HOCM. (Case 1) Pattern of LVH

HOCM (Hypertrophic Obstructive CardioMyopathy) usually has LVH pattern.

1 = leads commonly used for voltage criteria.  2 = T wave inversion with ST depression (example in V6), T wave upright with ST elevation (example in V1).  3 = intrinsicoid deflection (time from begin of QRS to peak domminant R or S wave) in V6, and P wave in V1.

Patient. 84 year old female known having HOCM. She was admitted for chest pain required recurrent admissions and has been denied interventional treatment. This admission she has diagnosis of non Q wave MI and agreed to have stent placement to LAD. She also has history of hypertension. All of her ECGs look similar.

Main criteria for LVH:         Voltage criteria Sensibility Specificity Accuracy Sokolow and Lyon, 1949. (When use Echo as gold standard) Limb lead - R I + S III > 2.5 mV 10.6 100 55 - R aVL 1.1 mV 10.6 100 55 - R aVF > 2.0 mV 1.3 99.5 50 - S aVR > 1.4 mV   Precordial lead - R V5 or R V6 > 2.6 mV 25 98 62 - R V6 + S V2 > 3.5 mV 55.6 89.5 73 - Largest R + largest S > 4.5 mV 45 93 69 More recent literatures - S V1 + R V6 > 3.5 mV       - S V2 + R V6 > 4.3 mV     - S V1 > 2.4 mV     - R V6 > 2.8 mV     - R aVL > 1.3 mV     Cornell, 1985 - R aVL + S V3 > 2.0 mV (Female)     - R aVL + S V3 > 2.8 mV (Male)     Onset of intrinsicoid deflection V5 or V6 = ).05-0.07 sec Supporting criteria     - Onset of intrinsicoid deflection in V 5 or V6 > 0.04 sec - STT abnormality typical pattern of LV strain* * = 1. ST depression and T wave inversion in left lateral leads (tall R wave). 2. ST elevation and upright T wave in right precordial leads (deep S wave). 3. Asymmetrical T wave inversion.           Romhilt-Estes point system, 1968 - Any limb lead R + S > 1.9 mV 3 - S V1 or S V2 > 2.9 mV 3 - R V5 or R V6 > 2.9 mV 3 - STT abnormality typical pattern of LV strain* 3 - P terminal force in V1 > 1 mV and > 0.04 msec 1 - Left axis deviation 1 - Intrinsicoid deflection in V5 or V6 > 4.9 msec 1 4 point = Probable LVH, 5 point or more = Definite LVH.

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