Chambers and pre-excitation
Left ventricular hypertrophy
Towering voltages with lateral strain — sensitive to nothing, but specific enough to act on.
66 bpmSinus
What you see
- Sokolow–Lyon: S in V1 plus R in V5 or V6 greater than 35 mm.
- R in aVL greater than 11 mm.
- Left ventricular strain: downsloping ST depression with asymmetrical T inversion in I, aVL, V5 and V6.
- Left atrial enlargement and left axis deviation often accompany it.
Why it looks like that
More myocardium generates a larger electrical vector, so the leads facing the left ventricle record bigger deflections. The strain pattern reflects delayed subendocardial repolarisation in a thick, relatively underperfused wall.
What to do
- Echocardiography to confirm and to distinguish hypertensive hypertrophy from hypertrophic cardiomyopathy or amyloid.
- Treat the cause — usually hypertension or aortic stenosis.
- LVH on the ECG is an independent predictor of cardiovascular events, so it should tighten blood pressure targets rather than be filed away.
The trap
Voltage criteria are unreliable in thin young people, who often exceed them with normal hearts, and in the obese or emphysematous, in whom real hypertrophy fails to meet them. Deep T wave inversion in the lateral leads out of proportion to the voltage should raise apical hypertrophic cardiomyopathy.
Sokolow–Lyonstrain patternhypertrophic cardiomyopathyaortic stenosis