Left ventricular electrical remodelling: a review

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.