Review Question - QID 104155

Left Ventricular Hypertrophy secondary to Age-related Aortic Stenosis. The EKG findings, along with the clinical presentation and physical examination, are indicative of left ventricular hypertrophy, most likely secondary to longstanding aortic stenosis.

Aortic stenosis is a major cause of chronic heart failure in elderly patients and is often due to senile calcification. Younger patients may also present with aortic stenosis due to underlying congenital valvular defects or rheumatic fever. Aortic stenosis causes a crescendo-decrescendo murmur during systole. The intensity of the murmur is dependent on the difference in pressures between the left ventricle and the aorta. As the condition worsens, the intensity of the murmur peaks later in systole. Late in the disease the A2 component (of S2) may also be diminished. When symptomatic, aortic stenosis may cause the triad of syncope, angina, and heart failure. Diagnosis can be confirmed with echocardiography. Treatment is purely surgical with valve replacement or balloon valvuloplasty.

Grimard and Larson discuss aortic stenosis - diagnosis and treatment. Aortic stenosis is the most common valve disease in developed countries affecting 3% of patients older than 65. Overall survival in symptomatic people without aortic valve replacement is 2-3 years. During the asymptomatic latent period, left ventricular hypertrophy and increased preload compensate for the increase in afterload caused by the valvular abnormality.

Schillaci et al discuss the role of EKG in the diagnosis of left ventricular hypertrophy in hypertension. It remains the first line method for detection. It predicts a several fold increase in age and risk factor adjusted cardiovascular morbidity and mortality in asymptomatic patients with essential hypertension. Cornell voltage product (S in V3 + R in aVL > 2.8 mV in men or > 2.0 mV in women) and Perugia criterion (one of S in V3 + R in aVL > 2.4 mV in men or > 2.0 mV in women, typical strain pattern, or Romhilt-Estes point score > or = 5) allow for detection of left ventricular hypertrophy in a higher proportion of patients carrying cardiovascular risk factors.

Image A depicts an EKG remarkable for left ventricular hypertrophy. Note the prominent voltage in the left precordial leads.

Incorrect Answers:
Answer 1: Atrial Fibrillation due to Rheumatic Heart Disease is incorrect, This is unlikely given the absence of atrial fibrillation on EKG and the patient's age.
Answer 2: Bicuspid Aortic Valve leading to Aortic Stenosis is incorrect, This is more common in younger patients and would not typically present with left ventricular hypertrophy on EKG.
Answer 4: Myocardial Ischemia due to Coronary Artery Disease is incorrect, The EKG does not show signs of myocardial ischemia, and the patient's symptoms are more consistent with aortic stenosis.
Answer 5: Ventricular Tachycardia secondary to Dilated Cardiomyopathy is incorrect, The EKG does not show ventricular tachycardia, and the patient's clinical presentation does not support this diagnosis.

Bullet Summary:
The EKG findings and clinical presentation strongly suggest Left Ventricular Hypertrophy secondary to Age-related Aortic Stenosis, requiring surgical intervention for definitive treatment.