Abstract 2557: Diagnosis of Left Ventricular Hypertrophy in the Presence of Anterior Fascicular Block: A Re-examination of the 2009 AHA/ACCF/HRS Guidelines
PURPOSE: The 2009 “AHA/ACCF/HRS Recommendations for Standardization and Interpretation of the Electrocardiogram” (ECG) state that in the presence of left anterior fascicular block (LAFB), left ventricular hypertrophy (LVH) should be diagnosed by criteria that include the depth of S-waves in left precordial leads, rather than those based on R-wave amplitude in leads I and aVL. This statement was based upon 2 small studies published in 1976 and 1988 that used manual ECG measurements and included limited control groups. We sought to reexamine the validity of this statement in a larger study that incorporated similar controls but modern computer-assisted ECG interpretation.
METHODS: We searched our hospital ECG database (Marquette MUSE) for recordings in which LVH had been diagnosed by any of 4 criteria: 1) Sokolow index (R-wave amplitude in aVL >11 mm); 2) Cornell criterion (R-wave-aVL + S-wave-V3 >28 mm in men and >20 mm in women); 3) Gertsch criterion (S-wave-III + maximal precordial lead voltage (R+S) ≥30 mm); 4) Bozzi criterion (SV1 or SV2+(RV6+SV6) >25 mm). Over a 22-month period, we identified 241 tracings with LAFB, from patients in whom echocardiogram had been performed within 90 days of the ECG. The “gold standard” for LVH was left ventricular mass index on echocardiogram greater than 115 g/m2 in men (95 g/m2 in women).
RESULTS: In the presence of LAFB all four ECG criteria identified LVH with similar accuracy, see Summary Table⇓.
CONCLUSIONS: In the presence of LAFB, either the Sokolow Index or the Cornell Criteria are as accurate in identifying LVH as the two criteria used in the 2009 multi-society ECG guidelines.
CLINICAL IMPLICATIONS: In the presence of LAFB there is approximately 60% certainty that fulfillment of either the Cornell Criteria or the Sokolow Index indicates the presence of anatomical LVH (by echocardiogram). The 2009 multi-society guidelines for ECG interpretation may have incorrectly eschewed these ECG criteria.