ECG reveals clinical findings obscured by left ventricular hypertrophy

A man born with a congenital heart murmur developed systemic arterial hypertension as an adult. At age 50, he went to the hospital because of dyspnea. He also had a pulmonic valve ejection click and murmur of pulmonic stenosis. When at the hospital, his echocardiogram showed hypertrophy of both ventricles as well as an enlarged right atrium.

“His electrocardiograms showed no evidence of the right ventricular and right atrial enlargement so evident on echocardiogram, presumably because it was obscured by the marked changes of left ventricular hypertrophy,” wrote D. Luke Glaney, author of a paper about the case that was published online Aug. 11 in the American Journal of Cardiology. Glaney is with the cardiology section within the department of medicine at the LSU Health Sciences Center in New Orleans, Louisiana.

The man also had an elevated level of serum creainine. The emergency department clinicians referred him to the nephrology clinic. He did not comply with his prescribed treatment.

Three years later, the 53-year-old man was admitted to the hospital with increasing dyspnea as well as a striking degree of anasarca. Both his abdomen and legs were markedly swollen.  

“An echocardiogram showed marked concentric left ventricular hypertrophy, a dilated left atrium, an even larger right atrium with bulging of the atrial septum into the left atrium, right ventricular hypertrophy, a flat ventricular septum with virtually no movement, and a D-shaped left ventricular cavity,” Glaney wrote.

In spite of life-long, moderate-to-severe congenital pulmonic stenosis, this individual’s electrocardiograms never gave the slightest indication of the right ventricular hypertrophy that was so clearly apparent on the echocardiogram.

“The most likely explanation is that the patient’s long standing severe systemic atrial hypertension caused sufficient changes of left ventricular hypertrophy on the electrocardiogram to obscure the changes of right ventricular hypertrophy,” Glaney wrote. “When cardiac failure produced anasarca, the massive amount of fluid between the heart and the electrodes obscured the voltage changes of left ventricular hypertrophy.”

The patient experienced worsening cardiac failure, he grew mentally disoriented, and his blood cultures strongly suggested infective endocarditis. Despite the administration of antibiotics and appropriate treatment for cardiac failure, the man died 10 days after entering the hospital.