LVH with ST/T Changes
Report:
Sinus rhythm 84/min
Three SVEBs in bigeminy
LBBB aberrancy
Left ventricular hypertrophy with ST/T changes
Left atrial abnormality
ST/T changes also suggestive of ischæmia
Possible old anteroseptal infarction
Comment:
In old patients with aortic stenosis angiodysplasia appears more commonly than in control population; it is known as Heydeâs syndrome13. This patient probably had it. The bleed was quite severe, wit several episodes of shock. The ECG reflects ischæmia additional to that due to LVH and valve stenosis alone: in V3 in particular, there is concordant plane ST segment depression. Most other leads show ST depression typical of LVH, convex upwards, but perhaps deeper than expected.
R wave loss in anteroseptal leads supports ischæmia, as do anginal symptoms. Yet there is no certainty here: aortic stenosis alone can cause angina and any severe LVH can be indistinguishable from ischæmia on ECGs. On the other hand, absence of angina in aortic stenosis make coronary disease relatively unlikely14.
The next day (Fig 8a), the anteroseptal ST depression improved, but the inferior leads still looked angry. The patient did in fact sustain an infarction, on troponin grounds.
LBBB aberrancy is distinguished from VEBs by lead V1: sharp descent, slower rise. The pauses are, however, fully compensatory. Weâll never know for sure.
8a. 9. 53 year old lady with advanced emphysema
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