Detection of left ventricular hypertrophy through ECG: diagnostic performance and comparison of ten ECG scores in different hypertrophic conditions

BACKGROUND: Different electrocardiographic (ECG) criteria were proposed to improve ECG-based detection of left ventricular hypertrophy (LVH), but external validation data are limited and their diagnostic performances in different conditions leading to LVH are not extensively assessed. AIM: to assess the robustness and limitations of ECG scores across distinct LVH phenotypes. METHODS: The LVH-MORE registry included 408 patients across four cohorts: HTN (n = 103), HCM (n = 104), sAS (n = 101), and controls (n = 100). LVH was defined by echocardiographic left ventricular mass index (LVMi) >115 g/m2 in male subjects and >95 g/m2 in female subjects. Ten ECG criteria were calculated, including Peguero-Lo Presti, Sokolow-Lyon, Cornell, Perugia, Romhilt-Estes, and others. Diagnostic performance was assessed using ROC curves (AUC), sensitivity (Sn), specificity (Sp). RESULTS: In the HTN cohort, Peguero-Lo Presti achieved the highest AUC for LVH detection (0.752 [95% CI: 0.616-0.888]), with Sn = 31% and Sp = 94%. Other scores showed similar or lower AUCs, with Perugia score showing higher sensitivity (54%). The highest specificity were reached by Sokolow-Lyon and Gubner-Ungerleider (100%). In the HCM cohort, all ECG scores showed modest diagnostic performance (AUC 0.529-0.628). The Perugia and Romhilt-Estes scores achieved the highest sensitivities (94% and 71%, respectively), whereas Sokolow-Lyon showed the highest specificity (90%). In the sAS cohort, AUCs ranged from 0.519 to 0.671. Sensitivity was higher for Perugia (66%) and Romhilt-Estes ≥4 (57%). Highest specificity was shown by Gubner-Ungerleider (95%). CONCLUSIONS: No single ECG criterion provided consistent diagnostic accuracy across different causes of LVH. Voltage-only ECG scores performed better in HTN patients while multi-parametric scores showed relatively better performance in HCM and sAS.