Chamber Hypertrophy and Enlargment: Difference between revisions

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Bij hypertrophy ontstaat er een verdikking van de hartspier. Dit kan verschllende oorzaken hebben. left ventrikelhypert treedt op bij overbelasting van de left ventrikel, zoals bij  hypertensie of aortaklepstenose. Rechter ventrikelhypertrophy treedt op bij overbelasting van de rechter ventrikel, zoals bij longziekten die een verhoogde longweerstand geven, zoals longemboliën en longemfyseem. Er bestaat ook een aangeboren vorm van hypertrophy: hypertrofische obstructieve cardiomyopathie.
{{authors|
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]
|moderator= [[user:Drj|J.S.S.G. de jong]]
|supervisor=
}}
In hypertrophy the heart muscle becomes thicker. This can have different causes. Left ventricular hypertrophy results from an increase in left ventricular workload, e.g., during hypertension or aortic valve stenosis. Right ventricular hypertrophy results from an increase in right ventricular workload, e.g., emphysema or pulmonary embolization.
These causes are fundamentally different from [[Miscellaneous#Hypertrophic_Obstructive_Cardiomyopathy|hypertrophic obstructive cardiomyopathy (HCM)]], which is a congenital misalignment of cardiomyocytes, resulting in hypertrophy.  


left en rechter ventrikelhypertrophy geeft verschillende beelden op het ECG.
Left and right ventricular hypertrophy can be distinguished on the ECG:


==Criteria voor left ventrikelhypertrophy==
=Left ventricular hypertrophy=
[[Image:E_lvh.jpg|thumb]]
[[Image:E_lvh.jpg|thumb|right|300px|LVH. R in V5 is 26mm, S in V1 in 15mm. The sum is 41 mm which is more than 35 mm and therefore LVH is present according to the Sokolow-Lyon criteria.]]
[[Image:left_ventrikel_hypertrophy.GIF|thumb]]
[[Image:LVH.png|thumb|250px]]
[[Image:LVH.jpg|thumb|ECG van een patient met LVH volgens de Sokolow-Lyon criteria]]
As the left ventricular wall becomes thicker, the QRS complexes become larger. This is especially true for leads V1-V6. The S wave in V1 is deep, the R wave in V4 is high. Often some ST depression can be seen in leads V5-V6, which is in this setting is called a 'strain pattern'.


Bij hypertrophy van de leftventrikel worden de QRS-complexen qua hoogte en diepte veel groter dan normaal. Met name in de afleidingen V1-V6. Hierbij is in V1 de S-deflectie diep en in V5 de R-top hoog. Ook is er vaak ST depressie in de laterale afleidingen V5-V6, soms aangeduid met als een 'strain patroon'.
To diagnose left ventricular hypertrhophy on the ECG one of the following criteria should be met:
The '''Sokolow-Lyon criterion'''<cite>Sokolow</cite>), this is most often used:
*R in V5 or V6 + S in V1 >35 mm.  


Om de diagnose LVH te stellen, moet een van de volgende criteria aanwezig zijn:
This criterion is not reliable below age 40 years.<cite>Chou</cite> In 10-29 year olds, the 99th percentile for SV1+RV5 is 53mm. In 20-39 year olds: 32% have SV2+RV5 > 35 mm.<cite>chou</cite> Correlation between LVH on ECG and echocardiography is low with ECG having a sensitivity of 27% and specificity of 88% for echocardiographically measured LVH<cite>echo</cite><cite>echo2</cite>. Moreover, both are independent estimators of worse prognosis.<cite>sundstrom</cite>.
*R in V5 of V6 + S in V1 >35 mm. (het zogenoemde Sokolow-Lyon criterium)
*R >26 mm in V5of V6;
*R >20 mm in I, II of III;
*R >12 mm in aVL (mits geen LAFB);


Het Cornell-criterium maakt onderscheid tussen mannen en vrouwen om de diagnose te kunnen stellen:
The '''Cornell-criterion''' has different values in men and women:
* R in aVL en S in V3 >28 mm bij mannen
* R in aVL and S in V3 >28 mm in men
* R in aVL en S in V3 >20 mm bij vrouwen
* R in aVL and S in V3 >20 mm in women


This is a better predicting criterion than the Sokolow-Lyon criterion, but less easy to remember, and therefore less often used.<cite>Levy</cite><cite>Sundstrom</cite>
In the [[Romhilt-Estes Score]] LVH is ''likely'' with 4 or more points. LVH is ''present'' with 5 or more points.<cite>Romhilt</cite> Romhilt has reviewed ECG LVH criteria and gives an overview of the many LVH scoring systems. <cite>Romhilt2</cite> Left ventricular hypertrophy has prognostic consequences as has been found in several studies.<cite>Levy</cite><cite>Sundstrom</cite>
{{clr}}
{{clr}}
==Example==
<gallery>
Image:ECG000027.jpg|ECG of patient with left ventricular hypertrophy according to the Sokolow-Lyon criteria
Image:Extreme_lvh2.jpg|Another example of extreme left ventricular hypertrophy in a patient with severe aortic valve stenosis.
Image:extreme_lvh.jpg|ECG of a patient with LVH and subendocardial ischemia leading to positive cardiovascular markers in blood testing.
Image:E0003191.png|LVH with repolarization changes as in this 12 lead ECG example has a worse prognosis than LVH without repolarization changes
</gallery>
{{clr}}
=Right ventricular hypertrophy=
[[Image:RVH.png|thumb|left]]
[[File:E000004.jpg|thumb|right|An example of right ventricular hypertrophy (and right atrial enlargement) in a patient with chronic pulmonary hypertension due to peripheral embolisation.]]
[[File:E000569.jpg|thumb|Another example fo right ventricular hypertrophy.]]
[[Image:E_rvh.jpg|thumb|450px|Right ventricular hypertrophy, the R wave is greater than the S wave in V1]]
Right ventricular hypertrophy occurs mainly in lung disease or in congenital heart disease.
The ECG shows a negative QRS complex in I (and thus a right [[heart axis]]) and a positive QRS complex in V1.
*QRS duration < 120ms
*Right [[heart axis]] (> 110 degrees)
* Dominant R wave:
** R/S ratio in V1 or V3R > 1, or R/S ratio in V5 or V6 <= 1
** R wave in V1 >= 7 mm
** R wave in V1 + S wave in V5 or V6 > 10.5 mm
** rSR= in V1 with R'= > 10 mm
** qR complex in V1
* Secondary ST-T changes in right precordial leads
* Right atrial abnormality
* Onset of intrinsicoid deflection in V1 between 0.035 and 0.055 s


==Criteria voor rechter ventrikelhypertrophy==
{{clr}}
[[Image:Rechter_ventrikel_hypertrophy.GIF|thumb|]]
[[Image:E_rvh.jpg|thumb|R groter dan S in V1]]
Rechter ventrikelhypertrophy wordt met name veroorzaakt door longziekten en congenitale hartziekten. Op het ECG toont I een negatief QRS en V1 een positief QRS.


*R > S in V1 (waarbij de R > 0.5 mV is)  
=Left atrial enlargement=
*Rechter asdraai (>+90 graden)
<div style="float:right;margin-left:10px">
<gallery>
Image:left_atrial_enlargement.jpg| Left atrial enlargement
Image:LAE.png| Left atrial enlargement with ECG.
Image:LAE-v1.png| Left atrial enlargement as seen in lead V1.
Image:LAE_12lead.jpg| Left atrial enlargement as seen on a 12 lead ECG
</gallery>
</div>
;Criteria for left atrial voor left atrial enlargement. Either
:P wave with a broad (>0.04 sec or 1 small square) and deeply negative (>1 mm) terminal part in V1
:P wave duration >0.12 sec in leads I and / or II
Left atrial enlargement is often seen in mitral valve insufficiency, resulting in back flow of blood from the left ventricle to the left atrium and subsequent increased local pressure.
{{clr}}
{{clr}}
=Right atrial enlargement=
<div style="float:right;margin-left:10px">
<gallery>
Image:right_atrial_enlargement.jpg|Right atrial enlargement
Image:RAE.png|Right atrial enlargement
</gallery>
</div>
;Right atrial enlargement is defined as either:
:P >2.5 mm in II / III and / or aVF
:P >1.5 mm in V1.
Right atrial enlargement can result from increased pressure in the pulmonary artery, e.g. after pulmonary embolization. A positive part of the biphasic p-wave in lead V1 larger than the negative part indicates right atrial enlargement. The width of the p wave does not change.
{{clr}}
=Biatrial enlargement=
;Biatrial enlargement
:Biphasic p wave in V1 of more than 0.04 sec duration. The positive initial part is > 1.5mm and the negative terminal part > 1mm
In biatrial enlargement the ECG shows signs of both left and right atrial enlargement. In V1 the p wave has large peaks first in a positive and later in a negative direction.
{{box|
==References==
<biblio>
#Sokolow Sokolow M, Lyon TP: ''The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads.'' Am Heart J 37: 161, 1949
#Levy pmid=11352882
#Sundstrom pmid=7923663
#Romhilt2 pmid=4240354
#Romhilt pmid=4231231
#echo pmid=8651126
#sundstrom pmid=11352882
#echo2 pmid=2137733
#chou ISBN=1437711022
</biblio>
}}
[[Category:ECG Textbook]]

Latest revision as of 09:59, 8 October 2014

Author(s) J.S.S.G. de Jong
Moderator J.S.S.G. de jong
Supervisor
some notes about authorship

In hypertrophy the heart muscle becomes thicker. This can have different causes. Left ventricular hypertrophy results from an increase in left ventricular workload, e.g., during hypertension or aortic valve stenosis. Right ventricular hypertrophy results from an increase in right ventricular workload, e.g., emphysema or pulmonary embolization. These causes are fundamentally different from hypertrophic obstructive cardiomyopathy (HCM), which is a congenital misalignment of cardiomyocytes, resulting in hypertrophy.

Left and right ventricular hypertrophy can be distinguished on the ECG:

Left ventricular hypertrophy

LVH. R in V5 is 26mm, S in V1 in 15mm. The sum is 41 mm which is more than 35 mm and therefore LVH is present according to the Sokolow-Lyon criteria.
LVH.png

As the left ventricular wall becomes thicker, the QRS complexes become larger. This is especially true for leads V1-V6. The S wave in V1 is deep, the R wave in V4 is high. Often some ST depression can be seen in leads V5-V6, which is in this setting is called a 'strain pattern'.

To diagnose left ventricular hypertrhophy on the ECG one of the following criteria should be met: The Sokolow-Lyon criterion[1]), this is most often used:

  • R in V5 or V6 + S in V1 >35 mm.

This criterion is not reliable below age 40 years.[2] In 10-29 year olds, the 99th percentile for SV1+RV5 is 53mm. In 20-39 year olds: 32% have SV2+RV5 > 35 mm.[3] Correlation between LVH on ECG and echocardiography is low with ECG having a sensitivity of 27% and specificity of 88% for echocardiographically measured LVH[4][5]. Moreover, both are independent estimators of worse prognosis.[6].

The Cornell-criterion has different values in men and women:

  • R in aVL and S in V3 >28 mm in men
  • R in aVL and S in V3 >20 mm in women

This is a better predicting criterion than the Sokolow-Lyon criterion, but less easy to remember, and therefore less often used.[7][8]

In the Romhilt-Estes Score LVH is likely with 4 or more points. LVH is present with 5 or more points.[9] Romhilt has reviewed ECG LVH criteria and gives an overview of the many LVH scoring systems. [10] Left ventricular hypertrophy has prognostic consequences as has been found in several studies.[7][8]

Example


Right ventricular hypertrophy

RVH.png
An example of right ventricular hypertrophy (and right atrial enlargement) in a patient with chronic pulmonary hypertension due to peripheral embolisation.
Another example fo right ventricular hypertrophy.
Right ventricular hypertrophy, the R wave is greater than the S wave in V1

Right ventricular hypertrophy occurs mainly in lung disease or in congenital heart disease. The ECG shows a negative QRS complex in I (and thus a right heart axis) and a positive QRS complex in V1.

  • QRS duration < 120ms
  • Right heart axis (> 110 degrees)
  • Dominant R wave:
    • R/S ratio in V1 or V3R > 1, or R/S ratio in V5 or V6 <= 1
    • R wave in V1 >= 7 mm
    • R wave in V1 + S wave in V5 or V6 > 10.5 mm
    • rSR= in V1 with R'= > 10 mm
    • qR complex in V1
  • Secondary ST-T changes in right precordial leads
  • Right atrial abnormality
  • Onset of intrinsicoid deflection in V1 between 0.035 and 0.055 s


Left atrial enlargement

Criteria for left atrial voor left atrial enlargement. Either
P wave with a broad (>0.04 sec or 1 small square) and deeply negative (>1 mm) terminal part in V1
P wave duration >0.12 sec in leads I and / or II

Left atrial enlargement is often seen in mitral valve insufficiency, resulting in back flow of blood from the left ventricle to the left atrium and subsequent increased local pressure.

Right atrial enlargement

Right atrial enlargement is defined as either
P >2.5 mm in II / III and / or aVF
P >1.5 mm in V1.

Right atrial enlargement can result from increased pressure in the pulmonary artery, e.g. after pulmonary embolization. A positive part of the biphasic p-wave in lead V1 larger than the negative part indicates right atrial enlargement. The width of the p wave does not change.

Biatrial enlargement

Biatrial enlargement
Biphasic p wave in V1 of more than 0.04 sec duration. The positive initial part is > 1.5mm and the negative terminal part > 1mm

In biatrial enlargement the ECG shows signs of both left and right atrial enlargement. In V1 the p wave has large peaks first in a positive and later in a negative direction.


References

  1. Sokolow M, Lyon TP: The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads. Am Heart J 37: 161, 1949

    [Sokolow]
  2. ISBN=1437711022

    [chou]
  3. Abergel E, Tase M, Menard J, and Chatellier G. Influence of obesity on the diagnostic value of electrocardiographic criteria for detecting left ventricular hypertrophy. Am J Cardiol. 1996 Apr 1;77(9):739-44. DOI:10.1016/s0002-9149(97)89209-0 | PubMed ID:8651126 | HubMed [echo]
  4. Levy D, Labib SB, Anderson KM, Christiansen JC, Kannel WB, and Castelli WP. Determinants of sensitivity and specificity of electrocardiographic criteria for left ventricular hypertrophy. Circulation. 1990 Mar;81(3):815-20. DOI:10.1161/01.cir.81.3.815 | PubMed ID:2137733 | HubMed [echo2]
  5. Sundström J, Lind L, Arnlöv J, Zethelius B, Andrén B, and Lithell HO. Echocardiographic and electrocardiographic diagnoses of left ventricular hypertrophy predict mortality independently of each other in a population of elderly men. Circulation. 2001 May 15;103(19):2346-51. DOI:10.1161/01.cir.103.19.2346 | PubMed ID:11352882 | HubMed [sundstrom]
  6. Sundström J, Lind L, Arnlöv J, Zethelius B, Andrén B, and Lithell HO. Echocardiographic and electrocardiographic diagnoses of left ventricular hypertrophy predict mortality independently of each other in a population of elderly men. Circulation. 2001 May 15;103(19):2346-51. DOI:10.1161/01.cir.103.19.2346 | PubMed ID:11352882 | HubMed [Levy]
  7. Levy D, Salomon M, D'Agostino RB, Belanger AJ, and Kannel WB. Prognostic implications of baseline electrocardiographic features and their serial changes in subjects with left ventricular hypertrophy. Circulation. 1994 Oct;90(4):1786-93. DOI:10.1161/01.cir.90.4.1786 | PubMed ID:7923663 | HubMed [Sundstrom]
  8. Romhilt DW and Estes EH Jr. A point-score system for the ECG diagnosis of left ventricular hypertrophy. Am Heart J. 1968 Jun;75(6):752-8. DOI:10.1016/0002-8703(68)90035-5 | PubMed ID:4231231 | HubMed [Romhilt]
  9. Romhilt DW, Bove KE, Norris RJ, Conyers E, Conradi S, Rowlands DT, and Scott RC. A critical appraisal of the electrocardiographic criteria for the diagnosis of left ventricular hypertrophy. Circulation. 1969 Aug;40(2):185-95. DOI:10.1161/01.cir.40.2.185 | PubMed ID:4240354 | HubMed [Romhilt2]
All Medline abstracts: PubMed | HubMed