We read the work by Angeli et al published in a recent issue of American Journal of Cardiology . Their work commendably describes a novel electrocardiographic criterion for diagnosing left ventricular hypertrophy (LVH) with greater sensitivity by accounting the body mass index in patients with systemic hypertension. The investigators defined LVH as a typical strain pattern or the product of Cornell voltage (R-wave height in lead aVL plus S-wave depth in lead V3) by body mass index >604 mm.kg/m ² They compared this to other traditional diagnostic criteria (Romhilt-Estes point score, Sokolow-Lyon, Cornell voltages, and Perugia score) and reported that the new method improves the sensitivity without affecting the already high specificity of the existing methods.

There has been significant evidence from previous studies validating the use of total 12-lead QRS voltage in diagnosing LVH, especially in patients with systemic hypertension. The investigators referenced a few studies that reported the total 12-lead QRS voltage as a superior criterion compared with the traditional criteria with cardiac weight at necropsy as a reference. They also point out that this criterion showed a greater performance in obese patients compared with the normal-weight patients where resultant overall performance in predicting LVH was low.

In one of our recent works, we identified a way of refining the total 12-lead QRS voltage criteria for diagnosing LVH. We specifically reported that the total 12-lead QRS voltage minus either set of limb leads (I, II, III) or (R, L, F), especially the latter, is a better criterion with a value of 110 mm being the most specific, sensitive, and accurate index for diagnosing LVH compared with the existing methods (inclusive comparison with the Cornell criteria). We wonder that the amplification of 9-lead QRS voltage (precordial leads and I, II, III) with body mass index may even be superior in terms of sensitivity compared with the method that investigators have reported. This is a potential avenue for refinement of the existing study and might lead to more accurate predictions of LVH across a wider spectrum of patients.