A 58-year-old man with hypertension presents with palpitations. His ECG shows left axis deviation, tall R waves in aVL, and deep S waves in lead III. Regarding the ECG findings in left ventricular hypertrophy (LVH), all of the following are true EXCEPT:

Explanation

## ECG Changes in Left Ventricular Hypertrophy (LVH) ### Pathophysiology of LVH **Key Point:** Chronic hypertension causes concentric left ventricular hypertrophy, increasing myocardial mass. The ECG reflects this through increased QRS voltage and repolarization abnormalities. **Clinical Pearl:** LVH is a major independent cardiovascular risk factor. The presence of strain pattern (ST depression + T-wave inversion in lateral leads) indicates severe LVH and is associated with increased mortality. ### Correct Statements (Options 0, 1, 3) **High-Yield:** Sokolow-Lyon voltage criteria (S~V1~ + R~V5/V6~ >35 mm) are **highly specific** (~90%) but **poorly sensitive** (~50%) for LVH. Many patients with LVH do not meet these criteria. **Key Point:** The **strain pattern** (ST depression + T-wave inversion in lateral leads I, aVL, V5–V6) indicates advanced LVH with diastolic dysfunction and carries poor prognosis. **High-Yield:** Cornell voltage criteria (R~aVL~ + S~V3~ >20 mm in women, >28 mm in men) are **more sensitive** (~60%) than Sokolow-Lyon criteria, making them superior for detecting LVH. ### Incorrect Statement (Option 2) — THE ANSWER **Key Point:** Left axis deviation in LVH occurs because the **hypertrophied left ventricle shifts the QRS axis LEFTWARD (not rightward)**. This is due to increased leftward forces from the enlarged left ventricle. **Warning:** This is a common trap. The axis shift is **leftward**, not rightward. A rightward axis shift suggests right ventricular hypertrophy (RVH), not LVH. **Mnemonic:** **LAD + LVH** = Left Axis Deviation with Left Ventricular Hypertrophy (both "left"). ### Comparison of LVH Voltage Criteria | Criterion | Voltage Threshold | Sensitivity | Specificity | Notes | | --- | --- | --- | --- | --- | | Sokolow-Lyon | S~V1~ + R~V5/V6~ >35 mm | ~50% | ~90% | High specificity; misses many LVH cases | | Cornell | R~aVL~ + S~V3~ >20 mm (♀), >28 mm (♂) | ~60% | ~85% | Better sensitivity than Sokolow-Lyon | | Strain pattern | ST↓ + T↓ in lateral leads | Variable | High | Indicates advanced LVH; poor prognosis | [cite:Harrison 21e Ch 295]