Article

Electrocardiographic left ventricular hypertrophy in patients with suspected acute cardiac ischemia—Its influence on diagnosis, triage, and short-term prognosis

the Department of Mathematics, Boston University, Boston, Massachusetts
Journal of General Internal Medicine (Impact Factor: 3.42). 12/1994; 9(12):666-673. DOI: 10.1007/BF02599006

ABSTRACT Objective: To understand the diagnostic and short-term prognostic significance of electrocardiographic left ventricular hypertrophy
(ECG-LVH) for patients who present to the emergency department with symptoms suggesting acute cardiac ischemia, defined as
new or unstable angina pectoris or acute myocardial infarction.

Design: Subgroup analysis of a multicenter, prospective study of coronary care unit admitting practices in the prethrombolytic era.

Setting: The emergency departments of six New England hospitals: two urban medical school teaching hospitals, two medical school—affiliated
community hospitals in smaller cities, and two rural nonteaching hospitals.

Patients: 5,768 patients presenting with symptoms suggesting possible acute cardiac ischemia, including 413 patients who had ECG-LVH
defined by the Romhilt-Estes point score criteria and 5,355 patients who had other electrocardiogram (ECG) findings.

Main results: Only 26% of the 413 patients who had ECG-LVH were ultimately judged to have had acute cardiac ischemia, compared with 72%
of patients who had primary ST-segment and T-wave abnormalities (p<0.001) and 36% of those who had other ECG abnormalities
(p<0.001). Overall, the ECG-LVH patients were one-third less likely than the patients who did not have ECG-LVH to have had
acute cardiac ischemia, after controlling for other predictors of acute ischemia by logistic regression (relative risk=0.66,
95% CI 0.46 to 0.94). The patients who had ECG-LVH were only one-fourth as likely to have had acute myocardial infarctions
as were the patients presenting with primary ST-segment and T-wave changes (12% vs 48%, p<0.001). Instead, a much larger proportion
had had congestive heart failure or hypertension. The admitting physicians had identified ECG-LVH poorly on the admitting
ECGs: only 22% of those who had ECG-LVH had been correctly identified, and for more than 70%, the secondary ST-segment and
T-wave changes of ECG-LVH had been read as being primary. The short-term mortality for the patients who had ECG-LVH was 7.5%.
This was intermediate between the mortality for patients who had primary ST-segment and T-wave abnormalities (10.6%) and those
who had other ECG abnormalities (5.1%). Mortality was not affected by whether the admitting physician had recognized ECG-LVH
initially.

Conclusion: ECG-LVH was not a benign ECG finding among the patients who had presented with symptoms suggesting an acute cardiac ischemic
syndrome: short-term mortality among the patients who had ECG-LVH (7.5%) approached that for the patients who had primary
ST-segment and T-wave abnormalities (10.6%, p=0.10). However, the patients who had ECG-LVH were one-thirdless likely to have had any acute cardiac ischemia than were the patients who did not have ECG-LVH, after logistic regression
was used to control for other predictors of acute ischemia. Specifically, acute myocardial infarction was only one-fourth
as likely when LVH was present on the admitting ECG (12%) as it was when primary ST-segment and T-wave abnormalities were
present (48%, p<0.001). Instead, congestive heart failure and hypertensive heart disease were more common. Thus, routine use
of thrombolytic therapy for patients who have ECG-LVH does not seem warranted. ECG-LVH was poorly recognized (in only 22%
of cases) by the physicians in the present study. Better recognition of this common ECG finding may lead to more effective
patient management.

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