Diagnostic criteria

• Sokolow and Lyon – S in V1 + R wave in V5 or V6 ≥ 35 mm.
• Cornell – R in aVL + S wave in V3 > 28 mm for men, or > 20 mm for women
• Roberts – QRS voltage in all leads > 175 to 225 mm.
• Scott
  • Limb leads:
    • R in I + S in 3 more than 25 mm
    • R in aVL more than 11 mm or >18 mm if left axis is present
    • R in aVF more than 20 mm
    • S in aVR more than 14 mm
  • Chest leads:
    • S in V1 or V2 + R in V5 or V6 more than 35 mm
    • R in V5 or V6 more than 26 mm
    • R + S in any V lead more than 45 mm
• Romhilt-Estes scoring system — A score of 5 or more indicates “definite” LVH; a score of 4 indicates “probable” LVH.

• R > S in V1 (suggestive); exclude other causes
  • Right bundle branch block
  • Posterior wall MI
  • WPW
  • Hypertrophic cardiomyopathy
  • Early precordial transition
• Other clues to diagnosis:
  • Right axis deviation (>+90)
  • R in V1 >6 mm
  • R in V1 + S in V5 or V6 >10.5 mm
  • R/S ratio in V1 >1
  • S/R ratio in V6 >1
  • Late intrinsicoid deflection in V1 (>0.035 sec)
  • Incomplete right bundle branch block
  • ST-T wave abnormalities (“strain”) in inferior leads
  • Right atrial hypertrophy/overload (“P pulmonale”)
  • S>R in leads I, II, III, particularly in children (S1S2S3 pattern)