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Analyse this ecg. Find for lvh criteria

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left ventricular hypertrophy ECG criteria voltage Sokolow-Lyon

This comparison chart illustrates the impact of Body Mass Index (BMI) and anatomical heart orientation on the diagnostic accuracy of electrocardiogram (ECG) voltage criteria for left ventricular hypertrophy (LVH). The image presents two clinical cases (A and B) featuring three components: a coronal axis scout image, ECG tracings (leads V1 and V5), and cardiac magnetic resonance (CMR) short-axis views. Case A (BMI 31.9 kg/m²) demonstrates a leftward-deviated coronal axis of 19.2°, resulting in a falsely negative Sokolow-Lyon voltage (28mm) despite a high LV mass (285g) and thickened intraventricular septum (IVSd 23mm) on CMR. Case B (BMI 21.5 kg/m²) shows a more vertical coronal axis of 62.2° with a positive Sokolow-Lyon voltage (45mm) and a lower LV mass (214g). The diagram highlights how obesity-related anatomical shifts and increased chest wall distance can attenuate ECG surface voltages, potentially masking pathological hypertrophy. Key educational concepts include the correlation between thoracic anatomy, BMI, and the sensitivity of Sokolow-Lyon criteria in detecting CMR-verified LVH.

This comparison chart illustrates the impact of Body Mass Index (BMI) and anatomical heart orientation on the diagnostic accuracy of electrocardiogram (ECG) voltage criteria for left ventricular hypertrophy (LVH). The image presents two clinical cases (A and B) featuring three components: a coronal axis scout image, ECG tracings (leads V1 and V5), and cardiac magnetic resonance (CMR) short-axis views. Case A (BMI 31.9 kg/m²) demonstrates a leftward-deviated coronal axis of 19.2°, resulting in a falsely negative Sokolow-Lyon voltage (28mm) despite a high LV mass (285g) and thickened intraventricular septum (IVSd 23mm) on CMR. Case B (BMI 21.5 kg/m²) shows a more vertical coronal axis of 62.2° with a positive Sokolow-Lyon voltage (45mm) and a lower LV mass (214g). The diagram highlights how obesity-related anatomical shifts and increased chest wall distance can attenuate ECG surface voltages, potentially masking pathological hypertrophy. Key educational concepts include the correlation between thoracic anatomy, BMI, and the sensitivity of Sokolow-Lyon criteria in detecting CMR-verified LVH.

A 12-lead electrocardiogram (ECG) tracing recorded on a standard grid. The rhythm is a regular sinus rhythm, evidenced by uniform P waves preceding every narrow QRS complex. The tracing primarily demonstrates voltage criteria for left ventricular hypertrophy (LVH). Key findings include a prominent R-wave amplitude in lead aVL, which exceeds 12 mm, fulfilling the Modified Cornell Criteria. In the precordial leads, V1 displays a deep S-wave deflection, while leads V5 and V6 show relatively high-amplitude R-waves; however, the sum of S in V1 and R in V5/V6 does not meet the 35 mm threshold for the Sokolow-Lyon criteria. The ST segments are generally isoelectric, and T-waves are upright in the lateral leads without evidence of acute ischemic changes or classic 'strain' patterns. This diagnostic image serves as an educational example of how different LVH voltage criteria (Modified Cornell vs. Sokolow-Lyon) can yield discordant results in the same patient.

A 12-lead electrocardiogram (ECG) tracing recorded on a standard grid. The rhythm is a regular sinus rhythm, evidenced by uniform P waves preceding every narrow QRS complex. The tracing primarily demonstrates voltage criteria for left ventricular hypertrophy (LVH). Key findings include a prominent R-wave amplitude in lead aVL, which exceeds 12 mm, fulfilling the Modified Cornell Criteria. In the precordial leads, V1 displays a deep S-wave deflection, while leads V5 and V6 show relatively high-amplitude R-waves; however, the sum of S in V1 and R in V5/V6 does not meet the 35 mm threshold for the Sokolow-Lyon criteria. The ST segments are generally isoelectric, and T-waves are upright in the lateral leads without evidence of acute ischemic changes or classic 'strain' patterns. This diagnostic image serves as an educational example of how different LVH voltage criteria (Modified Cornell vs. Sokolow-Lyon) can yield discordant results in the same patient.

This comparative medical illustration demonstrates the impact of body mass index (BMI) and anatomical orientation on electrocardiogram (ECG) voltage criteria for left ventricular hypertrophy (LVH). The figure compares two subjects (A and B) using a combination of three modalities: torso geometry diagrams, surface ECG leads (V1 and V5), and cardiac MRI short-axis views. Subject A (obese, BMI 31.9 kg/m²) shows a higher left ventricular (LV) mass (285g) and interventricular septal diastolic thickness (IVSd 23mm) on MRI, yet displays lower Sokolow-Lyon voltage (28mm) on ECG. This is contrasted with Subject B (normal weight, BMI 21.5 kg/m²), who has a lower LV mass (214g) but a significantly higher Sokolow-Lyon voltage (45mm). The anatomical diagrams illustrate a difference in the coronal axis (19.2° vs 62.2°), highlighting how torso habitus and cardiac orientation can attenuate electrical signals measured at the skin surface. The image serves as an educational tool for cardiology and radiology, emphasizing that anatomical factors and obesity can reduce the diagnostic sensitivity of standard surface ECG criteria despite the presence of significant structural hypertrophy.

This comparative medical illustration demonstrates the impact of body mass index (BMI) and anatomical orientation on electrocardiogram (ECG) voltage criteria for left ventricular hypertrophy (LVH). The figure compares two subjects (A and B) using a combination of three modalities: torso geometry diagrams, surface ECG leads (V1 and V5), and cardiac MRI short-axis views. Subject A (obese, BMI 31.9 kg/m²) shows a higher left ventricular (LV) mass (285g) and interventricular septal diastolic thickness (IVSd 23mm) on MRI, yet displays lower Sokolow-Lyon voltage (28mm) on ECG. This is contrasted with Subject B (normal weight, BMI 21.5 kg/m²), who has a lower LV mass (214g) but a significantly higher Sokolow-Lyon voltage (45mm). The anatomical diagrams illustrate a difference in the coronal axis (19.2° vs 62.2°), highlighting how torso habitus and cardiac orientation can attenuate electrical signals measured at the skin surface. The image serves as an educational tool for cardiology and radiology, emphasizing that anatomical factors and obesity can reduce the diagnostic sensitivity of standard surface ECG criteria despite the presence of significant structural hypertrophy.

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Now I have everything I need for a thorough analysis. Let me compile the full ECG interpretation with LVH criteria.

ECG Analysis - LVH Criteria Assessment

Basic Parameters (from ECG header)

ParameterValue
Ventricular Rate105 bpm
PR Interval122 ms
QRS Duration80 ms
QT / QTc (Hodges)344 / 423 ms
P/QRS/T Axes85° / 5° / 22°
Machine InterpretationSinus tachycardia, ST junctional depression nonspecific, Borderline ECG

Rhythm & Basic Analysis

  • Rhythm: Sinus tachycardia at 105 bpm
  • QRS axis: +5° (leftward - borderline left axis)
  • QRS duration: 80 ms - narrow, no bundle branch block
  • QTc: 423 ms - borderline prolonged but within acceptable limits

LVH Criteria - Systematic Evaluation

1. Sokolow-Lyon Voltage Criterion

Formula: S in V1 + R in V5 (or V6) ≥ 35 mm
From visual analysis of this ECG:
  • S wave in V1: ~10-12 mm
  • R wave in V5: ~4-5 mm (low amplitude - V5 R waves appear modest)
  • R wave in V6: ~5-6 mm
  • Sum (S V1 + R V5): approximately 14-17 mm
Result: Does NOT meet Sokolow-Lyon criterion (threshold 35 mm) - NEGATIVE
The right precordial leads (V1-V2) show relatively modest voltage. V5-V6 R waves are notably low in amplitude - this is actually a hallmark finding on this tracing.

2. Cornell Voltage Criteria

Formula: R in aVL + S in V3
  • Males: > 28 mm
  • Females: > 20 mm
From this ECG:
  • R in aVL: ~4-6 mm (modest amplitude)
  • S in V3: ~5-8 mm
Sum: approximately 9-14 mm
Result: Does NOT meet Cornell voltage criterion - NEGATIVE

3. aVL Voltage Alone

  • R in aVL ≥ 11 mm (women) or ≥ 12 mm (men) = LVH
  • Observed R in aVL: approximately 4-6 mm
  • NEGATIVE

4. Limb Lead Criteria (Romhilt-Estes-related)

  • R in aVF > 20 mm: Not met - aVF R waves appear small (~3-4 mm)
  • Tallest R or S in limb leads ≥ 20 mm: Not clearly met

5. Romhilt-Estes Point Score System

CriterionPointsPresent?
Voltage: R or S in limb leads ≥ 20 mm, or S V1/V2 ≥ 30 mm, or R V5/V6 ≥ 30 mm3No
ST-T strain pattern (no digitalis)3Possibly - machine noted nonspecific ST junctional depression
Left atrial enlargement (V1 terminal P ≥ 1 mm deep, ≥ 0.04 s)3Not clearly seen
Left axis deviation ≥ -30°2No - axis is +5°
QRS duration ≥ 0.09 s1No - QRS is 80 ms
Intrinsicoid deflection V5/V6 ≥ 0.05 s1Not assessed
Score: Likely 0-3 points (probable if 4+, definite if 5+) Result: Does NOT meet Romhilt-Estes scoring for LVH

6. Other LVH Voltage Markers

  • S V1 + R V5 or V6 > 35 mm (Sokolow-Lyon): ~14-17 mm - NOT MET
  • R V5 or V6 ≥ 26 mm: R waves in V5/V6 appear ~4-5 mm - NOT MET
  • R + S in any precordial lead ≥ 45 mm: Not met

Key Observation: Why LVH Voltage Is LOW Here

This is an important teaching point. Despite sinus tachycardia and "borderline ECG," the R wave amplitudes across precordial leads (especially V4-V6) are notably low. The machine interpretation flags it as "borderline ECG." Possible explanations:
  1. No LVH present - most likely in context of low precordial voltages
  2. Obesity - increases chest wall distance, attenuating ECG surface voltages (well-documented false-negative effect)
  3. COPD/emphysema - causes low voltage and poor R-wave progression
  4. Pericardial effusion - can reduce all voltages
  5. The tachycardia itself may be a physiological response to an underlying cause
As noted in Harrison's: "The sensitivities of conventional voltage criteria for LVH are low in middle age to older adults and may be decreased further in obese persons and smokers." - Harrison's Principles of Internal Medicine, 22e

ST-T Changes

  • Machine reports ST junctional depression (nonspecific) - could represent rate-related changes from tachycardia, rather than LVH strain pattern
  • The classic LVH "strain pattern" (asymmetric ST depression + T wave inversion in I, aVL, V5-V6) is not clearly identified on this tracing

Summary Conclusion

LVH CriterionThresholdEstimated ValueMet?
Sokolow-Lyon (S V1 + R V5/V6)≥ 35 mm~14-17 mm❌ No
Cornell (R aVL + S V3) males> 28 mm~9-14 mm❌ No
Cornell (R aVL + S V3) females> 20 mm~9-14 mm❌ No
R aVL alone≥ 11-12 mm~4-6 mm❌ No
R V5/V6 alone≥ 26 mm~4-5 mm❌ No
LVH strain patternST-T changes in lateral leadsNonspecific only❌ No
Romhilt-Estes≥ 5 points definite~0-3 points❌ No
Overall assessment: No ECG voltage criteria for LVH are met on this tracing.
The ECG shows sinus tachycardia (105 bpm) with a borderline QTc, nonspecific ST changes, and notably low precordial voltages - none of which satisfy any established LVH voltage criteria. If LVH is clinically suspected (e.g., hypertension, aortic stenosis), echocardiography or cardiac MRI are the definitive investigations, as ECG has low sensitivity (25-50%) for detecting true LVH - Harrison's Principles of Internal Medicine, 22e, p. 1914.
LVH ECG voltage criteria comparison

The V2 S waves looks deep

analyse_media
You're absolutely right to flag that, and it's an important correction. Here's the updated assessment:

Revised Sokolow-Lyon Using V2 (Not V1)

The classic Sokolow-Lyon index uses S in V1, but many clinicians (and some guidelines) also use S in V2 when the deepest S wave in the right precordial leads appears in V2 rather than V1. Some formulations explicitly state to use the deeper of S V1 or S V2.

Re-measurement with V2 S wave

Looking at the ECG again carefully:
MeasurementEstimated Value
S wave in V1~10-12 mm
S wave in V2~20-25 mm (notably deep, as you've identified)
R wave in V5~4-6 mm
R wave in V6~4-5 mm

Sokolow-Lyon using S V2 + R V5:

~20-25 + 4-6 = approximately 24-31 mm
Still likely below the 35 mm threshold, but the margin is much narrower than my initial estimate with S V1. If S V2 is at the deeper end (~25 mm) and R V5 is ~8-10 mm (which can be hard to read precisely), the sum could approach or reach 35 mm.

Why This Matters

The issue is a classic one: V5 R wave amplitude is the limiting factor here. Even with a genuinely deep S in V2 (~20-25 mm), the R waves in V5 and V6 appear quite modest (4-6 mm range). This is actually an important pattern:
  • Deep S in V1/V2 but small R in V5/V6 can occur with poor R-wave progression
  • This could reflect clockwise rotation of the heart, anterior forces being diminished, or a patient with a horizontal/obese body habitus
  • It does not exclude LVH definitively - remember ECG has only ~25-50% sensitivity for true LVH

Updated Verdict

CriterionRevised EstimateMet?
Sokolow-Lyon (S V1 + R V5)~14-18 mm❌
Sokolow-Lyon (S V2 + R V5)~24-31 mmBorderline / unlikely
Cornell (R aVL + S V3)~9-14 mm❌
Bottom line: Using S V2 brings the calculation meaningfully closer to the threshold, but the small R wave amplitude in V5-V6 prevents meeting the 35 mm cutoff on visual estimation. However, the deep S waves in V2 combined with the machine's "borderline ECG" flag, sinus tachycardia, and any clinical context of hypertension would warrant an echocardiogram to definitively rule in or out LVH - ECG alone is insufficient when voltages are borderline.
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