Summary of Various ECG Criteria for Left Ventricular Hypertrophy (LVH)

Left ventricular hypertrophy (LVH) is an increase in left ventricular myocardial mass, most commonly caused by long-standing hypertension, aortic stenosis, and cardiomyopathies. While echocardiography is the diagnostic gold standard, the electrocardiogram (ECG) remains a widely used screening and prognostic tool. Multiple ECG criteria have been developed to improve detection of LVH, each with its own strengths and limitations.

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Voltage-Based Criteria

Sokolow–Lyon Criteria

This is the most traditional and commonly taught criterion. LVH is suggested when the sum of the S wave in V1 and the R wave in V5 or V6 is ≥35 mm, or when the R wave in V5 or V6 alone is ≥26 mm. Although easy to remember, its sensitivity is low, particularly in obese individuals and older adults.

Cornell Voltage Criteria

LVH is present when the sum of the S wave in V3 and the R wave in aVL exceeds 28 mm in men or 20 mm in women. Compared with Sokolow–Lyon, this criterion has better specificity and performs particularly well in women.

Peguero–Lo Presti Criteria

This newer voltage criterion uses the deepest S wave in any lead plus the S wave in V4. A total ≥28 mm in men or ≥23 mm in women suggests LVH. Studies show improved sensitivity compared with older voltage-based methods.

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Voltage Plus Duration Criteria

Cornell Voltage-Duration Product

This criterion multiplies the Cornell voltage (SV3 + RaVL) by the QRS duration. A value ≥2440 mm·ms indicates LVH. Including QRS duration improves diagnostic accuracy and correlates better with left ventricular mass.

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Point-Based Criteria

Romhilt–Estes Point Score System

This system assigns points to multiple ECG features including increased QRS voltage, ST-T strain pattern, left atrial enlargement, left axis deviation, prolonged QRS duration, and delayed intrinsicoid deflection. A score ≥5 points indicates definite LVH, while 4 points suggests probable LVH. It offers higher specificity but is more complex to apply.

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Repolarization-Based Features

LVH Strain Pattern

LVH may be associated with downsloping ST-segment depression and asymmetric T-wave inversion in lateral leads (I, aVL, V5–V6). Although not diagnostic alone, the strain pattern indicates advanced hypertrophy and is associated with increased cardiovascular risk.

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Limitations of ECG Criteria

Low sensitivity: many patients with echo-proven LVH have normal ECGs

ECG voltages are influenced by body habitus, age, lung disease, and chest wall thickness

No single criterion is universally superior

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Clinical Significance

Despite limitations, ECG-detected LVH is a strong independent predictor of cardiovascular morbidity and mortality. Regression of LVH on ECG with antihypertensive therapy is associated with improved clinical outcomes.

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Key Message

ECG criteria for LVH provide valuable screening and prognostic information. Using multiple criteria together and interpreting them in the clinical context improves diagnostic yield, with echocardiography remaining essential for confirmation.