R in V1 > 6 mm qR complex in V1
(R in V1) + (S in V5 or V6) >10.5 mm
R/S ratio in V1 >1 S/R ratio in V6 >1
Increased VAT in V1
Right bundle branch block
ST-T wave abnormalities ("strain") in right precordial leads
Right atrial abnormality
S1S2S3 pattern S1Q3T3 pattern
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•Minimally depressed•Slight upward convexity
Abnormalities of ST segment
•T wave inversion in right oriented leads (V1 to V4)•Most marked in V1 V2 & diminishes progressively in amplitude
Abnormalities of T wave
•Decreased in amplitude or even inverted in right precordial leads &/or inferior leads
Abnormalities of U wave
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• RVH is frequently associated with right atrial abnormality
• Manifests as a tall & peaked P wave in standard lead II
Abnormalities of P wave
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SI SII SIII SYNDROME
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CLINICAL CORRELATION
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BIVENTRICULAR HYPERTROPHY
Biventricular Hypertrophy
ECG OF LVH associated with
RADdegree of clock wise rotation
( particularly seen in RVH with RV
dilatation
Relatively tall R wave in V1
(R/S >1)
When P wave of LAA is seen with
Right Axis deviation of
QRS to right of 90 degree
S wave in lead V5 or lead V6 equal
to or greater than 0.7 mV
R/S ratio in lead V5 or V6
equal to or less than 1
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TAKE HOME MESSAGE DIAGNOSING LVH
SOKOLOV LYON CRITERIA
VOLTAGE IN aVL
NON VOLTAGE CRITERIA
CLINICAL CORRELATION
DIAGNOSING RVH
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Thank you