EKG of the Week

A 54 y/o male complains of chest pain.

Q1. What does the EKG show?

A1. Left Ventricular Hypertrophy

EKG Findings

  • Large S waves in anterior precordial leads
  • Large R waves in lateral precordial leads
  • R wave in aVL + S wave in V3 greater than 28 mm in males, greater than 20 mm in females
  • S wave in V1 + R wave in V5 or V6 greater than 35 mm if age over 40, greater than 40 mm if age 30 to 40, greater than 60 mm if age 16 to 30
  • R wave in aVL greater than 11 mm
  • T waves deflected opposite to QRS complex (strain pattern)
  • Large S waves in anterior precordial leadsLarge R waves in lateral precordial leadsR wave in aVL + S wave in V3 greater than 28 mm in males, greater than 20 mm in femalesS wave in V1 + R wave in V5 or V6 greater than 35 mm if age over 40, greater than 40 mm if age 30 to 40, greater than 60 mm if age 16 to 30R wave in aVL greater than 11 mmT waves deflected opposite to QRS complex (strain pattern)

(Ritchie JV, Juliano ML, Thurman R. Chapter 23. ECG Abnormalities. In: Knoop KJ, Stack LB, Storrow AB, Thurman)

Left ventricular hypertrophy may mimic or obscure ACS on the ECG. LVH may feature prominent left-sided forces, manifesting as large rS or QS complexes in the right precordial leads—yet these changes seldom extend beyond V1 and V2 in the case of LVH. Consistent with the rule of appropriate discordance, the leads demonstrating such a pattern feature discordant ST segment elevation and tall, vaulted T waves, paralleling the changes of AMI. The initial portion of the elevated ST segment in LVH is generally concave, as opposed to the obliquely straight or convex pattern that usually (but not always) is seen with ST segment elevation in AMI. In LVH, the left precordial leads (and at times leads I and aVL) may show evidence of repolarization abnormality (or strain pattern), with ST segment depression and asymmetrically inverted T waves. The presence of this strain pattern in the left precordial leads is reassuring when ST segment elevation and tall T waves in the right precordial leads are being attributed to LVH rather than to AMI because one is essentially the mirror image of the other. The changes in LVH should be static over time.

(Kurz et al. Acute Coronary Syndrome. In Rosen’s Emergency Medicine, 8th ed. Ch. 78)