Written by Esteban Davila MD and Eric Tang MD
Learning Objectives
- Recognize the common ECG characteristics of LVH
- Understand the limitations of ECG diagnostic criteria for OMI in patients with LVH and utilize strategies to workup these patients
- Differentiate between LVH and OMI
LVH ECG
Voltage Characteristics
ECG Practice (7 ECGs)
What voltage findings are suggestive of LVH? Just focus on voltage.
Hold up…I’m an EM doctor. Do I care about diagnosing LVH in the ED?
In most cases…no. However, you do care about diagnosing MI in LVH. The presence of LVH on ECG makes the diagnosis of ischemia very difficult and this has tortured EM doctors since the dawn of our specialty. In fact, the Fourth Universal Definition of MI excludes the LVH from “classic” STEMI findings (Table 2 below). Knowing that the typical rules of ST segment elevation and depression may not apply to LVH is crucial.
Non-voltage Characteristics
The following LVH findings are classically known as “strain pattern” but now are often referred to as “repolarization abnormalities.” Not every ECG with LVH will have these abnormalities.
LVH and OMI
Why is it difficult to distinguish LVH and OMI?
- LVH is excluded when using STEMI criteria
- LVH might cause enough STE to meet STEMI criteria
- Common patterns normally specific for OMI can be normal in LVH
- Have you noticed in LVH that the tallest R waves and deepest S waves are in leads that may be reciprocal to each other? This means there may be ST segments that are reciprocal to each other.
- ECG findings that look like strain pattern may also represent OMI in LVH
- Patients may clinically present exactly as a patient with ACS may present
Tips for identifying OMI in LVH
The following are ECG findings that may indicate OMI in LVH. The absence of these findings does not rule out OMI and the presence of these findings does not necessarily rule in OMI.
Lastly, accept that there are no perfect ways to distinguish LVH from OMI with ECG, so use your adjuncts to aid your decision making (serial ECGs, troponin, echo)
ECG Practice (14 half ECGs)
Evaluate each set of limb or precordial limbs.
After completion
Consider reviewing the following additional resources:
- LVH with anterior ST Elevation. When is it anterior STEMI?
- Jesse McLaren EM cases | ECG cases 13: LVH + occlusion MI
- ECG Weekly: STAT ECG Diagnoses: How to identify acute coronary occlusion in LVH with strain
- Chapters 11 and 14 of Tomas Garcia’s 12 Lead ECG: Art of Interpretation
- Ed Burns Left Ventricular Hypertrophy (LVH)