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Radiology · Additional topics

Left ventricular hypertrophy on ECG

Left ventricular hypertrophy is an increase in myocardial muscle mass, which is reflected on the electrocardiogram by a change in the amplitude of ventricular complexes. Specific voltage criteria in the chest leads and the calculation of specialized indices are used to make the diagnosis.

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Main ECG markerIncreased R-wave amplitude in the left chest leads V5 and V6
Mandatory calculationSokolow–Lyon index and Cornell voltage criteria
ECG monitoringPerformed at least twice a year to assess dynamics
Additional changesST-segment depression and inverted T-wave in leads V5, V6
3 min readFor medical studentsUpdated 10.10.2026
Material prepared by WhiteCoat Pro editorial team based on platform study guidesPending instructor review

General ECG signs of hypertrophy

Any increase in myocardial muscle mass naturally alters the electrocardiographic picture. General features indicating hypertrophy of any heart chamber include:

  • Increased amplitude of the ventricular complex waves (R wave) or atrial complex (P wave).
  • Appearance of signs of myocardial ischemia, which is associated with inadequate blood supply to the increased muscle mass.
  • Signs of intraventricular conduction disturbances.
  • Deviation of the electrical axis of the heart (EAH) towards the hypertrophied chamber.

Main and additional criteria for left ventricular hypertrophy

Diagnosis of left ventricular hypertrophy is based on a detailed assessment of the chest leads.

Main (amplitude) ECG signs:

  • A tall R wave in lead V5 or V6 exceeds 16 mm.
  • Normal R-wave progression is disrupted: its amplitude in V6 is greater than in V5, and in V5 is greater than in V4 (forming the ratio RV6 > RV5 > RV4).
  • In the right chest leads (V1, V2), a deep S wave is recorded, exceeding 12 mm.
  • The sum of the amplitudes of the R wave in V5 (or V6) and the S wave in V1 is more than 28 mm.

Additional signs (repolarization and electrical axis changes):

  • Deviation of the electrical axis of the heart to the left.
  • In the left chest leads (V5, V6), ST-segment depression and the formation of an inverted T-wave are noted.
  • In the right chest leads (V1, V2), conversely, ST-segment elevation is recorded.
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Index calculation and instrumental monitoring

When recording a standard 12-lead ECG, the physician is required to calculate specific parameters: the Sokolow–Lyon index and the Cornell voltage criteria. Electrocardiographic monitoring of the patient's condition must be carried out at least twice a year.

If ECG indices reveal signs of progressive left ventricular hypertrophy, or if the patient has not reached the target blood pressure, echocardiography (EchoCG) is mandatory at least once a year.

On EchoCG, the diagnosis is confirmed by visualizing left ventricular cavity dilation and wall hypertrophy. The study must determine the LVMI (left ventricular mass index) and assess diastolic function.

Associated changes and late stages

Left ventricular hypertrophy is often accompanied by changes in other parts of the heart, which is also reflected on the electrocardiogram.

Obstructed blood outflow into the left ventricle leads to left atrial overload. On the ECG, this manifests as signs of hypertrophy — P-mitrale (a wide, notched P wave wider than 0.10–0.12 s, clearly visible in leads I, II, aVL, V5, V6). Dilation and structural remodeling of the atrial myocardium often result in rhythm disorders, specifically atrial fibrillation.

In the late stages of pathology development (as pulmonary hypertension develops), the ECG may record signs of biventricular hypertrophy, when both ventricles are involved in the pathological process.

How to memorize

A simple formula to memorize the main amplitude sign: R(V5/V6) + S(V1) > 28 mm. Left chest leads (V5, V6) show a tall R wave, while the right ones (V1, V2) show a deep S wave.

Class and exam questions

How often should an ECG be recorded in diagnosed hypertrophy?

A control 12-lead ECG must be performed at least twice a year.

Which indices must be calculated from the ECG?

For an objective assessment of left ventricular hypertrophy, calculating the Sokolow–Lyon index and Cornell voltage criteria is mandatory.

What happens to the ST segment in the left chest leads?

Leads V5 and V6 record ST-segment depression and an inverted T wave, which are classified as additional ECG signs.

When is EchoCG mandatory?

EchoCG is performed at least once a year if ECG reveals progressive hypertrophy (based on indices) or if target BP is not achieved.

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What else to study on this topic

  • ECG criteria for right ventricular hypertrophy
  • Differential diagnosis of left and right atrial hypertrophy (P-mitrale and P-pulmonale)
  • Echocardiography and Doppler ultrasound in the assessment of valvular regurgitation
  • Radiological signs of cardiac chamber enlargement ("third arch")

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Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.