Last week’s 5-minute EKG discussion was lead by our APD, Dr. Scott Heinrich. You get handed this EKG from a patient in triage with chest pain. Should you activate the cath lab? … The answer: No This EKG is showing left ventricular hypertrophy (LVH) with repolarization abnormality, also known as LVH with strain. This can be easily confused for ischemia, so how do we differentiate between the two? First and foremost, you must meet criteria for left ventricular hypertrophy. While the gold standard for diagnosing LVH is through echo, there are several different EKG criteria we can use to diagnose LVH, including:
In LVH, the myocardium becomes thickened, which causes the electricity to move more slowly through the heart. This slowed conduction causes widening of the QRS and repolarization abnormalities. This will appear on EKG as increased R wave peak time of >50ms in leads V5 or V6 and ST depressions with T wave inversions in lateral (left-sided) leads. It is important to note that in LVH with strain, T wave inversions are often asymmetric, in contrast to the symmetric t wave inversions often seen in ischemia.  Ex: Deep, symmetric inverted t waves in Wellen’s (type B) In summary, in LVH with strain you will see:
Lastly, here are some tips from EKG guru Amal Mattu that may help to differentiate between LVH with strain and ischemia:
Resources:
"LVH" redirects here. For the Las Vegas hotel formerly known as "LVH", see Westgate Las Vegas.
Left ventricular hypertrophy (LVH) is thickening of the heart muscle of the left ventricle of the heart, that is, left-sided ventricular hypertrophy and resulting increased left ventricular mass. Causes[edit]While ventricular hypertrophy occurs naturally as a reaction to aerobic exercise and strength training, it is most frequently referred to as a pathological reaction to cardiovascular disease, or high blood pressure.[2] It is one aspect of ventricular remodeling. While LVH itself is not a disease, it is usually a marker for disease involving the heart.[3] Disease processes that can cause LVH include any disease that increases the afterload that the heart has to contract against, and some primary diseases of the muscle of the heart.[citation needed] Causes of increased afterload that can cause LVH include aortic stenosis, aortic insufficiency and hypertension. Primary disease of the muscle of the heart that cause LVH are known as hypertrophic cardiomyopathies, which can lead into heart failure.[citation needed] Long-standing mitral insufficiency also leads to LVH as a compensatory mechanism.[citation needed] Associated genes include OGN, osteoglycin.[4] Diagnosis[edit]The commonly used method to diagnose LVH is echocardiography, with which the thickness of the muscle of the heart can be measured. The electrocardiogram (ECG) often shows signs of increased voltage from the heart in individuals with LVH, so this is often used as a screening test to determine who should undergo further testing.[citation needed] Echocardiography[edit]Left ventricular hypertrophy gradingby posterior wall thickness[5]
Two dimensional echocardiography can produce images of the left ventricle. The thickness of the left ventricle as visualized on echocardiography correlates with its actual mass. Left ventricular mass can be further estimated based on geometric assumptions of ventricular shape using the measured wall thickness and internal diameter.[6] Average thickness of the left ventricle, with numbers given as 95% prediction interval for the short axis images at the mid-cavity level are:[7]
CT & MRI[edit]CT and MRI-based measurement can be used to measure the left ventricle in three dimensions and calculate left ventricular mass directly. MRI based measurement is considered the “gold standard” for left ventricular mass,[8] though is usually not readily available for common practice. In older individuals, age related remodeling of the left ventricle's geometry can lead to a discordancy between CT and echocardiographic based measurements of left ventricular mass.[9] ECG criteria[edit]Left ventricular hypertrophy with secondary repolarization abnormalities as seen on ECG Histopathology of (a) normal myocardium and (b) myocardial hypertrophy. Scale bar indicates 50 μm. Gross pathology of left ventricular hypertrophy. Left ventricle is at right in image, serially sectioned from apex to near base. There are several sets of criteria used to diagnose LVH via electrocardiography.[10] None of them are perfect, though by using multiple criteria sets, the sensitivity and specificity are increased. The Sokolow-Lyon index:[11][12]
The Cornell voltage criteria[13] for the ECG diagnosis of LVH involve measurement of the sum of the R wave in lead aVL and the S wave in lead V3. The Cornell criteria for LVH are:
The Romhilt-Estes point score system ("diagnostic" >5 points; "probable" 4 points):
Other voltage-based criteria for LVH include:
Treatment[edit]Treatment is typically focused on resolving the cause of the LVH with the enlargement not permanent in all cases. In some cases the growth can regress with the reduction of blood pressure.[14] LVH may be a factor in determining treatment or diagnosis for other conditions, for example, LVH is used in the staging and risk stratification of Non-ischemic cardiomyopathies such as Fabry's Disease.[15] Patients with LVH may have to participate in more complicated and precise diagnostic procedures, such as Echocardiography or Cardiac MRI.[16][17] See also[edit]
References[edit]
External links[edit]What does left ventricular hypertrophy with repolarization abnormality mean?Left ventricular hypertrophy is a thickening of the wall of the heart's main pumping chamber. This thickening may result in elevation of pressure within the heart and sometimes poor pumping action. The most common cause is high blood pressure.
What is left ventricular hypertrophy with QRS widening?When the myocardium as abnormally thickened, electrical activity takes longer to traverse throughout the whole heart, thus the duration of the QRS complex may be widened. This is referred to as "LVH with QRS widening".
Is left ventricular hypertrophy life threatening?What is the prognosis (outlook) for people with left ventricular hypertrophy? Left untreated, LVH (and related underlying heart conditions) increases your risk of serious heart disease or even death. Treatment to slow or stop the progression of left ventricular hypertrophy lowers the risk of severe heart damage.
What is the life expectancy of someone with left ventricular hypertrophy?The majority of patients with hypertrophic cardiomyopathy have no symptoms and most have a near-normal life expectancy.
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Left ventricular hypertrophy with qrs widening and repolarization abnormality
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