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The diagnosis of left ventricular hyperthrophy in the presence of complete RBBB is very difficult.

The usual voltage criteria, such as combining the S wave in right precordial leads with the R wave in lateral precordial leads lose sensivity, because of decreased ampitude of the S wave in the right precordial leads.

In this case:

- the presence of P mitrale suggests the presence of the left ventricular hypertrophy,

- the presence of R wave in lead aVL of 14 mm is highly suggestive of the left ventricular hypertrophy,

- the combination of the R wave in lead I  plus the S wave in lead III being greater then 25 mm is also high specyfic but not specyfic,

- the Q wave in leads I and aVL dosen't indicate infarction because it is less than one-third of the ampitude following R wave and is less than 0,04 seconds in duration.