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

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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 (pConclusion: 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.