EKG of the Week 2017 10-8

A 70 y/o male with a long standing history of hypertension presents to the ED complaining of chest pain. Vital signs are: Pulse 60, BP 200/110, Respirations 18. His EKG is below.

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1.       What does the EKG show?

2.       What is the significance of these findings?



The EKG shows evidence of Left Ventricular Hypertrophy (LVH) with ST depressions in leads V4-V6. This is known as “LVH with strain”.

This pattern indicates strain on the left ventricle, and represents a patient at increased risk for coronary artery disease.


The EKG shows a sinus rhythm with a PAC (beat #2).

There is large voltage on the EKG. The S wave in lead V1 is approximately 30 mm. The S wave in lead V2 is approximately 25 mm. The R wave in aVL is approximately 20 mm. This is consistent with Left Ventricular Hypertrophy (LVH). LVH is a common complication of long standing hypertension. There are several different diagnostic criteria for LVH on EKG. Some are:

1.       R wave in lead V5 or V6 > 25 mm

2.       S wave in lead V1 or V2 > 25 mm

3.       R wave in lead V5 or V6 + the S wave in lead V1 > 35 mm

When the LVH pattern is accompanied by ST depressions and T wave inversions in the lateral precordial leads (as in this EKG), this is referred to as “LVH with strain”. Similar to right ventricular strain in the setting of pulmonary embolism, this finding represents left ventricular strain. It is caused by delayed repolarization of the left ventricle so the spread of repolarization is reversed. This EKG finding is not very sensitive but it is pretty specific for LVH with strain (specificity 90-100%). It indicates some degree of systolic dysfunction. Patients with LVH with strain have an increased risk for coronary artery disease, MI and ventricular arrhythmias.

LVH with strain on an EKG represents a poor long term prognostic factor.



(Wagner, Marriott’s Practical Electrocardiography, 10th Ed. pp. 84, 91)

(Ogah et al. Cardiovasc J Afr 2008; 19: 39–45.)