What are the next steps for a patient with abnormal ECG results indicating probable left atrial enlargement and possible anteroseptal infarct who wants to be a kidney donor?

Management of Abnormal ECG in a Potential Kidney Donor

A patient with an abnormal ECG showing left atrial enlargement, left axis deviation, low voltage in extremity leads, and possible anteroseptal infarct requires comprehensive cardiac evaluation before being cleared as a kidney donor.

Initial Assessment and Significance of ECG Findings

• Left atrial enlargement on ECG is associated with hypertension and may be an early sign of hypertensive heart disease, even before left ventricular hypertrophy is evident 1
• Left axis deviation is considered a "borderline" ECG finding that may indicate underlying cardiovascular abnormalities, particularly when combined with other ECG abnormalities 2
• Low voltage in extremity leads can be associated with various conditions including obesity, emphysema, pericardial effusion, or infiltrative cardiomyopathies 3
• The finding of "possible anteroseptal infarct" is particularly concerning as it may indicate previous myocardial damage that could impact donor candidacy 3, 4

Recommended Next Steps

1. Comprehensive Cardiac Imaging

• Echocardiography should be performed to:
  • Confirm left atrial enlargement and assess its severity 3
  • Evaluate left ventricular function and detect any wall motion abnormalities suggestive of previous infarction 3
  • Assess for left ventricular hypertrophy, which may be associated with left atrial abnormality 5
  • Rule out valvular heart disease that could explain left atrial enlargement 3

2. Stress Testing

• Stress testing (exercise or pharmacologic) with imaging is indicated to:
  • Evaluate for inducible ischemia, especially given the ECG finding of possible anteroseptal infarct 3
  • Exercise ECG alone may have limited utility due to the baseline ECG abnormalities 3
  • Consider myocardial perfusion imaging or stress echocardiography to better assess for coronary artery disease 3

3. Laboratory Testing

• Cardiac biomarkers (troponin) should be measured to rule out recent myocardial injury 3
• Assessment of cardiovascular risk factors including lipid profile, HbA1c, and renal function 3

4. Consider Advanced Imaging

• If initial testing suggests coronary artery disease or prior infarction:
  • Cardiac MRI or CT coronary angiography may be needed to better characterize myocardial scarring or coronary anatomy 3
  • Invasive coronary angiography may be necessary if non-invasive testing suggests significant coronary artery disease 3

Risk Stratification and Decision Making

• The presence of abnormal ECG findings significantly increases cardiovascular risk and may predict poor outcomes 6, 7
• Potential kidney donors must have thorough cardiovascular risk assessment as they will undergo surgery and live with a single kidney 3
• Decision algorithm for donor candidacy:
  1. If echocardiography shows normal cardiac structure and function, and stress testing shows no evidence of ischemia → proceed with additional donor evaluation 3
  2. If evidence of significant structural heart disease, prior myocardial infarction, or inducible ischemia → candidate may be unsuitable as a kidney donor 3
  3. If mild abnormalities are found → individualized risk assessment by a cardiologist is needed before proceeding 3

Follow-up Considerations

• If cleared for donation, periodic cardiac follow-up is recommended given the baseline ECG abnormalities 3
• Annual ECG monitoring may be appropriate while on the transplant waitlist 3
• Modification of cardiovascular risk factors should be emphasized regardless of donation status 3

Important Caveats

• The prevalence of abnormal ECG findings is higher among patients with advanced kidney disease than in the general population 3
• Left atrial enlargement on ECG may be an early marker of hypertensive heart disease even before clinical manifestations 1
• The combination of multiple ECG abnormalities (as in this case) warrants more thorough evaluation than any single abnormality 2