From the Guidelines
The EKG findings of left ventricular hypertrophy (LVH), probable left atrial enlargement, and possible anterior Q waves require prompt cardiology consultation and further evaluation, as these findings suggest underlying cardiac pathology that may include hypertensive heart disease, valvular disease, or ischemic heart disease. These findings are concerning for increased morbidity and mortality, and thus, warrant thorough investigation and management. The presence of LVH, as indicated by the EKG, is a significant predictor of cardiovascular risk, as noted in the 2007 guidelines for the management of arterial hypertension 1.
The initial management should include a comprehensive cardiac workup with:
- Echocardiography to confirm structural changes and assess ventricular function, as it is more sensitive than electrocardiography in predicting cardiovascular risk 1
- Cardiac biomarkers to rule out acute myocardial injury
- Assessment of cardiovascular risk factors
Blood pressure control is essential if hypertension is present, typically starting with an ACE inhibitor like lisinopril 10-20mg daily or an ARB such as losartan 50-100mg daily, as recommended by the guidelines 1. If coronary artery disease is suspected, especially with the anterior Q waves, stress testing or coronary angiography may be indicated. Additional medications might include beta-blockers (metoprolol 25-100mg twice daily) to reduce myocardial oxygen demand and statins (atorvastatin 20-80mg daily) for lipid management.
The American Heart Association recommends that interpretation of ECGs for LVH should use only validated criteria, without deviation from the validated formulas 1. The terms strain, systolic, and diastolic should not be used in diagnostic statements related to LVH, and the terms probable, possible, and borderline should be used with caution 1.
These findings reflect cardiac remodeling where increased afterload leads to myocardial thickening (LVH), while left atrial enlargement often indicates chronically elevated filling pressures. The anterior Q waves raise concern for previous myocardial infarction or abnormal septal depolarization. Regular follow-up with serial EKGs and cardiac imaging is necessary to monitor disease progression and treatment response.
From the Research
EKG Interpretation
The EKG shows left ventricular hypertrophy, probable left atrial enlargement, and possible anterior Q waves. The presence of left ventricular hypertrophy is indicated by the RSR' pattern in V1 or V2, which is probably a normal variant, and the multiple LVH criteria met 2. The probable left atrial enlargement is suggested by the P-wave duration and morphology 3.
Clinical Implications
Left ventricular hypertrophy is a powerful, independent predictor of atrial fibrillation, ventricular arrhythmias, and sudden cardiac death 4. The presence of left atrial enlargement and left ventricular hypertrophy increases the risk of cardiovascular events and mortality 5, 4. The management of left ventricular hypertrophy involves lifestyle changes, medications, surgery, and implantable devices 5.
Diagnostic Correlation
The ECG criteria for left atrial enlargement and left ventricular hypertrophy correlate poorly with both transthoracic echocardiograms and cardiac magnetic resonance imaging 3. The Romhilt-Estes criteria demonstrate the strongest correlation with transthoracic echocardiograms for left ventricular hypertrophy, followed by Sokolow-Lyon, Modified Cornell, and Cornell criteria 3, 2.
Management Plan
The management plan for a patient with left ventricular hypertrophy, probable left atrial enlargement, and possible anterior Q waves should include:
- Aggressive control of hypertension to regress left ventricular hypertrophy and lower the risk of atrial fibrillation and sudden cardiac death 4
- Further investigation of the relationship between diastolic dysfunction, left ventricular hypertrophy, and genetic factors, and their association with sudden cardiac death 4
- Consideration of lifestyle changes, medications, surgery, and implantable devices to manage left ventricular hypertrophy 5
- Correlation with cardiac imaging, such as transthoracic echocardiogram and cardiac magnetic resonance imaging, to confirm the diagnosis and guide management 3