What is the LV strain pattern on ECG?

• A. ST-segment depression with T-wave inversion in left-sided leads (I, aVL, V5-V6) with LVH
• B. ST-segment elevation in inferior leads
• C. Prominent U waves
• D. Prolonged PR interval

Answer: (A)

Left ventricular strain is a repolarization abnormality seen with LVH or increased LV workload. The hallmark pattern appears in the lateral leads that reflect the left ventricle (I, aVL, V5–V6): the ST segment shows depression with a downward-sloping or scooped appearance starting at the J point, and the T waves in those same leads invert. This discordant ST-T change happens because the stressed or hypertrophied left ventricle alters the normal repolarization pattern. This set of changes in the lateral leads is the classic description of LV strain. It’s different from ST elevation in inferior leads (which points to an inferior MI), prominent U waves (seen with hypokalemia or digoxin effects), or a prolonged PR interval (first-degree AV block).