ECG Topic - Left Ventricular Hypertrophy (LVH)

Last updated 1/25/26

Intro

The primary ECG manifestations of left ventricular hypertrophy are increased QRS voltage, secondary repolarization abnormalities (the “LV strain pattern”), and associated structural markers such as left atrial enlargement. Although the ECG is insensitive for detecting anatomic LVH, its clinical importance in the emergency department lies in interpretation, not diagnosis. Recognizing LVH allows the clinician to determine whether ST-segment and T-wave abnormalities represent secondary changes from hypertrophy or primary ischemia.

Pathophysiology

Left ventricular hypertrophy reflects increased myocardial mass from either pressure overload (most commonly chronic hypertension or aortic stenosis) or volume overload (such as aortic insufficiency or mitral regurgitation). In response to this chronic workload, the ventricle enlarges in an effort to generate greater contractile force.

On the ECG, increased LV mass means more myocardial cells depolarizing simultaneously, producing a larger net electrical vector and therefore higher QRS amplitudes. This voltage increase is most evident in the precordial leads, which lie closest to the left ventricle. In addition, an enlarged LV displaces the heart closer to the anterior chest wall, further augmenting recorded voltages.

Because these changes reflect electrical mass rather than anatomy, LVH is diagnosed on ECG using voltage-based criteria, which are useful but imperfect. Importantly, these criteria are valid only when ventricular activation occurs through normal conduction pathways. In the presence of abnormal LV conduction such as left bundle branch block, Wolff–Parkinson–White syndrome, ventricular rhythms, or severe electrolyte or drug effects, QRS morphology is distorted and standard LVH voltage criteria should not be applied. LVH can be diagnosed in a right bundle branch block (RBBB) as conduction through the LV is normal.

ECG Findings

Precordial voltages in LVH are large and may even touch and overlap. This reflects not only increased myocardial mass generating larger electrical forces, but also anterior displacement of the enlarged left ventricle toward the chest wall, which preferentially augments the precordial leads. This pattern is known as Seamen’s sign and has been shown to be non-inferior to traditional voltage criteria for identifying LVH. (PMID: 35669958)

Example 1

Example 2

Example 3

In LVH, the net vector moves leftward, posterior and slightly inferior. This can result in the following:

Example: Tall R waves in the lateral (I, V5-V6) and inferior leads (II, aVF)

Same ECG: Deep S waves in V1-V3, aVR

Going back to this ECG:

• R in I ≥ 12 mm ✅
• R in aVL ≥ 11 mm ❌
• R in aVF ≥ 20 mm ✅

Same ECG:

• Assuming this patient is a male, the deepest S wave in V3 + S wave in V4 ≥ 28mm fulfilling Peguero Lo Presti criteria. In fact, the depth of V3 alone is ≥ 28mm.

• Sokolow-Lyon - S in V1 or V2 + R in V5 or V6 ≥ 35mm ✅
• Seamens’ Sign: any precordial QRS complex overlap ✅
• Cornell Criteria: R in aVL + S in V3 ≥ 28mm (assuming male) ✅

Basic Algorithm

Only 1 criteria is required to make the diagnosis of LVH on ECG. If you’re looking at an ECG and LVH is on your differential, consider going down the following algorithm

1. Step 1: Apply Seamens’ Sign or Sokolow Lyon. If either criteria is met, then LVH is likely present. If not, proceed with next step.
2. Step 2: Are there tall R waves in the limb leads? or are there deep S waves in the precordial leads? Choose one and either apply the R wave criteria or Peguero Lo Presti. If any criteria is met, then LVH is likely present.

Practice ECGs

Is LVH present in the following ECGs?

ECG 1

ECG 2

ECG 3

ECG 4

ECG 5

Key Points

• LVH on ECG reflects increased electrical mass with a dominant leftward, posterior, and often inferior depolarization vector.
• This produces tall R waves in lateral and often inferior leads, deep S waves in right precordial leads, and sometimes overlapping precordial complexes (Seamen’s sign).
• Voltage criteria are specific but insensitive and are valid only with normal left ventricular conduction.
• The clinical value of identifying LVH in the ED is interpretive, not anatomic.
• Recognizing LVH helps distinguish secondary “strain” repolarization changes when present from primary ischemia (see related posts)

Related Posts

• ECG Topic: LVH with strain vs. LVH with OMI

Resources

• Brady WJ, Harrigan RA. Critical Decisions in Emergency and Acute Care Electrocardiography. 2nd ed. Wiley-Blackwell.
• Burns E, Buttner R. Left Ventricular Hypertrophy. LITFL ECG Library.
• Davila E. The ECG. 2025.
• Garcia TB. 12-Lead ECG: The Art of Interpretation. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins.
• Surawicz B, Knilans TK. Chou’s Electrocardiography in Clinical Practice. 6th ed. Philadelphia, PA: Elsevier.
• Walker P, Jenkins CA, Hatcher J, Freeman C, Srica N, Rosell B, Hanna E, March C, Seamens C, Storrow A, McCoin N. Seamens' Sign: a novel electrocardiogram prediction tool for left ventricular hypertrophy. PeerJ. 2022 May 31;10:e13548. doi:10.7717/peerj.13548. PMID: 35669958.
• Yu Z, Song J, Cheng L, Li S, Lu Q, Zhang Y, Lin X, Liu D. Peguero-Lo Presti criteria for the diagnosis of left ventricular hypertrophy: A systematic review and meta-analysis. PLoS One. 2021 Jan 29;16(1):e0246305. doi:10.1371/journal.pone.0246305. PMID: 33513186.

This post is for education and not medical advice.