A 28-year-old male with a history of HIV, asthma, hypertension, end stage renal disease, and cocaine use. He is admitted because of increased dyspnea and cough; he is found to have pneumonia. An ECG is performed (Figure 1).
Figure 1
The ECG shows which of the following?
Show Answer
The correct answer is: D. Biventricular enlargement.
The ECG shows a horizontal axis (-7°). The P wave morphology suggests a left atrial abnormality (biphasic in V1 with a prominent, wide negative terminal deflection). The voltage in the precordial leads is diagnostic of LV enlargement as well as RV enlargement (S in V4 is 15-20 mm or greater).
The echocardiogram shows severe concentric left ventricular hypertrophy with right ventricular dilation, right ventricular enlargement, and an estimated right ventricular pressure of 68 mm Hg. There is also modest tricuspid regurgitation was present as well as left atrial enlargement. Vectorcardiogram (VCG) (Figure 2) shows a characteristic loop of combined ventricular enlargement in the horizontal plane. The VCG shows left posterior voltage as reflected in the initial portion of the VCG in the horizontal plane as typically seen in LVH. However, the counterclockwise loop continues into the "northwest quadrant" or right posterior direction; this is reflected in the large V waves in leads V4and 5 of the ECG. Such is diagnostic for biventricular enlargement. Therefore, the correct answer is D.
Figure 2
References
Varriale P, et al. Vectorcardiogram of combined ventricular hypertrophy: posterior counterclockwise loop (Frank system). Br Heart J 1969;31:457-61.
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