AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the ECG: Part V: Cardiac Chamber Hypertrophy

Authors, Journal, Affiliations, Type, DOI

• Authors: E. William Hancock, Barbara J. Deal, David M. Mirvis, Peter Okin, Paul Kligfield, Leonard S. Gettes
• Journal: Journal of the American College of Cardiology, Vol. 53, No. 11, 2009:992–1002
• Affiliations: Stanford, Northwestern, Tennessee, Cornell, Cornell, North Carolina
• Type: Multi-society scientific statement (AHA/ACCF/HRS)
• DOI: https://doi.org/10.1016/j.jacc.2008.12.015

Overview

Part V of the AHA/ACCF/HRS ECG Standardization series, covering ECG criteria for left ventricular hypertrophy, right ventricular hypertrophy, biventricular hypertrophy, and atrial P-wave abnormalities. The document documents the extensive but low-sensitivity (generally <50%) LVH criteria, emphasizing that no single criterion is superior and that criteria must be validated and specified by name. It standardizes terminology — recommending "secondary ST-T abnormality" over "strain," "atrial abnormality" over enlargement/overload, and "intraatrial" over "interatrial" conduction delay — and acknowledges that QRS voltage criteria are substantially confounded by age, sex, race, and body habitus.

Keywords

Left ventricular hypertrophy, right ventricular hypertrophy, biventricular hypertrophy, Sokolow-Lyon, Cornell voltage, Romhilt-Estes, atrial abnormality, P terminal force, secondary ST-T abnormality, LVH strain, LBBB, RBBB, intraatrial conduction delay

Key Takeaways

Left Ventricular Hypertrophy — Diagnostic Criteria

General Performance Characteristics

• Sensitivity of all QRS voltage criteria is generally <50% (often 25–35%); specificity is generally 85–90%
• No single criterion has demonstrated superiority over the others; criteria are often not additive because positive test results for different criteria overlap substantially
• In mild-to-moderate hypertension: only 11.2% of patients with LVH by either Cornell or Sokolow-Lyon met both criteria
• Automated systems should apply multiple validated criteria; reports must specify which criteria were examined and which were abnormal

Widely Used Voltage Criteria

Limb lead criteria:

• Lewis formula: (R I − S I) + (S III − R III) ≥16 mm
• Gubner: R I + S III ≥25 mm
• R aVL ≥11 mm (Sokolow); R aVF ≥20 mm

Precordial criteria:

• Sokolow-Lyon: S V1 + R V5 ≥35 mm (introduced 1949; most widely used)
• S V1 + R V5 or R V6 ≥35 mm; S V2 + R V5,6 ≥45 mm

Combined limb + precordial:

• Cornell voltage: S V3 + R aVL ≥28 mm (men); ≥20 mm (women) — gender-adjusted; introduced 1985
• Cornell voltage-duration product: (S V3 + R aVL) × QRS duration ≥2,436 mm·ms

Point score system:

• Romhilt-Estes: Incorporates QRS voltage, QRS axis, QRS duration, QRS onset-to-peak time, P-wave morphology, and ST-T changes; introduced 1968

Factors Confounding LVH Criteria

• Age: QRS voltages decline with age; criteria generally apply to adults >35 years; low accuracy in 16–35-year-olds and athletes
• Sex: Women have slightly lower upper QRS voltage limits; large difference only for S V3; gender adjustment improves some criteria
• Race: African-Americans have higher upper normal QRS voltages (Sokolow-Lyon more sensitive/less specific); Hispanic-Americans have lower limits; Cornell shows lower sensitivity/higher specificity in African-Americans
• Obesity: Adipose tissue and increased heart-to-electrode distance reduce QRS voltage; Sokolow-Lyon is less often positive in obese patients; Cornell voltage-duration product is more often in LVH range in obese patients — divergent criterion behavior

QRS Duration and Intraventricular Conduction in LVH

• QRS duration frequently increased in LVH: increased LV wall thickness + intramural fibrosis prolongs transmural impulse conduction
• Widened QRS in LVH pattern: loss of septal Q wave; slurred R-wave upstroke → "incomplete LBBB" commonly seen only with LVH; progression from LVH alone → incomplete LBBB may be observed

ST-T Abnormalities with LVH

• The term "strain" (introduced 1941) is discouraged; "secondary ST-T abnormality" is the preferred terminology
• Pattern: J-point depression; upwardly convex downsloping ST depression; asymmetrical T-wave inversion — these represent secondary changes from depolarization disturbance, not primary ischemia
• ST-T abnormalities provide major supporting evidence for LVH beyond voltage alone
• Evidence suggests ST-T abnormalities in LVH are associated with larger LV mass and higher CV morbidity and mortality than increased voltage alone (Framingham, LIFE study data)
• Whether "typical" vs "lesser" ST-T patterns differ in clinical implication is unresolved

Supporting Criteria (Do Not Diagnose Alone)

• Left atrial P-wave abnormality: P-wave changes frequently associated with LVH and hypertension; may be earliest ECG sign of hypertensive heart disease; supporting criterion only — adequate standalone accuracy not established
• Left axis deviation: May reflect hypertrophy, fascicular block, or age-related axis shift; supporting criterion only
• QT prolongation: Slight QT prolongation in LVH (secondary to QRS prolongation and altered ion channels); not diagnostic by itself

LVH in Conduction Disorders

In LBBB:

• Results conflicting (35–41); some conclude diagnosis should not be attempted in pure LBBB
• High prevalence of anatomic LVH in LBBB patients (may be 90%+ at autopsy) limits specificity estimation
• Criteria with reasonable specificity (but low sensitivity) in LBBB: QRS duration >~155 ms + precordial voltage criteria + left atrial P-wave abnormality
• Recommendation: diagnose LVH in LBBB with caution when strict criteria met; otherwise avoid

In left anterior fascicular block:

• QRS vector shifts posterior/superior → larger R waves in I/aVL; smaller R waves with deeper S waves in V5/V6
• Criteria using S-wave depth in left precordial leads improve LVH detection in this setting

In RBBB:

• RBBB reduces amplitude of S waves in right precordial leads → reduces sensitivity of standard LVH criteria
• Criteria for LVH in RBBB: S V1 >2 mm (0.2 mV); R V5,6 >15 mm (1.5 mV); QRS axis <−30° + S III + largest R/S in precordial lead >30 mm — sensitivities 46–68%, specificities 57–71%
• Left atrial abnormality and left axis deviation have enhanced diagnostic value in the presence of RBBB

AHA 2009 Recommendations (LVH)

1. Use only validated criteria without modification from tested form
2. No single criterion recommended above others
3. Computer systems should use all criteria supported by valid evidence
4. Reports must specify which criteria were used and which were abnormal
5. Adjust for sex, race, and body habitus when validated adjustments exist
6. Do not use terms "strain," "systolic overload," or "diastolic overload"
7. Use "probable," "possible," and "borderline" with caution
8. Diagnose LVH in complete LBBB with caution

Right Ventricular Hypertrophy

General Performance

• ECG sensitivity for RVH is generally lower than for LVH; RV QRS vectors must overcome dominant LV vectors before appearing on surface ECG; considerable RVH required before ECG changes emerge
• Best accuracy: Congenital heart disease (especially pressure overload patterns)
• Intermediate: Acquired disease, primary pulmonary hypertension in adults
• Lowest: Chronic obstructive pulmonary disease

Diagnostic Criteria (Table 2 Key Criteria)

Standard criteria:

• R V1 ≥6 mm; R:S ratio V1 >1.0
• Deep S V5 ≥10 mm; deep S V6 ≥3 mm
• R aVR ≥4 mm
• R V1 + S V5,6 ≥10.5 mm (Sokolow)
• R-wave peak time in V1 >0.035 s (with QRS <120 ms)
• QR complex in V1

Supporting criteria: RSR' V1 (QRS <120 ms); S>R in I, II, III; S I and Q III pattern; R:S V1 > R:S V3,4; negative T-wave V1–V3; P II amplitude >2.5 mm

RVH ECG Patterns

• Volume overload pattern: Similar to incomplete RBBB; associated with right axis deviation and secondary ST-T changes
• Pressure overload pattern: Predominantly tall R waves (Rs, R, or Qr complexes) in right precordial leads; associated with right axis deviation and secondary ST-T changes
• Diagnosis almost always requires right axis deviation + prominent anterior forces in right precordial leads; these features also occur as normal variants

COPD Pattern

• Reflects low diaphragm from increased lung volume rather than true RVH
• ECG: low voltage limb leads; frontal QRS axis rightward/superior/indeterminate; rightward P-wave axis >60°; persistent S waves all precordial leads; low R amplitude V6
• RVH in COPD suggested only if R V1 is relatively increased; clinical context mandatory

Biventricular Hypertrophy

• Recognition is poor: cancellation of increased QRS vectors from both ventricles results in very low sensitivity
• Suggested when LVH criteria are met AND: prominent S V5 or V6, right axis deviation, unusually tall biphasic R/S complexes in several leads, right atrial abnormality signs
• In CHD with RVH: combined tall R + deep S in V2–V4 with combined amplitude >60 mm (6.0 mV) suggests LVH coexisting with RVH

Atrial (P-Wave) Abnormalities

Preferred Terminology (AHA 2009)

• Use "left atrial abnormality" and "right atrial abnormality" — NOT enlargement, overload, strain, or hypertrophy (these imply specific anatomic changes not reliably distinguishable by P-wave morphology)
• Use "intraatrial conduction delay" rather than "interatrial" — delay typically occurs in Bachmann's bundle (a specialized interatrial pathway) and possibly within LA myocardium; the distinction is often not determinable

Left Atrial Abnormality Criteria

• PTF-V1 (P terminal force in V1): Product of amplitude × duration of terminal negative component in V1 — most frequently used criterion
• P-wave duration ≥120 ms with widely notched P wave (notch ≥40 ms separation) — appears to have equal value to PTF-V1
• Terminal P-wave axis −30 to −90° — also useful
• Purely negative P wave in V1: suggestive but can occur without increased PTF
• P-wave widening ≥120 ms is present in the large majority of patients with electrocardiographic LAA signs
• Delay is more closely linked to left atrial abnormality than right, because it often represents delay in Bachmann's bundle → "intraatrial" preferred

Right Atrial Abnormality Criteria

• Tall upright P wave >2.5 mm in lead II — peaked or pointed appearance (summation of enhanced right + simultaneous left atrial components)
• Prominent initial positivity in V1 or V2 ≥1.5 mm (0.15 mV) — rightward/anterior initial P vector
• Rightward P-wave axis and peaked form without increased amplitude: supporting signs
• Total P-wave duration: usually normal (unlike left atrial abnormality)
• Exception: surgically repaired CHD (especially single-ventricle physiology) → P-wave prolongation occurs and is a risk factor for atrial tachyarrhythmias

Combined Atrial Abnormality

• Diagnosed by presence of features of both LAA and RAA
• Limited evidence regarding accuracy of combined criteria

AHA 2009 Recommendations (Atrial Abnormalities)

1. Use "atrial abnormality" not enlargement/overload/strain/hypertrophy
2. Use multiple ECG criteria to recognize atrial abnormalities
3. Use "intraatrial conduction delay" when P-wave widening occurs without increased right or left atrial amplitude

Pediatric Criteria

• Standards for QRS voltage in children derived from Canadian studies (Davignon et al.); widely used in North America
• Higher upper-normal voltage limits when higher sampling rates are used (500 samples/sec Scottish data; 1200 samples/sec Dutch data) — amplitude criteria in children should be adjusted for sampling rate
• Gender and racial differences similar to adults exist in children >10 years
• ECG best used as a screening tool in pediatrics; must be correlated with other measurements for hypertrophy assessment

Limitations of the Document

• Published 2009; predates widespread routine echocardiography as gold standard; reference standards were often autopsy, chest X-ray, or early 2D echo
• Sensitivity of all LVH criteria remains poor even by 2009 standards; limitations remain relevant today
• Pediatric criteria require updating for modern high sampling-rate digital ECGs
• Biventricular hypertrophy criteria have very limited evidence base
• LBBB diagnostic guidance for LVH remains provisional given conflicting studies

Key Concepts Mentioned

• concepts/ECG-Ventricular-Hypertrophy — comprehensive LVH/RVH criteria, confounders, and secondary ST-T terminology
• concepts/ST-T-Changes — secondary ST-T abnormalities in LVH
• concepts/Inter-Atrial-Block — intraatrial conduction delay, LAA criteria
• concepts/Atrial-Cardiomyopathy — P-wave abnormalities as markers of atrial disease

Key Entities Mentioned

• entities/HCM — LVH in concentric hypertrophy setting
• entities/Heart-Failure — LVH as hypertensive heart disease marker

Wiki Pages Updated

• wiki/sources/ecg-chambers-aha-2009.md — created
• wiki/concepts/ECG-Ventricular-Hypertrophy.md — created
• wiki/concepts/ST-T-Changes.md — LVH table entry updated: "strain pattern" → "secondary ST-T abnormality"; AHA terminology note added; source count 5→6
• wiki/concepts/Inter-Atrial-Block.md — AHA 2009 criteria and terminology context added; source count 1→2
• wiki/sourceindex.md — new entry added
• wiki/wikiindex.md — ECG-Ventricular-Hypertrophy entry added; ST-T-Changes and Inter-Atrial-Block descriptions updated