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. 2024 Jan;29(1):e13097.
doi: 10.1111/anec.13097. Epub 2023 Nov 24.

ISE/ISHNE expert consensus statement on the ECG diagnosis of left ventricular hypertrophy: The change of the paradigm

Ljuba Bacharova  1 , Philippe Chevalier  2   3 , Bulent Gorenek  4 , Christian Jons  5 , Yi-Gang Li  6 , Emanuela T Locati  7 , Maren Maanja  8 , Andrés Ricardo Pérez-Riera  9   10 , Pyotr G Platonov  11 , Antonio Luiz Pinho Ribeiro  12   13 , Douglas Schocken  14 , Elsayed Z Soliman  15 , Jana Svehlikova  16 , Larisa G Tereshchenko  17 , Martin Ugander  18   19 , Niraj Varma  20 , Zaklyazminskaya Elena  21 , Takanori Ikeda  22
Affiliations

ISE/ISHNE expert consensus statement on the ECG diagnosis of left ventricular hypertrophy: The change of the paradigm

Ljuba Bacharova et al. Ann Noninvasive Electrocardiol. 2024 Jan.

Abstract

The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria. The classical paradigm postulates that the increased left ventricular mass generates a stronger electrical field, increasing the leftward and posterior QRS forces, reflected in the augmented QRS amplitude. However, the low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm. The theoretical background for voltage measured at the body surface is defined by the solid angle theorem, which relates the measured voltage to spatial and non-spatial determinants. The spatial determinants are represented by the extent of the activation front and the distance of the recording electrodes. The non-spatial determinants comprise electrical characteristics of the myocardium, which are comparatively neglected in the interpretation of the QRS patterns. Various clinical conditions are associated with LVH. These conditions produce considerable diversity of electrical properties alterations thereby modifying the resultant QRS patterns. The spectrum of QRS patterns observed in LVH patients is quite broad, including also left axis deviation, left anterior fascicular block, incomplete and complete left bundle branch blocks, Q waves, and fragmented QRS. Importantly, the QRS complex can be within normal limits. The new paradigm stresses the electrophysiological background in interpreting QRS changes, i.e., the effect of the non-spatial determinants. This postulates that the role of ECG is not to estimate LV size in LVH, but to understand and decode the underlying electrical processes, which are crucial in relation to cardiovascular risk assessment.

Keywords: ECG; left ventricular hypertrophy; new paradigm.

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Conflict of interest statement

Niraj Varma, Elsayed Z. Soliman, Christian Jons, Philippe Chevalier are Editorial Board members of Annals of Noninvasive Electrocardiology and co‐authors of this article. To minimize bias, they were excluded from all editorial decision‐making related to the acceptance of this article for publication.

Figures

FIGURE 1
FIGURE 1
Central illustration: The new ECG‐LVH paradigm. LAD, left axis deviation; LAFB, left anterior fascicular block; LBBB, left bundle branch block.
FIGURE 2
FIGURE 2
The spatial angle theorem (Holland & Arnsdorf, ; Holland & Arnsdorf, 1981) and the determinants influencing the QRS amplitude. The spatial angle theorem postulates that the externally recorded electrocardiographic potential is related to the spatial and non‐spatial determinants.
See this image and copyright information in PMC

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