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Tuesday, 7 October 2014

Autumn 2: Recognising hypertrophy

Hello and welcome to this week's #ECGclass!

This week it's @J_vanOppen here and we'll be talking about hypertrophy. To join in, ask questions or add comments, please use the hashtag #ECGclass so everyone can follow.

Here we go!

First of all, let's do some revision of last time's material. @hcwetherell talked about a methodical approach to ECG interpretation of Rhythm - Rate - Intervals (looking at each lead in turn) - Axis.

What do you reckon to this ECG?


Rhythm: sinus (P waves before every QRS complex).
Rate: 70ish (300 divided by number of big squares between R peaks).
Intervals: PR 4 small squares, QRS 2 and QT 9 (normal).
Axis: Normal (Lead I and aVF both predominantly positive).

This is a normal ECG.


Right, revision over! Let's move on with tonight's class.

Case 1

Your patient, an 83 year old gentleman, was seen in ED last week with breathlessness. He feels much better today after a week on furosemide. You record an ECG in clinic:


Q1: Have a go describing this ECG in terms of Rhythm - Rate - Intervals - Axis.

Rhythm: sinus
Rate: 65
Intervals: PR, QRS and QT intervals normal length
Axis: Normal

Q2: Compare this to the normal ECG we saw during revision - what looks different? Look at the precordial leads (V1-V6) in particular.


Let's recall some anatomy here. The back of the heart (predominantly left ventricle) is twisted forwards around the mediastinum. This is because the muscle hypertrophies to overcome obstruction in the system (remember Starling's Law?). The left ventricle is straining, hence the ST depression in the lateral chest leads.

>> This is left ventricular hypertrophy (LVH) with strain pattern due to aortic stenosis.

Here's a #FOAMed resource on voltage criteria for LVH: http://lifeinthefastlane.com/ecg-library/basics/left-ventricular-hypertrophy/


Case 2

Your next patient is a young woman with recurrent syncope and chest pain, but the ECG picture is just as applicable to your older patients with chronic lung disease.


Q3: Let's apply the Rhythm - Rate - Intervals - Axis method to this ECG.

Rhythm: sinus
Rate: 100
Intervals: PR interval upper end of normal
Axis: negative Lead I and positive aVF -> right axis deviation

Q4: What's abnormal on this trace?

ST depression and T wave inversion in inferior and chest leads.
Dominant R wave in V1 and S wave in V6 suggests right ventricular hypertrophy.
The tall p wave ('p pulmonale' - look at Lead II) shows right atrial hypertrophy.


This is a patient with pulmonary hypertension whose right heart chambers are working hard to overcome the increased pressure.


Thank you for joining in with this evening's #ECGclass! Hope you enjoyed it and found it useful.

There's a great, comprehensive guide to ECG hypertrophies at http://www.frca.co.uk/article.aspx?articleid=100689

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