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| [[Aortic stenosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Aortic stenosis}}
{{Aortic stenosis}}


{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@perfuse.org]; {{LG}}; '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@perfuse.org]
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{LG}}; {{USAMA}} '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu]


==Overview==
==Overview==
Line 8: Line 13:


==Electrocardiogram==
==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.
*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.<ref>{{Cite journal
| author = [[Markku Kupari]], [[Heikki Turto]] & [[Jyri Lommi]]
| title = Left ventricular hypertrophy in aortic valve stenosis: preventive or promotive of systolic dysfunction and heart failure?
| journal = [[European heart journal]]
| volume = 26
| issue = 17
| pages = 1790–1796
| year = 2005
| month = September
| doi = 10.1093/eurheartj/ehi290
| pmid = 15860517
}}</ref>


*Progressive [[calcific aortic valve disease|calcification of the aortic valve]] may extend beyond the valve and may result in conduction abnormalities of the heart including [[heart block]].
*Progressive [[calcific aortic valve disease|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'''''.
*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.
 
==EKG Criteria for LVH==
*To diagnose [[left ventricular hypertrophy]] on the EKG one of the following criteria should be met:


:*'''Sokolow-Lyon criteria:'''
===Criteria for LVH===
::*R in V5 or V6 + S in V1 >35 mm.
To diagnose [[left ventricular hypertrophy]] on the EKG one of the following criteria should be met:
<ref>{{Cite journal
| author = [[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]]
| title = Improvements in ECG accuracy for diagnosis of left ventricular hypertrophy in obesity
| journal = [[Heart (British Cardiac Society)]]
| volume = 102
| issue = 19
| pages = 1566–1572
| year = 2016
| month = October
| doi = 10.1136/heartjnl-2015-309201
| pmid = 27486142
}}</ref><ref>{{Cite journal
| author = [[P. N. Casale]], [[R. B. Devereux]], [[P. Kligfield]], [[R. R. Eisenberg]], [[D. H. Miller]], [[B. S. Chaudhary]] & [[M. C. Phillips]]
| title = Electrocardiographic detection of left ventricular hypertrophy: development and prospective validation of improved criteria
| journal = [[Journal of the American College of Cardiology]]
| volume = 6
| issue = 3
| pages = 572–580
| year = 1985
| month = September
| pmid = 3161926
}}</ref>
   
*Sokolow-Lyon criteria:
:*R in V5 or V6 + S in V1 > 35 mm


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


:*'''Cornell-criteria''' has different values in men and women:
*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 > 28 mm in men
::* R in aVL and S in V3 >20 mm in women
:* R in aVL and S in V3 > 20 mm in women


*In the '''Romhilt-Estes Score''',<ref name="pmid4240354">{{cite journal |author=Romhilt DW, Bove KE, Norris RJ, ''et al.'' |title=A critical appraisal of the electrocardiographic criteria for the diagnosis of left ventricular hypertrophy |journal=Circulation |volume=40 |issue=2 |pages=185–95 |year=1969 |month=August |pmid=4240354 |doi= |url=}}</ref>
*In the Romhilt-Estes Score,<ref name="pmid4240354">{{cite journal |author=Romhilt DW, Bove KE, Norris RJ, ''et al.'' |title=A critical appraisal of the electrocardiographic criteria for the diagnosis of left ventricular hypertrophy |journal=Circulation |volume=40 |issue=2 |pages=185–95 |year=1969 |month=August |pmid=4240354 |doi= |url=}}</ref>:
:*[[LVH]] is ''likely'' with 4 or more points and  
:*[[LVH]] is likely with 4 or more points, and  
:*[[LVH]] is ''present'' with 5 or more points <ref name="pmid4231231">{{cite journal |author=Romhilt DW, Estes EH |title=A point-score system for the ECG diagnosis of left ventricular hypertrophy |journal=Am. Heart J. |volume=75 |issue=6 |pages=752–8 |year=1968 |month=June |pmid=4231231 |doi= |url=}}</ref>.
:*[[LVH]] is present with 5 or more points <ref name="pmid4231231">{{cite journal |author=Romhilt DW, Estes EH |title=A point-score system for the ECG diagnosis of left ventricular hypertrophy |journal=Am. Heart J. |volume=75 |issue=6 |pages=752–8 |year=1968 |month=June |pmid=4231231 |doi= |url=}}</ref>.


==Examples of EKG Findings in patients with AS==
==Examples of EKG Findings in patients with AS==
=====Left Ventricular Hypertrophy=====
Shown below is an electrocardiogram depicting left ventricular hypertrophy.
[[Image:LVH-ECG.jpg|left|300px|LVH-ECG]]
[[Image:LVH-ECG.jpg|center|300px|LVH-ECG]]
<br clear="left"/>
 
=====Severe LVH in a patient with Severe Aortic Stenosis=====
[[Image:Extreme_lvh2.jpg|left|300px|Example of severe [[left ventricular hypertrophy]] in a patient with severe aortic valve stenosis.]]
<br clear="left"/>
<br clear="left"/>


=====Patient with LVH and Subendocardial Ischemia=====
Shown below is an EKG depicting left ventricular hypertrophy and subendocardial ischemia.
[[Image:extreme_lvh.jpg|left|300px|EKG of a patient with LVH and subendocardial ischemia leading to positive cardiovascular markers in blood testing.]]
[[Image:extreme_lvh.jpg|center|500px|EKG of a patient with LVH and subendocardial ischemia leading to positive cardiovascular markers in blood testing.]]
<br clear="left"/>
<br clear="left"/>


=====LVH & Left Ventricular Strain Pattern=====
Shown below is an EKG depicting left ventricular hypertrophy and left ventricular strain pattern.
[[Image:LVH.png|left|300px|[[Left ventricular hypertrophy]]; left ventricular strain due to aortic stenosis.]]
[[Image:LVH.png|center|500px|[[Left ventricular hypertrophy]]; left ventricular strain due to aortic stenosis.]]
<br clear="left"/>
<br clear="left"/>
''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)<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=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 |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==
==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)<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=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 |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level C]])<nowiki>"
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}
==Sources==
*2008 ACC/AHA Guidelines incorporated into the 2006 guidelines for the management of patients with valvular heart disease <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=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 |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}
[[CME Category::Cardiology]]


[[Category:Disease]]
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[[Category:Valvular heart disease]]
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Latest revision as of 16:06, 5 January 2017
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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

  • 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.

LVH-ECG
LVH-ECG


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.
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.
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]

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

  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)
  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)
  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)
  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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