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Topics for study:
> QRS amplitude (voltage criteria; i.e., tall R-waves in LV leads, deep S-waves in RV leads)
Delayed intrinsicoid deflection in V6 (i.e., time from QRS onset to peak R is >0.05 sec)
Widened QRS/T angle (i.e., left ventricular strain pattern, or ST-T oriented opposite to QRS direction)
Leftward shift in frontal plane QRS axis
Evidence for left atrial enlargement (LAE) (lessonVII)
+ECG Criteria PointsVoltage Criteria (any of):
- R or S in limb leads >20 mm
- S in V1 or V2 > 30 mm
- R in V5 or V6 >30 mm
3 pointsST-T Abnormalities:
Without digitalis
With digitalis
3 points
1 pointLeft Atrial Enlargement in V1 3 pointsLeft axis deviation 2 pointsQRS duration 0.09 sec 1 pointDelayed intrinsicoid deflection in V5 or V6 (>0.05 sec) 1 point
S in V3 + R in aVL > 24 mm (men)
S in V3 + R in aVL > 20 mm (women)
Limb-lead voltage criteria:R in aVL >11 mm or, if left axis deviation, R in aVL >13 mm plus S in III >15 mm
R in I + S in III >25 mm
Chest-lead voltage criteria:S in V1 + R in V5 or V6 > 35 mm
Example 1: (Limb-lead Voltage Criteria; e.g., R in aVL >11 mm; note wide QRS/T angle)
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Example 2: (ESTES Criteria: 3 points for voltage in V5, 3 points for ST-T changes)
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(Note also the left axis deviation of -40 degrees, and left atrial enlargement)
Right axis deviation (>90 degrees)
Tall R-waves in RV leads; deep S-waves in LV leads
Slight increase in QRS duration
ST-T changes directed opposite to QRS direction (i.e., wide QRS/T angle)
May see incomplete RBBB pattern or qR pattern in V1
Evidence of right atrial enlargement (RAE) (lessonVII)
Any one or more of the following (if QRS duration <0.12 sec):Right axis deviation (>90 degrees) in presence of disease capable of causing RVH
R in aVR > 5 mm, or
R in aVR > Q in aVR
Any one of the following in lead V1:R/S ratio > 1 and negative T wave
qR pattern
R > 6 mm, or S < 2mm, or rSR' with R' >10 mm
Other chest lead criteria:R in V1 + S in V5 (or V6) 10 mm
R/S ratio in V5 or V6 < 1
R in V5 or V6 < 5 mm
S in V5 or V6 > 7 mm
ST segment depression and T wave inversion in right precordial leads is usually seen in severe RVH such as in pulmonary stenosis and pulmonary hypertension.
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R/S ratio in V5 or V6 < 1
S in V5 or V6 > 6 mm
RAD (>90 degrees)
Criteria for LVH and RVH both met
LVH criteria met and RAD or RAE present