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©2013 UpToDate ® Print Email LVH with repolarization abnormalities Precordial leads in a hypertensive patient with left ventricular hypertrophy (LVH). The ECG far exceeds commonly used voltage criteria for LVH in the precordial leads: the S in V1 plus the R in V5 equals 50 mm (upper limit of normal 35 mm). Voltage criteria alone may not be diagnostic of LVH. However, the associated repolarization abnormality (formerly referred to as a "strain" pattern) in leads V5 and V6, characterized by downward sloping ST segment depression and T wave inversion, make LVH highly likely. Left atrial abnormality consistent with enlargement is also present as shown by the biphasic P wave with a broad negative deflection in lead V1. These changes can be induced by a chronic pressure load (hypertension or aortic stenosis) or a chronic volume load (aortic or mitral regurgitation or dilated cardiomyopathy). Courtesy of Ary Goldberger, MD.