23-38: Left Ventricular Hypertrophy

ECG Findings

• Largest R wave plus largest S wave in precordial leads > 45 mm

• R wave in V₄, V₅, V₆ > 26 mm

• S wave in V₁ + R wave in V₅ or V₆ > 35 mm

• R wave in aVL > 11 mm

• R wave in aVF > 20 mm

• S wave in aVR > 14 mm

• R wave in I + S wave in III > 25 mm

• ST depression and T-wave inversion in left-sided leads

• Left axis deviation

Pearls

1. LVH is often a sign of disease states such as systemic hypertension or aortic stenosis.

2. ST elevations seen in LVH can be confused as myocardial ischemia. There are no clear criteria to distinguish the two; the clinical presentation is of essence, as well as comparison to old ECGs and serial ECGs.

3. LVH may manifest on the ECG in many different ways. Several different systems for diagnosing LVH by ECG have been promoted (listed earlier), but none have been shown to be perfectly sensitive or specific.