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January 2005 EKG case:

 A 60 year old steelworker is admitted with frequent episodes of syncope while at work.  He has a history of occasional dull central chest pain which improved with beta blockers given to him by his doctor. His blood pressure is 122/90 and he has a systolic ejection murmur.

What does the EKG show and what is your diagnosis?

Rate:    52

Rhythm:  Sinus bradycardia

Axis:    Normal

PR:    Normal

QRS:   Tall R waves V5-V6; Deep S waves V1, V2, and V3

ST:    Depressed in II, III, AVF and V5, V6

T:   T wave inversion in I, AVL, II, III, AVF, and V4, V5, V6

EKG Diagnosis: Left ventricular hypertrophy

• Clinical Diagnosis: Aortic stenosis or Hypertrophic obstructive cardiomyopathy
• Practice Points: -Aortic stenosis can present in many ways.  These include angina, syncope, dyspnea, or the incidental discovery of a murmur.  The left ventricle becomes hypertrophied due to the obstruction in the left ventricular outflow tract.
• The criteria for LVH include:
• -R wave in V4-V6 > 27mm
• -Tallest R wave plus deepest S wave in precordial leads > 40mm
• -S wave in V1-V3 > 30mm
• -R wave in AVL >13mm
• -R wave in AVF >20mm
• -If ST segment depression and T wave inversion are present in V4-V6 and/or I, AVL, then LVH with strain is present.

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