Key result
Reframing ECG LVH as left ventricular electrical remodeling better reflects electrophysiological substrates independent of mass.
Why the study?
High-resolution imaging has exposed fundamental flaws in the traditional Voltage Paradigm for electrocardiographic LVH diagnosis, as non-spatial determinants decoupling QRS amplitude from left ventricular mass are unaccounted for.
Reframes the traditional ECG diagnosis of left ventricular hypertrophy into Left Ventricular Electrical Remodeling (LVER) to better reflect electrophysiological risk phenotypes.
May encourage ECG reinterpretation emphasizing electrical remodeling; leaves open prospective validation of outcomes independent of mass.
The traditional electrocardiographic diagnosis of left ventricular hypertrophy (LVH) rests on the Voltage Paradigm, which assumes a linear relationship between QRS amplitude and left ventricular mass. High-resolution cardiac imaging has exposed fundamental anomalies in this framework: most patients with anatomic LVH have normal QRS amplitudes, while many with high amplitudes have normal mass. These discrepancies arise from non-spatial determinants—conduction velocity, fibrosis, cell-to-cell coupling and thoracic conductivity—that the linear model cannot accommodate. We propose replacing the term ‘ECG-LVH’ with Left Ventricular Electrical Remodeling (LVER), a framework endorsed by the International Society of Electrocardiology and the International Society for Holter and Noninvasive Electrocardiology encompassing four phenotypes: high QRS amplitude, conduction delay, low QRS amplitudes and QRS fragmentation. Each phenotype reflects a specific electrophysiological substrate carrying prognostic information independent of mass. LVER reframes the clinical task as electrical risk phenotyping.
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Bachárová et al. (2026) conducted a review in Left ventricular hypertrophy. Left Ventricular Electrical Remodeling (LVER) framework was evaluated. The traditional ECG diagnosis of left ventricular hypertrophy should be reframed as Left Ventricular Electrical Remodeling to better reflect electrophysiological substrates independent of mass.
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