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However, the low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm. The theoretical background for voltage measured at the body surface is defined by the <jats:italic>solid angle theorem<\/jats:italic>, which relates the measured voltage to spatial and non\u2010spatial determinants. The spatial determinants are represented by the extent of the activation front and the distance of the recording electrodes. The non\u2010spatial determinants comprise electrical characteristics of the myocardium, which are comparatively neglected in the interpretation of the QRS patterns. Various clinical conditions are associated with LVH. These conditions produce considerable diversity of electrical properties alterations thereby modifying the resultant QRS patterns. The spectrum of QRS patterns observed in LVH patients is quite broad, including also left axis deviation, left anterior fascicular block, incomplete and complete left bundle branch blocks, Q waves, and fragmented QRS. Importantly, the QRS complex can be within normal limits. The new paradigm stresses the electrophysiological background in interpreting QRS changes, i.e., the effect of the non\u2010spatial determinants. This postulates that the role of ECG is not to estimate LV size in LVH, but to understand and decode the underlying electrical processes, which are crucial in relation to cardiovascular risk assessment.<\/jats:p>","DOI":"10.1111\/anec.13097","type":"journal-article","created":{"date-parts":[[2023,11,25]],"date-time":"2023-11-25T02:12:34Z","timestamp":1700878354000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":17,"title":["ISE\/ISHNE expert consensus statement on the ECG diagnosis of left ventricular hypertrophy: The change of the paradigm"],"prefix":"10.1111","volume":"29","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1742-8962","authenticated-orcid":false,"given":"Ljuba","family":"Bacharova","sequence":"first","affiliation":[{"name":"International Laser Center CVTI  Bratislava Slovak 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