Chamber Hypertrophy and Enlargment: Difference between revisions

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Chamber Hypertrophy and Enlargment (view source)

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Left and right ventricular hypertrophy can be distinguished on the ECG:
Left and right ventricular hypertrophy can be distinguished on the ECG:


==Left ventricular hypertrophy==
=Left ventricular hypertrophy=
[[Image:E_lvh.jpg|thumb|right|300px|LVH. R in V5 is 26mm, S in V1 in 15mm. The sum is 41 mm which is more than 35 mm and therefore LVH is present according to the Sokolow-Lyon criteria.]]
[[Image:E_lvh.jpg|thumb|right|300px|LVH. R in V5 is 26mm, S in V1 in 15mm. The sum is 41 mm which is more than 35 mm and therefore LVH is present according to the Sokolow-Lyon criteria.]]
[[Image:LVH.png|thumb|250px]]
[[Image:LVH.png|thumb|250px]]
As the left ventricular wall becomes thicker, the QRS complexes become larger. This is especially true for leads V1-V6. The S wave in V1 is deep, the R wave in V4 is high. Often some ST depression can be seen in leads V5-V6, which is in this setting is called a 'strain pattern'.
As the left ventricular wall becomes thicker, the QRS complexes become larger. This is especially true for leads V1-V6. The S wave in V1 is deep, the R wave in V4 is high. Often some ST depression can be seen in leads V5-V6, which is in this setting is called a 'strain pattern'.


To diagnose left ventricular hypertrhophy on the ECG one of the following criteria should be met:
To diagnose left ventricular hypertrhophy on the ECG one of the following criteria should be met:
The '''Sokolow-Lyon criterium'''<cite>Sokolow</cite>), this is most often used:
The '''Sokolow-Lyon criterion'''<cite>Sokolow</cite>), this is most often used:
*R in V5 or V6 + S in V1 >35 mm.  
*R in V5 or V6 + S in V1 >35 mm.  


Other criteria:
This criterion is not reliable below age 40 years.<cite>Chou</cite> In 10-29 year olds, the 99th percentile for SV1+RV5 is 53mm. In 20-39 year olds: 32% have SV2+RV5 > 35 mm.<cite>chou</cite> Correlation between LVH on ECG and echocardiography is low with ECG having a sensitivity of 27% and specificity of 88% for echocardiographically measured LVH<cite>echo</cite><cite>echo2</cite>. Moreover, both are independent estimators of worse prognosis.<cite>sundstrom</cite>.
*R >26 mm in V5 or V6;
*R >20 mm in I, II or III;
*R >12 mm in aVL (in the absence of [[Conduction delay#LAFB|left anterior fascicular block]]);


The '''Cornell-criterium''' has different values in men and women:
The '''Cornell-criterion''' has different values in men and women:
* R in aVL and S in V3 >28 mm in men
* R in aVL and S in V3 >28 mm in men
* R in aVL and S in V3 >20 mm in women
* R in aVL and S in V3 >20 mm in women


In the '''Romhilt-Estes Score''' LVH is ''likely'' with 4 or more points. LVH is ''present'' with 5 or more points:
This is a better predicting criterion than the Sokolow-Lyon criterion, but less easy to remember, and therefore less often used.<cite>Levy</cite><cite>Sundstrom</cite>
Romhilt-Estes point score system ("diagnostic" >5 points; "probable" 4 points):<cite>Romhilt</cite>
{| class="wikitable"
||'''ECG Criteria'''||'''Points'''
|-
||Voltage Criteria (any of):
# R or S in limb leads ≥20&nbsp;mm
# S in V<sub>1</sub> or V<sub>2</sub> ≥30&nbsp;mm
# R in V<sub>5</sub> or V<sub>6</sub> ≥30&nbsp;mm
||3
|-
||ST-T Abnormalities:
* ST-T vector opposite to QRS without digitalis
* ST-T vector opposite to QRS with digitalis
||
3<br/>
1
|-
||Negative terminal P mode in V<sub>1</sub> 1&nbsp;mm in depth and 0.04 sec in duration (indicates left atrial enlargement)
||3
|-
||Left axis deviation (QRS of -30° or more)
||2
|-
||QRS duration ≥0.09 sec
||1
|-
||Delayed [[intrinsicoid deflection]] in V<sub>5</sub> or V<sub>6</sub> (>0.05 sec)
||1
|}


Romhilt has reviewed ECG LVH criteria and gives an overview of the many LVH scoring systems. <cite>Romhilt2</cite> Left ventricular hypertrophy has prognostic consequences as has been found in several studies.<cite>Levy</cite><cite>Sundstrom</cite>
In the [[Romhilt-Estes Score]] LVH is ''likely'' with 4 or more points. LVH is ''present'' with 5 or more points.<cite>Romhilt</cite> Romhilt has reviewed ECG LVH criteria and gives an overview of the many LVH scoring systems. <cite>Romhilt2</cite> Left ventricular hypertrophy has prognostic consequences as has been found in several studies.<cite>Levy</cite><cite>Sundstrom</cite>
{{clr}}
{{clr}}
===Example===
==Example==
<gallery>
<gallery>
Image:ECG000027.jpg|ECG of patient with left ventricular hypertrophy according to the Sokolow-Lyon criteria
Image:ECG000027.jpg|ECG of patient with left ventricular hypertrophy according to the Sokolow-Lyon criteria
Image:Extreme_lvh2.jpg|Another example of extreme left ventricular hypertrophy in a patient with severe aortic valve stenosis.
Image:Extreme_lvh2.jpg|Another example of extreme left ventricular hypertrophy in a patient with severe aortic valve stenosis.
Image:extreme_lvh.jpg|ECG of a patient with LVH and subendocardial ischemia leading to positive cardiovascular markers in blood testing.
Image:extreme_lvh.jpg|ECG of a patient with LVH and subendocardial ischemia leading to positive cardiovascular markers in blood testing.
Image:E0003191.png|LVH with repolarization changes as in this 12 lead ECG example has a worse prognosis than LVH without repolarization changes
</gallery>
</gallery>
{{clr}}
{{clr}}


==Right ventricular hypertrophy==
=Right ventricular hypertrophy=
[[Image:RVH.png|thumb|left]]
[[Image:RVH.png|thumb|left]]
[[File:E000004.jpg|thumb|right|An example of right ventricular hypertrophy (and right atrial enlargement) in a patient with chronic pulmonary hypertension due to peripheral embolisation.]]
[[File:E000004.jpg|thumb|right|An example of right ventricular hypertrophy (and right atrial enlargement) in a patient with chronic pulmonary hypertension due to peripheral embolisation.]]
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{{clr}}
{{clr}}


==Left atrial enlargement==
=Left atrial enlargement=
<div style="float:right;margin-left:10px">
<div style="float:right;margin-left:10px">
<gallery>
<gallery>
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{{clr}}
{{clr}}


==Right atrial enlargement==
=Right atrial enlargement=
<div style="float:right;margin-left:10px">
<div style="float:right;margin-left:10px">
<gallery>
<gallery>
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{{clr}}
{{clr}}


==Biatrial enlargement==
=Biatrial enlargement=
;Biatrial enlargement
;Biatrial enlargement
:Biphasic p wave in V1 of more than 0.04 sec duration. The positive initial part is > 1.5mm and the negative terminal part > 1mm
:Biphasic p wave in V1 of more than 0.04 sec duration. The positive initial part is > 1.5mm and the negative terminal part > 1mm
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#Romhilt2 pmid=4240354
#Romhilt2 pmid=4240354
#Romhilt pmid=4231231
#Romhilt pmid=4231231
#echo pmid=8651126
#sundstrom pmid=11352882
#echo2 pmid=2137733
#chou ISBN=1437711022
</biblio>
</biblio>
}}
}}
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