Left Ventricular Hypertrophy (LVH)

ECG Diagnostic criteria
  • There are numerous voltage criteria for diagnosing LVH, summarised below
  • The most commonly used are the Sokolov-Lyon criteria: S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm
  • Voltage criteria must be accompanied by non-voltage criteria to be considered diagnostic of LVH
Voltage Criteria

Limb Leads

  • R wave in lead I + S wave in lead III > 25 mm
  • R wave in aVL > 11 mm
  • R wave in aVF > 20 mm
  • S wave in aVR > 14 mm

Precordial Leads

  • R wave in V4, V5 or V6  > 26 mm
  • R wave in V5 or V6 plus S wave in V1 > 35 mm
  • Largest R wave plus largest S wave in precordial leads > 45 mm
Non Voltage Criteria
  • Increased R wave peak time > 50 ms in leads V5 or V6
  • ST segment depression and T wave inversion in the left-sided leads: AKA the left ventricular ‘strain’ pattern

  • 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

Additional ECG changes seen in LVH
ECG LVH V2 and V5
LVH by voltage criteria: S wave in V2 + R wave in V5 > 35 mm

ECG LV Strain V6
LV strain pattern: ST depression and T wave inversion in the lateral leads

Causes of LVH
  • Hypertension (most common cause)
  • Aortic stenosis
  • Aortic regurgitation
  • Mitral regurgitation
  • Coarctation of the aorta
  • Hypertrophic cardiomyopathy

Handy Tips
  • Voltage criteria alone are not diagnostic of LVH
  • 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)

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).


Advanced Reading



LITFL Further Reading


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

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner


  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.

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