ECG Case 106: Left Atrial and Left Ventricular Hypertrophy (LVH)

ECG Interpretation

  • Sinus rhythm, rate 60/min
  • Bifid P wave (best seen in lead V3) suggesting left atrial hypertrophy
  • Left ventricular hypertrophy by ‘voltage criteria’ (height of R wave in lead V6 plus depth of S wave in lead V2 = 50 mm)
  • Lateral T wave inversion in lead I, aVL, V5 and V6 (left ventricular strain pattern)

Left Atrial and Left Ventricular Hypertrophy (LVH)
Left Atrial and Left Ventricular Hypertrophy (LVH)

Clinical interpretation

These are the classic changes of left atrial and left ventricular hypertrophy. In a patient with heart failure and a heart murmur the likely diagnosis is severe aortic valve disease.

What to do ?

The heart failure must be treated with diuretics, but it is essential to establish the cause of the left ventricular hypertrophy before selecting long-term treatment. It could be due to aortic stenosis or regurgitation, to mitral regurgitation or to hypertension.

While an angiotensin-converting enzyme inhibitor would be appropriate treatment for a patient with hypertension or mitral regurgitation, it would be potentially dangerous in a patient with aortic stenosis. An echocardiogram is the essential next step.

This patient had severe aortic stenosis, and needed an aortic valve replacement.