How do you diagnose left ventricular hypertrophy (LVH) on an electrocardiogram (EKG)?

How to Check for Left Ventricular Hypertrophy on EKG

Use the Sokolow-Lyon Index (S wave in V1 + R wave in V5 or V6 ≥ 3.5 mV) as your primary screening criterion, then apply Cornell Voltage Criteria (S in V3 + R in aVL > 2.8 mV for men, > 2.0 mV for women) for additional sensitivity. 1

Primary Voltage Criteria (Apply These First)

Sokolow-Lyon Index

• Measure the S wave depth in lead V1 and add it to the tallest R wave in either V5 or V6 1
• Diagnose LVH if this sum is ≥ 3.5 mV (35 mm) 1
• This remains the most widely accepted and practical criterion for initial screening 1

Cornell Voltage Criteria

• For men: S wave in V3 + R wave in aVL > 2.8 mV indicates LVH 1
• For women: S wave in V3 + R wave in aVL > 2.0 mV indicates LVH 1
• The R wave in aVL alone > 1.1 mV can also suggest LVH 1

Additional Simple Voltage Criteria

• R wave in V5 or V6 > 2.6 mV 1
• Sum of R waves in V5 + V6 > 4.5 mV 1

Romhilt-Estes Point Score System (For Comprehensive Assessment)

Use this scoring system when you need higher diagnostic certainty—≥5 points = definite LVH, 4 points = probable LVH 1:

Voltage Criteria (3 points)

• Any limb lead R or S wave ≥ 2.0 mV, OR 1
• S wave in V1 or V2 ≥ 3.0 mV, OR 1
• R wave in V5 or V6 ≥ 3.0 mV 1

Supporting Features That Strengthen the Diagnosis

These findings cannot diagnose LVH alone but provide strong corroborative evidence when voltage criteria are present:

ST-T Wave Abnormalities (Most Important Supporting Feature)

• Look for lateral ST depression with T wave inversion in leads I, aVL, V5, and V6 1
• This pattern (previously called "strain") indicates larger left ventricular mass and higher cardiovascular risk than voltage criteria alone 2
• The presence of ST-T abnormalities significantly increases diagnostic confidence 2

Left Atrial Abnormality

• P wave abnormalities suggesting left atrial enlargement frequently accompany LVH 1
• This may be the earliest ECG sign in hypertensive heart disease 2
• Use only as supporting evidence, not for diagnosis 2

Left Axis Deviation

• QRS axis more negative than -30° may accompany LVH 1
• Cannot distinguish whether this results from hypertrophy itself or concurrent left anterior fascicular block 2

QT Interval Prolongation

• Slight QT prolongation often accompanies LVH 1
• Reflects altered ion channels in the hypertrophic process 2

Critical Pitfalls: Bundle Branch Blocks and Conduction Delays

Complete Left Bundle Branch Block (LBBB)

• Generally do NOT attempt to diagnose LVH with standard criteria in complete LBBB 1
• If you must assess LVH with LBBB present, use QRS duration > 155 ms combined with precordial voltage criteria 1
• In one study of hypertensive patients with LBBB, Sokolow-Lyon ≥ 3.0 mV showed the best performance (sensitivity 22.2%, specificity 88.3%) 3
• Standard criteria show significantly decreased sensitivity and specificity in LBBB 3

Right Bundle Branch Block (RBBB)

• Use specific modified criteria: SV1 > 2 mm, RV5 or V6 > 15 mm, and QRS axis left of -30° with SIII > largest R/S in precordial lead > 30 mm 1

Left Anterior Fascicular Block (LAFB)

• R wave amplitude in leads I and aVL are NOT reliable for LVH diagnosis when LAFB is present 1, 4
• LAFB shifts the QRS vector posteriorly and superiorly, artificially increasing R waves in I and aVL 2, 4
• Instead, use criteria incorporating S wave depth in left precordial leads (V5, V6) 1, 4

Practical Algorithm for Clinical Use

1. First, check for bundle branch blocks or fascicular blocks—if present, apply the special criteria above 1

2. Calculate Sokolow-Lyon Index (S in V1 + R in V5 or V6)—if ≥ 3.5 mV, LVH is likely 1

3. Apply Cornell Criteria (S in V3 + R in aVL)—use gender-specific cutoffs 1

4. Look for ST-T abnormalities in lateral leads—their presence with voltage criteria strongly supports LVH and indicates higher risk 2, 1

5. Check for supporting features (left atrial abnormality, left axis deviation, QT prolongation) to increase diagnostic confidence 1

6. Consider Romhilt-Estes scoring when diagnostic certainty is critical 1

Important Clinical Context

The sensitivity of ECG criteria for LVH is relatively low (ranging from 7.6% to 40.9% in patients without conduction abnormalities), but specificity is high (70.2% to 99.2%) 3. This means a positive ECG is reliable for diagnosing LVH, but a negative ECG does not exclude it—echocardiography remains the gold standard when clinical suspicion is high 3.