ECG-Left-ventricular-hypertrophy-LVH-2.jpg
Diagnose and give differentials
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Reading File
Finding Sources
Finding Sources
Reading File
Reading File
Here is the full systematic ECG analysis:
ECG Interpretation
Technical Details
- Paper speed: 25 mm/s | Calibration: 10 mm/mV
- Leads: Standard 12-lead with rhythm strip (lead II)
Systematic Analysis
| Parameter | Finding |
|---|---|
| Rate | ~50-55 bpm (sinus bradycardia) |
| Rhythm | Regular sinus rhythm |
| Axis | Markedly deviated to the left (-60°) |
| P waves | Normal morphology, upright in II, inverted in aVR |
| PR interval | ~160-180 ms (normal) |
| QRS duration | ~90-100 ms (not widened; no BBB) |
| QRS morphology | qR in I and aVL; rS in II, III, aVF |
| Transition zone | Delayed (persistent deep S waves through V4-V5) |
| Voltage | Markedly increased in precordial leads |
| ST segments | Downsloping depression in I, aVL, V5-V6; elevation in V1-V3 |
| T waves | Asymmetric inversion in lateral leads (I, aVL, V5-V6) |
Primary Diagnosis
1. Severe Left Ventricular Hypertrophy (LVH) with Strain Pattern
The ECG meets both major voltage criteria by wide margins:
- Sokolow-Lyon criterion (SV1 or SV2 + RV5 or RV6 > 35 mm): Met - estimated ~55 mm
- Cornell voltage criterion (SV3 + RaVL > 28 mm in men / > 20 mm in women): Met - estimated ~51 mm
- RaVL > 11 mm: Met (another widely used single-lead criterion)
The LV strain pattern is the secondary repolarization abnormality that accompanies severe LVH: asymmetric ST depression with T-wave inversion in the lateral leads (I, aVL, V5-V6), with reciprocal ST elevation and tall T waves in the right precordial leads (V1-V3). This is a "pressure overload" repolarization pattern and does NOT represent ischemia in isolation. - Harrison's Principles of Internal Medicine 22E, p. (CARDIAC ENLARGEMENT AND HYPERTROPHY section)
2. Left Anterior Fascicular Block (LAFB)
Criteria met:
- Left axis deviation to approximately -60°
- qR pattern in I and aVL
- rS pattern in II, III, and aVF
- QRS duration normal (< 120 ms)
- No other cause of LAD (no inferior MI)
LAFB is the most common conduction abnormality and frequently co-exists with LVH because both share hypertensive and hypertrophic etiologies. - Goldman-Cecil Medicine, Fig. 42-5
3. Sinus Bradycardia
Rate approximately 50-55 bpm. This can be a normal variant (well-trained individual, vagotonia) or secondary to medications (beta-blockers, which are often prescribed for hypertension/LVH).
Differential Diagnoses for the Voltage and Repolarization Pattern
| Differential | Supporting Features | Against |
|---|---|---|
| Hypertensive Heart Disease | Most common cause of LVH; explains voltage + strain + LAFB | Requires clinical correlation |
| Hypertrophic Cardiomyopathy (HCM) | Extreme voltage, deep septal Q waves, repolarization changes | Septal Q waves not prominent here; asymmetric pattern of LVH would need echo |
| Aortic Stenosis | Severe pressure overload produces identical LVH + strain pattern | Requires clinical/echo correlation |
| Athletic Heart ("Athlete's ECG") | High voltage, bradycardia seen in trained athletes | Strain pattern argues strongly against benign athletic remodeling; athletes typically have no repolarization abnormality |
| Dilated Cardiomyopathy | Can show LVH pattern and conduction disease | Less likely without low voltages or LBBB |
| Coarctation of the Aorta | Causes LVH with hypertension | Rare in adults without known history |
Key Clinical Takeaways
- The strain pattern (asymmetric ST-T changes in lateral leads) distinguishes pathological LVH from the benign high-voltage seen in young/athletic individuals. Athletes should NOT have ST depression and T-wave inversions.
- LVH with strain is an independent marker of increased cardiovascular mortality - it should prompt evaluation and optimization of underlying cause (most commonly hypertension).
- Next steps should include:
- Blood pressure measurement and hypertension workup
- Echocardiogram (gold standard for LVH; assess wall thickness, diastolic dysfunction, LVEF, valvular disease)
- Renal function (hypertensive nephropathy)
- Lipid panel and cardiovascular risk stratification
- If HCM suspected: genetic testing, family history
Primary ECG Diagnosis: Sinus bradycardia with severe LVH (meets Sokolow-Lyon and Cornell criteria), LV strain pattern, and left anterior fascicular block. The clinical picture is most consistent with longstanding hypertensive heart disease or aortic stenosis until proven otherwise by echocardiography.
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