Left ventricular hypertrophy (LVH) on ECG reflects increased left ventricular mass, usually from chronic pressure overload (hypertension, aortic stenosis, hypertrophic cardiomyopathy). ECG sensitivity: moderate (20–60%) ECG specificity: high (>85–95%). Echocardiography is the gold standard for confirming LV mass and quantifying severity.

Key ECG Findings

Increased QRS voltage
- Tall R waves in left-sided leads: I, aVL, V5–V6
- Deep S waves in right-sided leads: V1–V3
LV “strain” pattern (highly suggestive when present)
- ST-segment depression + asymmetric T-wave inversion in lateral leads (I, aVL, V5–V6)
- Typically downsloping ST depression with inverted T waves (“strain” appearance)
Other supportive features
- Left axis deviation (usually ≤ –30°)
- Left atrial enlargement (P mitrale: notched/bifid P wave in lead II, deep negative component in V1)
- Delayed intrinsicoid deflection in V5–V6 (>0.05 s)
- QRS duration mildly prolonged (0.10–0.11 s)
- Poor R-wave progression across precordial leads or prominent R wave in aVR (less common)

Major Voltage Criteria (Most Commonly Used)

Criterion	Threshold / Formula	Notes / Performance
Sokolow-Lyon Index (most popular, simple)	S in V1 + R in V5 or V6 > 35 mm (3.5 mV) OR R in aVL > 11 mm (1.1 mV)	Sensitivity ~20–30%, specificity >85–90% Often overestimates in young, thin, or athletic patients
Cornell Voltage	Men: S in V3 + R in aVL > 28 mm (2.8 mV) Women: S in V3 + R in aVL > 20 mm (2.0 mV)	Better sensitivity (~40–50%), specificity ~95% Gender-specific thresholds
Peguero-Lo Presti (newer, improved sensitivity)	Deepest S in any lead + S in V4 ≥ 2.8 mV (men) or ≥ 2.3 mV (women)	Higher sensitivity (~60%) while maintaining specificity ≥90%
Romhilt-Estes Point Score	“Definite” LVH if ≥5 points “Probable” if 4 points (voltage 3 pts + strain 3 pts + LAE 3 pts + LAD 2 pts + etc.)	Multifactorial – more comprehensive, includes non-voltage features

High-Yield Notes for Exams & Clinical Practice

Voltage criteria alone are insufficient → combine with strain pattern for higher diagnostic confidence.
Common causes: long-standing hypertension (most frequent), aortic stenosis, HCM, athlete’s heart (physiologic LVH – usually no strain).
Limitations: low sensitivity (misses many echo-confirmed LVH cases); false positives common in young, thin, or athletic individuals.
Prognostic significance: ECG-detected LVH predicts increased cardiovascular risk (heart failure, arrhythmias, sudden death) – even if echo is borderline.
Next step if ECG suggests LVH: echocardiography to confirm, measure LV mass index, assess wall thickness, and determine etiology.

Exam Pearl: Look for lateral strain pattern (ST depression + T inversion in I, aVL, V5–V6) – it greatly increases the likelihood that voltage changes represent true pathologic LVH rather than normal variant.

ECG Showing LVH

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ECG - Left Ventricular Hypertrophy

Key ECG Findings

Major Voltage Criteria (Most Commonly Used)

High-Yield Notes for Exams & Clinical Practice

ECG Showing LVH

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