What is the characteristic electrocardiogram (ECG) pattern of left ventricular hypertrophy (LVH), specifically in terms of wave morphology in leads V1 and V5-6?

Left Ventricular Hypertrophy ECG Pattern

Yes, the characteristic ECG pattern of left ventricular hypertrophy (LVH) is accurately described as deep S waves in V1 combined with tall R waves in V5-6. 1

Primary Voltage Criteria

The most commonly used and validated voltage criteria for LVH detection include:

• Sokolow-Lyon criteria: S wave in V1 + R wave in V5 or V6 ≥35 mm (3.5 mV), which directly reflects the pattern you described 1, 2
• Cornell voltage criteria: R wave in aVL + S wave in V3 >28 mm in men or >20 mm in women 1
• Cornell product: Cornell voltage × QRS duration >2440 mm·ms 1

The Sokolow-Lyon criterion specifically captures the deep S wave in the right precordial lead (V1) representing right ventricular forces, combined with the tall R wave in left precordial leads (V5-6) representing the increased left ventricular mass 1, 2. This pattern emerges because LVH shifts the QRS vector leftward and posteriorly, creating larger amplitude deflections in the left precordial leads 1.

Understanding the Physiologic Basis

The ECG pattern requires both increased wall thickness AND sufficient chamber dilatation to manifest. 3 The product of wall thickness and chamber radius (h·R) must exceed a critical threshold—specifically >2.6 cm²—for LVH to appear on ECG 3. This explains why increased left ventricular mass alone does not always produce ECG changes; the geometric relationship between wall thickness and chamber size determines whether voltage criteria are met 3.

Performance Characteristics and Limitations

No single criterion should be used exclusively—multiple criteria improve sensitivity while accepting reduced specificity. 1

The diagnostic accuracy of voltage criteria varies considerably:

• Sensitivity: Ranges from 7.6% to 40.9% in most populations, with Sokolow-Lyon and Cornell criteria among the more sensitive 4, 2
• Specificity: Generally high, ranging from 70.2% to 99.2% 4
• The 12-lead sum of voltages with time-voltage area measurements can achieve sensitivity up to 76% at 98% specificity, significantly outperforming simple voltage criteria 5

Supporting Features Beyond Voltage

Additional ECG findings that support LVH diagnosis include:

• Left atrial abnormality: P wave duration ≥120 ms or increased P terminal force in V1, present in the majority of LVH cases 6, 2
• Secondary ST-T abnormalities: ST depression and T wave inversion in lateral leads (I, aVL, V5-6), though these should not be called "strain" 1
• Left axis deviation: May support the diagnosis but is not independently diagnostic 1
• Prolonged QRS duration: Slight prolongation is common with LVH 1

Critical Clinical Pitfalls

Adjust interpretation for patient demographics—age, gender, race, and body habitus significantly affect voltage criteria. 1, 7 Women have lower voltage thresholds than men, and voltage naturally decreases with age and increased body mass 1.

In the presence of left bundle branch block (LBBB), LVH diagnosis should be made with extreme caution or avoided entirely. 1, 4 When LBBB is present, only specific criteria with QRS duration >155 ms and very high voltage thresholds (Sokolow-Lyon ≥3.0 mV) maintain reasonable specificity of 88.3%, though sensitivity drops to 22.2% 4.

In left anterior fascicular block, the S wave depth in V5-6 increases, making criteria that include left precordial S waves more reliable than R wave amplitude in aVL. 1

Right bundle branch block reduces S wave amplitude in right precordial leads, decreasing sensitivity of standard voltage criteria. 1 In this setting, left atrial abnormality and left axis deviation become more valuable diagnostic features 1.

Practical Diagnostic Approach

When evaluating for LVH on ECG:

1. Measure S wave depth in V1 and R wave height in V5 or V6—if the sum ≥35 mm, Sokolow-Lyon criteria are met 1, 2
2. Check Cornell voltage (R in aVL + S in V3) using gender-specific thresholds 1
3. Assess for left atrial abnormality—P wave duration ≥120 ms or notched P wave with ≥40 ms between peaks 6, 7
4. Look for secondary ST-T changes in lateral leads 1
5. Exclude bundle branch blocks that would invalidate standard criteria 1, 4

When multiple criteria are positive, diagnostic confidence increases substantially, though echocardiography remains the gold standard for definitive LVH diagnosis. 6, 2