Aortic stenosis electrocardiogram

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Mohammed A. Sbeih, M.D. [2]; Lakshmi Gopalakrishnan, M.B.B.S. [3]; Usama Talib, BSc, MD [4] Assistant Editor-In-Chief: Kristin Feeney, B.S. [5]

Overview

The electrocardiogram in the patient with moderate to severe aortic stenosis may reveal left ventricular hypertrophy and heart block.

Electrocardiogram

Although there are no specific findings on the EKG, the presence of left ventricular hypertrophy (LVH) secondary to chronic pressure overload of the left ventricle due to aortic stenosis is commonly observed.^[1]

Progressive calcification of the aortic valve may extend beyond the valve and may result in conduction abnormalities of the heart including heart block.

Progressive concentric hypertrophy of the left ventricular wall may lead to larger QRS complexes, especially observed in 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 left ventricular strain pattern.

Criteria for LVH

To diagnose left ventricular hypertrophy on the EKG one of the following criteria should be met: ^[2]^[3]

Sokolow-Lyon criteria:

R in V5 or V6 + S in V1 > 35 mm

Other criteria:

R > 26 mm in V5 or V6
R > 20 mm in I, II or III
R > 12 mm in aVL (in the absence of left anterior fascicular block)

Cornell criteria 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

In the Romhilt-Estes Score,^[4]:

LVH is likely with 4 or more points, and
LVH is present with 5 or more points ^[5].

Examples of EKG Findings in patients with AS

Shown below is an electrocardiogram depicting left ventricular hypertrophy.

Shown below is an EKG depicting left ventricular hypertrophy and subendocardial ischemia.

EKG of a patient with LVH and subendocardial ischemia leading to positive cardiovascular markers in blood testing.

Shown below is an EKG depicting left ventricular hypertrophy and left ventricular strain pattern.

Left ventricular hypertrophy; left ventricular strain due to aortic stenosis.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org

2008 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease – Evaluation of Asymptomatic Adolescents or Young Adults With Aortic Stenosis (DO NOT EDIT)[6]

2008 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease – Evaluation of Asymptomatic Adolescents or Young Adults With Aortic Stenosis (DO NOT EDIT)^[6]

Class I
“1. An ECG is recommended yearly in the asymptomatic adolescent or young adult with AS who has a Doppler mean gradient greater than 30 mm Hg or a peak velocity greater than 3.5 m per second (peak gradient greater than 50 mm Hg) and every 2 years if the echocardiographic Doppler mean gradient is less than or equal to 30 mm Hg or the peak velocity is less than or equal to 3.5 m per second (peak gradient less than or equal to 50 mm Hg). (Level of Evidence: C)”

References

↑ Markku Kupari, Heikki Turto & Jyri Lommi (2005). “Left ventricular hypertrophy in aortic valve stenosis: preventive or promotive of systolic dysfunction and heart failure?”. European heart journal. 26 (17): 1790–1796. doi:10.1093/eurheartj/ehi290. PMID 15860517. Unknown parameter |month= ignored (help)
↑ Oliver J. Rider, Ntobeko Ntusi, Sacha C. Bull, Richard Nethononda, Vanessa Ferreira, Cameron J. Holloway, David Holdsworth, Masliza Mahmod, Jennifer J. Rayner, Rajarshi Banerjee, Saul Myerson, Hugh Watkins & Stefan Neubauer (2016). “Improvements in ECG accuracy for diagnosis of left ventricular hypertrophy in obesity”. Heart (British Cardiac Society). 102 (19): 1566–1572. doi:10.1136/heartjnl-2015-309201. PMID 27486142. Unknown parameter |month= ignored (help)
↑ P. N. Casale, R. B. Devereux, P. Kligfield, R. R. Eisenberg, D. H. Miller, B. S. Chaudhary & M. C. Phillips (1985). “Electrocardiographic detection of left ventricular hypertrophy: development and prospective validation of improved criteria”. Journal of the American College of Cardiology. 6 (3): 572–580. PMID 3161926. Unknown parameter |month= ignored (help)
↑ Romhilt DW, Bove KE, Norris RJ; et al. (1969). “A critical appraisal of the electrocardiographic criteria for the diagnosis of left ventricular hypertrophy”. Circulation. 40 (2): 185–95. PMID 4240354. Unknown parameter |month= ignored (help)
↑ Romhilt DW, Estes EH (1968). “A point-score system for the ECG diagnosis of left ventricular hypertrophy”. Am. Heart J. 75 (6): 752–8. PMID 4231231. Unknown parameter |month= ignored (help)
↑ Bonow RO, Carabello BA, Chatterjee K; et al. (2008). “2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons”. Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)

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[1] Markku Kupari, Heikki Turto & Jyri Lommi (2005). “Left ventricular hypertrophy in aortic valve stenosis: preventive or promotive of systolic dysfunction and heart failure?”. European heart journal. 26 (17): 1790–1796. doi:10.1093/eurheartj/ehi290. PMID 15860517. Unknown parameter |month= ignored (help)

[2] Oliver J. Rider, Ntobeko Ntusi, Sacha C. Bull, Richard Nethononda, Vanessa Ferreira, Cameron J. Holloway, David Holdsworth, Masliza Mahmod, Jennifer J. Rayner, Rajarshi Banerjee, Saul Myerson, Hugh Watkins & Stefan Neubauer (2016). “Improvements in ECG accuracy for diagnosis of left ventricular hypertrophy in obesity”. Heart (British Cardiac Society). 102 (19): 1566–1572. doi:10.1136/heartjnl-2015-309201. PMID 27486142. Unknown parameter |month= ignored (help)

[3] P. N. Casale, R. B. Devereux, P. Kligfield, R. R. Eisenberg, D. H. Miller, B. S. Chaudhary & M. C. Phillips (1985). “Electrocardiographic detection of left ventricular hypertrophy: development and prospective validation of improved criteria”. Journal of the American College of Cardiology. 6 (3): 572–580. PMID 3161926. Unknown parameter |month= ignored (help)

[pmid4240354-4] Romhilt DW, Bove KE, Norris RJ; et al. (1969). “A critical appraisal of the electrocardiographic criteria for the diagnosis of left ventricular hypertrophy”. Circulation. 40 (2): 185–95. PMID 4240354. Unknown parameter |month= ignored (help)

[pmid4231231-5] Romhilt DW, Estes EH (1968). “A point-score system for the ECG diagnosis of left ventricular hypertrophy”. Am. Heart J. 75 (6): 752–8. PMID 4231231. Unknown parameter |month= ignored (help)

[pmid18820172-6] Bonow RO, Carabello BA, Chatterjee K; et al. (2008). “2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons”. Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)

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