Diagnostic Utility of Electrocardiography and Transthoracic Echocardiography in the Diagnosis of Left Ventricular Hypertrophy in Patients With Known Hypertension

Document Type : Original Article


Department of Medicine, Krishna Institute of Medical Sciences “Deemed to be University”, Karad, Maharashtra, India.


Background: Left ventricular hypertrophy (LVH) is a significant risk factor for cardiovascular events. The increase in LV mass is usually screened by electrocardiography (ECG), which is often insensitive. Despite being insensitive, ECG is cost-effective compared with echocardiography. Therefore, this study aimed to assess the diagnostic utility of ECG and echocardiography in the diagnosis of LVH among patients with hypertension.
Methods: This comparative prospective study was carried out on 200 patients with hypertension. ECG and echocardiography were performed on all the patients to evaluate the presence of LVH. The Sokolow–Lyon index, the Romhilt–Estes point, and the Cornell voltage criteria were the ECG criteria used. For 2D echocardiography, interventricular septal thickness (IVST) and left ventricular posterior wall thickness (LVPWT) were considered. The χ2 test was employed to test the significance of the qualitative variables. A P value of less than 0.05 was considered statistically significant.
Results: The specificity of the Cornell voltage criteria was high compared with that of the other criteria of ECG, although the sensitivity was low for all the other ECG criteria. The occurrence of LVH according to the IVST criteria of 2D echocardiography was significantly associated with the severity and duration of hypertension (P = 0.042). The majority of the patients with diastolic dysfunction were in Stage I hypertension.
Conclusions: The diagnostic utility of ECG compared with echocardiography was found to be insensitive. Hence, echocardiography is the preferred method in the detection of LVH in patients with hypertension. However, improved ECG criteria can be adopted in the future for LVH detection due to its cost-effective nature. (Iranian Heart Journal 2021; 22(1): 74-83)


  1. Verdecchia P, Angeli F, Gattobigio R, Sardone M, Pede S, Reboldi GP. Regression of left ventricular hypertrophy and prevention of stroke in hypertensive subjects, Am J Hypertens 2006; 19(5):493–99.
  2. Kostis JB. From hypertension to heart failure: update on the management of systolic and diastolic dysfunction. Am J Hypertens 2003;16(9):18–22.
  3. Frey N, Katus HA, Olson EN, Hill JA. Hypertrophy of the heart: a new therapeutic target? Circulation 2004;109(13):1580-89.
  4. Bombelli M., Facchetti R, Carugo S, Madotto F, Arenare F, Quarti‐Trevano F, et al. Left ventricular hypertrophy increases cardiovascular risk independently of in‐office and out‐of‐office blood pressure values. J Hypertens 2009;27(12):2458–64.
  5. Gosse P, Jan E, Coulon P, Cremer A, Papaioannou G, Yeim, S. ECG detection of left ventricular hypertrophy: The simpler, the better? J Hypertens 2012;30(5):990–6.
  6. Levy D, Savage DD, Garrison RJ, Anderson KM, Kannel WB, Castelli WP. Echocardiographic criteria for left ventricular hypertrophy: the Framingham Heart Study. Am J Cardiol 1987;59(9):956-60.
  7. Kaplan NM, Lieberman E, Neal W. Kaplan’s clinical hypertension. 8th ed. Philadelphia: Lippincott, Williams & Wilkins, 2002.
  8. Hammond IW, Devereux RB, Alderman MH, Lutas EM, Spitzer MC, Crowley JS, et al. The prevalence and correlates of echocardiographic left ventricular hypertrophy among employed patients with uncomplicated hypertension. J Am Coll Cardiol 1986;7(3):639-50.
  9. Katholi RE, Couri DM. Left Ventricular Hypertrophy: Major Risk Factor in Patients with Hypertension: Update and Practical Clinical Applications. Int J Hypertens 2011;2011:495349.
  10. de Simone G, Gottdiener JS, Chinali M, Maurer MS. Left ventricular mass predicts heart failure not related to previous myocardial infarction: The Cardiovascular Health Study. Eur Heart J 2008;29(6):741–47.
  11. Zile MR, Baicu CF, Gaasch WH. Diastolic heart failure—Abnormalities in active relaxation and passive stiffness of the left ventricle. N Engl J Med 2004;350(19):1953–9.
  12. Levy D, Garrison RJ, Savage DD, Kannel WL, Castelli WP. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med 1990;322(22):1561–6.
  13. Kannel WB, Levy D, Cupples LA. Left ventricular hypertrophy and risk of cardiac failure: Insights from the Framingham Study. J Cardiovasc Pharmacol 1987;10(6):S135–40.
  14. Costa F, Rivera IR, de Vasconcelos MLC, Costa AFP, Povoa RM, Bombig MTN, et al. Electrocardiography in the diagnosis of ventricular hypertrophy in patients with chronic renal disease. Arq Bras Cardiol 2009;93(3):353-59.
  15. Mohamed AL, Yong J, Masiyati J, Lim L, Tee SC. The prevalence of diastolic dysfunction in patients with hypertension referred for  echocardiographic assessment of left ventricular function. Malays J Med Sci 2004;11(1):66-74.
  16. Bacharova L, Ugander M. Left ventricular hypertrophy: the relationship between the electrocardiogram and cardiovascular magnetic resonance imaging. Ann Noninvasive Electrocardiol 2014;19(6):524–33.
  17. Hancock EW, Deal BJ, Mirvis DM, Okin P, Kligfield P, Gettes LS. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V:electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol 2009;119(10):e251-61.
  18. Bacharova L, Estes HE, Schocken DD, Ugander M, Soliman EZ, Hill JA, et al. The 4th report of the working group on ECG diagnosis of left ventricular hypertrophy. J Electrocardiol 2017;50(1):11–15.
  19. Casiglia E, Schiavon L, Tikhonoff V, Bascelli A, Martini B, Mazza A, et al. Electrocardiographic criteria of left ventricular hypertrophy in general population. Eur J Epidemiol 2008;23(4):261–71.
  20. Sullivan JM, Zwaag RV, El-Zeky F, Ramanathan KB, Mirvis DM. Left ventricular hypertrophy. J Am Coll Cardiol 1993;22:508-13.
  21. Martynova E, Kuznetsov V, Solovyev V, Evlampieva L. Todosiychuk V, Krinochkin D, et al. Automated computer analysis in diagnostics of left ventricular hypertrophy by electrocardiography. J Electrocardiol 2007;40(4):S41-S2.
  22. Sundstrom J, Lind L, Arnlov J, Zethelius B, Andren B, Lithell HO. Echocardiographic and Electrocardiographic diagnosis of left ventricular hypertrophy predict mortality independently of each other in a population elderly men. Circulation 2001;103:2346-51.
  23. Salles G, Leocádio S, Bloch K, Nogueira AR, Muxfeldt E. Combined QT interval and voltage criteria improve left ventricular hypertrophy detection in resistant hypertension. Hypertension 2005;46(5):1207–12.
  24. Chapman N, Mayet J, Ozkor M, Lampe FC, Thom SA, Poulter NR. QT intervals and QT dispersion as measures of left ventricular hypertrophy in an unselected hypertensive population. Am J Hypertens. 2001;14(5):455–62.
  25. Martinez MA, Sancho T, Armada E, Rubio JM, Anton JL, Torre A. Prevalence of left ventricular hypertrophy in patients with mild hypertension in primary care: impact of echocardiography on cardiovascular risk stratification. Am J Hypertens 2003;16(7):556-63.
  26. Pewsner D, Juni P, Egger M, Battaglia M, Sundstrom J, Bachmann LM. Accuracy of electrocardiography in diagnosis of left ventricular hypertrophy in arterial hypertension: Systematic review. BMJ 2007;335(7622):711-14.
  27. Antoniucci D, Seccareccia F, Menotti A, Dovellini EV, Prati PL, Rovelli F, Fazzini PF: Prevalence and correlates of echocardiographic determined left ventricular hypertrophy in 2318 asymptomatic middle-aged men: the ECCIS project. Epidemiologia e Clinica della Cardiopatie Ischemia Silente. G Ital Cardiol 1997;27(4):363–9.
  28. Izzo R, Losi MA, Stabile E, Lonnebakken MT, Canciello G, Esposito G, et al. Development of left ventricular hypertrophy in treated hypertensive outpatients. Hypertension. 2017;69(1):136–42.
  29. Singh G, Bawa AG, Kapila S, Kaur A, Garg S. Assessment of sensitivity of ECG criteria for diagnosis of left ventricular hypertrophy in hypertension patients. International Journal of Medical and Health Research 2017;3(3):52-4.
  30. Avdic S, Mujcinovic Z, Asceric M, Nukic S, Kusljugic Z, SmajicE, et al. Left ventricular diastolic dysfunction in essential hypertension. Bosn J Basic Med Sci 2007;7(1):15-20.
  31. Parrinello G, Pinto A, Colomba D, Bologna P, Santolini R, Paterna S, et al. Relationship between left ventricular hypertrophy, diastolic function and extracardiac atherosclerosis in newly diagnosed hypertensives. Am J Hypertens 2001;14(S1):162A-63A.