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ECG - Left Ventricular Hypertrophy
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.