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Posts Tagged ‘LVH AND STEMI’

LVH is   a common ECG  finding .Classically  it should produce tall  R waves and deep S waves in V1-V3 .

But it is well known deep q waves also can occur in LVH  especially in severe  forms of pathological LVH.

Q-LVH INCOMPLET LBBB STEMI DIFFERENTIAL DIAGNOSIS

Why the septal R disappears in some is not clear .( due to  myocardial dis-array ? )

LVH  results in  secondary ST /T  changes either inherent or associated  conduction delay. (In-complete LBBB )

Final message

Errors  mistaking LVH for STEMI  is more common than we realise . Propagation of the  term  Q -LVH with ST elevation  will help  reduce this common error in coronary care units.

 

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LVH is traditionally believed to be adverse marker for both coronary events and cardiac failure. . (Framingham ) While  this may be  true most of  time  we  also  have evidence to  suggest  patients with LVH  tolerate ischemic injury better.The area of MI is less.  In fact , the coronary drug project was not able to identify LVH as a major risk factor  for MI.  But many other studies continued to portray  LVH  dangerous parameter in ACS.

This paper from Sheba medical center Israel   tries  to answer this  question succinctly !

Summary

LVH  indeed  is an  adverse  predictor  for cardiac outcome  in the  long term.Meanwhile , since the   7 day mortality of STEMI  is well below  3% if  associated with LVH    keeps the controversy alive  ( 5-7% in non LVH group ) .This piece of statistics     gives credibility to the belief   LVH  may  really prevent  early deaths  in STEMI.

This phenomenon about LVH is  consistent with our observation  in  one of the Asia’s oldest coronary  care units (Started in 1972)   .None of the  STEMI patients with LVH  had a cardiogenic shock  in the recent past   !

* It is important to realise not all LVH are same. Inherited LVH, Diabetic LVH and  uremic(  or sub uremic ) LVH  behave differently. Since  the concept  of LVH is  carried  by physicians   in  a single basket ,  we tend to miss the  true benefits of LVH that occur purely due to good exercise training or a mild HT !

In other words , LVH that do not involve interstitial proliferation  is  probably  good for the heart !

Final message

With due regards to Framingam study  , presence of LVH in ECG in any form of acute coronary  syndrome  should  bring a sense of comfort  in the coronary care units .I agree  , it may increase risk of sudden death in some of the population but still it has some unique and definite  advantages at times of  ACS.

Reference

1 Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Prognostic
implications of echocardiographically determined left ventricular mass in the
Framingham Heart Study. N Engl J Med 1990;322:1561–1566

2.The Coronary Drug Project Research Group. Left ventricular hypertrophy patterns and prognosis. Experienced post infarction in the Coronary Drug Project.Circulation 1974;49:862–869.

3.Behar S, Reicher-Reiss H, Abinadar E, Agmon J, Barzilai J, Friedman Y, Kaplinsky E, Kauli N, Kishon Y, Palant A. Long-term prognosis after acute myocardial infarction in patients with left ventricular hypertrophy on the
electrocardiogrm. Am J Cardiol 1992;69:985–990.

*Coronary drug project (A old study done in early 1970s has more credibility when LVH was not considered as pharma target !)

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