ECG of the Week - 23rd March 2015 - Interpretation

This ECG is from a 35 yr old male who presented to the Emergency Department following an episode of exertional syncope. He has 1 previous episode of syncope several years prior without investigation. Otherwise he is fit & well with no relevant family history.
Check out the comments on our original post here.

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Rate:

• 78 bpm

Rhythm:

• Regular
• Sinus rhythm

Axis:

• Normal

Intervals:

• PR - Normal (~180ms)
• QRS - Normal (100ms)
• QT - 360ms (QTc Bazette 410 ms)

Segments:

• Concave ST elevation leads V2-4
• Nil ST depression

Additional:

• Voltage criteria for LVH
• R wave V5 + S wave V1 ~35mm
• R wave aVF >20mm
• Narrow deep Q waves leads II, III, aVF, V4-6
• Partial RBBB pattern - rSr' in lead V1

Interpretation:

• Given the history of exertional syncope plus LVH with infero-lateral deep Q waves the major concern would be hypertrophic cardiomyopathy.
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What happened ?

The ECG changes were appreciated and the patient had a cardiology review and urgent echo. His echo was entirely normal and he was discharged with out-patient cardiology follow-up.

For a bit more on echo findings in HCM and new echo modalities check out the following:

• Williams LK, Frenneaux MP, Steeds RP. Echocardiography in hypertrophic cardiomyopathy diagnosis, prognosis, and role in management. Eur J Echocardiogr. 2009 Dec;10(8):iii9-14 PMID: 19889657 Full text here
• Afonso LC, Bernal J, Bax JJ, Abraham TP. Echocardiography in Hypertrophic Cardiomyopathy The Role of Conventional and Emerging Technologies. J Am Coll Cardiol Img. 2008;1(6):787-800. Full text here.
• Losi MA, Nistri S, Galderisi M, Betocchi S, Cecchi F, Olivotto I, Agricola E, Ballo P, Buralli S, D'Andrea A, D'Errico A, Mele D, Sciomer S, Mondillo S; Working Group of Echocardiography of the Italian Society of Cardiology. Echocardiography in patients with hypertrophic cardiomyopathy: usefulness of old and new techniques in the diagnosis and pathophysiological assessment. Cardiovasc Ultrasound. 2010 Mar 17;8:7. Full text here

I was wondering on our readers thoughts on diagnostic criteria for HCM and the reliability /negative predictive value of a normal resting echo in these cases. Do patients need to go on for dynamic testing (stress echo) and/or cardiac MRI ?

References / Further Reading

Life in the Fast Lane

• Hypertrophic cardiomyopathy 

Textbook

• Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.