Diagnostic criteria

  Strain pattern is observed in lateral leads (I, aVL, V5, V6) with prominent R waves.

  Classically ST segment depression and asymmetrically negative T waves are seen in these leads.

  In some patients, only asymmetrically negative T waves are seen in these leads.

  Unlike acute coronary syndromes, dynamic ECG changes are NOT observed in isolated strain pattern.



Clinical significance

  Strain pattern is usually observed in patients with left ventricular hypertrophy and/or dilation

      (such as in systemic hypertension or aortic valve disease).

  However, all patients with left ventricular hypertrophy do not show strain pattern.

  Strain pattern itself is NOT an ECG sign of myocardial ischemia.

  ST segment depression and T wave negativity have several causes other than coronary artery disease,

      and strain pattern is one of them.

  Although strain pattern is not a sign of cardiac ischemia,

      its presence also does not necessitate the absence of coronary artery disease.

  Patients with strain pattern may also have coincidental coronary artery disease.

      If acute coronary syndrome developes in such a patient, dynamic ECG changes are usually observed.



Prognostic significance of left ventricular strain pattern

Strain pattern increases the risk of

  Myocardial infarction

  Heart failure development

  Stroke.



Click here for the coexistence of left ventricular strain pattern and myocardial ischemia


References

  Am J Cardiol 2007;100:94-98.

  European Journal of Heart Failure 2011;13:384-391.

  Circulation 2006;113:67-73.

  Hypertension 2004;44:48-54.

  Br Heart J 1992;67:304-307.




ECG 1a. A 42 years-old man with dilated cardiomyopathy, prosthetic aortic and mitral valves, and normal coronary arteries.
In addition to the increased voltage, the ST segment depression and asymmetrically negative T waves in lateral leads show
left ventricular strain pattern. The rhythm is atrial fibrillation.

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ECG 1b. Three years ago, his ECG was similar.

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ECG 2. Above is the ECG of a 57 years-old hypertensive woman with normal coronary arteries. Strain pattern is seen.
The rhythm is atrial fibrillation. Echocardiography showed diffuse left ventricular hypertrophy.

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ECG 3. Strain pattern is seen in the ECG of a 74 years-old hypertensive woman with normal coronary arteries.
Echocardiography showed left ventricular hypertrophy.

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ECG 4. Strain pattern is seen in the ECG of a middle-aged hypertensive man with normal coronary arteries.
Echocardiography showed left ventricular hypertrophy.

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ECG 5. Strain pattern is seen in the ECG of a 53 years-old hypertensive man with normal coronary arteries.
Echocardiography showed diffuse left ventricular hypertrophy.

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ECG 6. The ECG above belongs to a 84 years-old hypertensive woman with normal coronary arteries.
Echocardiography showed left ventricular hypertrophy. However, there is NO strain pattern in her ECG.
Strain pattern is not necessarily seen in all hypertensive patients with left ventricular hypertrophy.

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ECG 7a. Strain pattern is seen in the ECG of a 54 years-old hypertensive woman with normal coronary arteries.
Echocardiography detected left ventricular hypertrophy.

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ECG 7b. After 6 years, her ECG still shows left ventricular strain pattern.
Echocardiography showed left ventricular hypertrophy.

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ECG 8. The ECG above belongs to a 58 years-old hypertensive woman with normal coronary arteries.
The subtle ST segment depression and T wave changes in leads V5 and V6 are due to the strain pattern, but not the ischemia.
As seen in this example, strain pattern may sometimes be subtle.

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ECG 9. The ECG above is from a middle-aged hypertensive woman with normal coronary arteries.
Leads V4 to V6 show negative T waves but not ST segment depression.
Some cases of left ventricular strain pattern may not have ST segment depression.

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ECG 10. The above ECG is from a 72 years-old man who had undergone mitral valve replacement 8 months ago.
It was recorded during pericarditis without effusion (2 weeks after surgical drainage of the effusion).
Widespread T wave negativity suggests pericarditis, NOT left ventricular strain.




ECG 11. The above ECG is from a 74 years-old asymptomatic man who was awaiting for knee surgery (for gonarthrosis).
He was asymptomatic since he could not walk freely because of the gonarthrosis.
The upsloping ST segment and biphasic T wave in lead V5 is NOT TYPICAL for LV strain.
After recoring of the above ECG, coronary angiography was performed which showed significant stenoses in the LAD
and its Diagonal branch. He then underwent coronary artery bypass graft surgery (before knee surgery).

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ECG 12. The above ECG is from a 65 years-old woman with untreated chronic hypertension.
Echocardiography showed a dilated left ventricle with a depressed LVEF of 35%.
Coronary angiography showed coronary artery ectasia.
Large amplitude QRS complexes are seen in lead I and III (left ventricular hypertrophy).
Leads I, aVL, and V4 to V6 show negative T waves (strain pattern).

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