Left Ventricular Hypertrophy (LVH)

ECG Diagnostic criteria
  • There is no single universally accepted ECG definition of LVH
  • ECG evidence of LVH requires a validated voltage, voltage-duration or composite criterion to be met; these criteria have high specificity but low sensitivity
  • Sokolow-Lyon and Cornell criteria are among the most commonly used criteria
  • Non-voltage ECG features (ST depression, T wave inversion in left-sided leads) increase diagnostic confidence but are not mandatory
LVH by Sokolow-Lyon criteria: S wave in V1 + R wave in V5 ≥ 35mm
ST depression and T wave inversion in V5 are supportive features (“LV strain pattern”)
Commonly used ECG-LVH criteria [Detailed overview]
CriterionDiagnostic threshold
Sokolow–LyonSV1+ max(RV5,V6) ≥ 35mm
CornellRaVL+SV3 > 28mm in men, > 20mm in women
Peguero–Lo PrestiSD​+SV4 ​≥ 28mm in men, ≥ 23mm in women
Cornell voltage-duration product [RaVL+SV3+8mm in women] × QRS duration > 2440 mm·ms
Romhilt-Estes score≥5 points: definite LVH; 4 points: probable LVH

SV1 = S wave in V1, max(RV5,V6) = tallest R wave in either V5 or V6, SD = deepest S wave in any lead

Non-voltage ECG features
ECG LV Strain V6
LV strain pattern: ST depression and T wave inversion in the lateral leads
Pathophysiology
  • The left ventricle hypertrophies in response to pressure overload secondary to conditions such as aortic stenosis and hypertension
  • This results in increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) and increased S wave depth in the right-sided leads (III, aVR, V1-3)
  • The thickened LV wall leads to prolonged depolarisation (increased R wave peak time) and delayed repolarisation (ST and T-wave abnormalities) in the lateral leads
Causes of LVH
  • Hypertension (most common)
  • Aortic stenosis
  • Aortic regurgitation
  • Mitral regurgitation
  • Coarctation of the aorta
  • Hypertrophic cardiomyopathy
Handy Tips
  • Voltage criteria should not be interpreted in isolation; consider repolarisation abnormalities, atrial findings, QRS duration, axis and clinical context.
  • ECG changes are an insensitive means of detecting LVH (patients with clinically significant left ventricular hypertrophy seen on echocardiography may still have a relatively normal ECG)
  • Anatomical confirmation requires echocardiography or cardiac MRI
ECG Examples
Example 1
ECG Left ventricular hypertrophy (LVH) 2

Left ventricular hypertrophy (LVH):

  • Markedly increased LV voltages: huge precordial R and S waves that overlap with the adjacent leads (SV2 + RV6 >> 35 mm).
  • R-wave peak time > 50 ms in V5-6 with associated QRS broadening.
  • LV strain pattern with ST depression and T-wave inversions in I, aVL and V5-6.
  • ST elevation in V1-3.
  • Prominent U waves in V1-3.
  • Left axis deviation.

Severe LVH such as this appears almost identical to left bundle branch block — the main clue to the presence of LVH is the excessively high LV voltages. 

Example 2
ECG LVH ST elevation not MI
ECG reproduced from Dr Smith’s ECG blog
  • There are massively increased QRS voltages — the S waves in V3 are so deep they are literally falling off the page!
  • The ST elevation in V1-3 is simply in proportion to the very deep S waves (“appropriate discordance”).
  • The LV strain pattern is seen in all leads with a positive R wave (V5-6, I, II, III, aVF).

References

Historical references

Review articles

Advanced Reading

Online

Textbooks

LITFL Further Reading

ECG LIBRARY

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

MBBS FACEM DDU (Emergency) CCPU. Emergency Physician in Melbourne, Australia. Co-Ultrasound Lead for Emergency Medicine at The Alfred Hospital. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor of the LITFL ECG Library.

7 Comments

  1. does the LVH with strain pattern carry any pathologic significance? Or does it just further confirm patient has LVH.

  2. The strain pattern just further confirms LVH. It´s presence is associated with a poor prognosis.

  3. “…(patients with clinically significant left ventricular hypertrophy seen on echocardiography may still have a relatively normal ECG)”

    –> If you see this. Think of infiltrative restrictive cardiomyopathy disease like amyloid.

  4. Just want to say that this site is the best, and you’ve helped someone start from zero with ECGs, something that scared me for a long time, much love from Egypt!

  5. In terms of the criteria at the top of the page, there doesn’t appear to be any reference to the use of V2 when the depth of the S wave is greater than that of V1. Later examples on this page use V2 so may be worth mentioning in the criteria. This is also discussed in Garcia (2013) “The art of interpretation”.

  6. This is a very clear and practical breakdown of LVH ECG criteria. I especially appreciated how the article highlights that voltage criteria alone are not sufficient for diagnosis and should be interpreted alongside strain patterns and clinical context. The visual examples make it much easier to connect theory with real ECG interpretation. Great resource for both learners and clinicians reviewing LVH fundamentals.

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