About hypertrophic cardiomyopathy

  The presence of ventricular hypertrophy in the absence of an obvious cause such as systemic hypertension or aortic stenosis is called as hypertrophic cardiomyopathy.

  Incidence is about 0.2% in the general population.

  Generally involves left ventricle. Sometimes, it may involve both ventricles.

  Although the ECG is abnormal in 70-90% of the cases, there is no diagnostic ECG finding.

  Hypertrophy of the left ventricle may be concentric, asymmetric septal or apical.

  Hypertrophy pattern influences the ECG findings.



ECG abnormalities that may be observed in hypertrophic cardiomyopathy

  Left ventricular hypertrophy or biventricular hypertrophy.

  Right atrial abnormality, left atrial abnormality, or biatrial abnormality.

  Increased R wave amplitude in right precordial leads.

  Abnormal Q waves.

  Nonspecific ST segment and/or T wave changes: apical hypertrophic cardiomyopathy may show deeply negative T waves and/or ST segment depression in leads II, III, aVF, V4-V6. The depth (amplitude) of these negative T waves may vary throughout the day.

  Bundle branch blocks or fascicular blocks.

  Wolff Parkinson White Syndrome pattern.

  Short PR interval (without delta wave).

  Supraventricular arrhythmias, ventricular arrhythmias.

  Prolonged QT interval.

  Negative U wave.



Hypertrophic cardiomyopathy and treadmill exercise test

  If a patient with hypertrophic cardiomyopathy undergoes treadmill exercise test, ST segment depression may be observed even if there is no significant coronary artery stenosis.



References

  Chest 1983;84:644-647.

  Circulation 1985;71:45-56.

  Circulation 1968;37:759-788.

  Am J Cardiol 1979;44:401.

  Tex Heart Inst J 2012;39:750-755.

  Tex Heart Inst J 2012;39:758-760.




ECG 1a. The Holter (ambulatory ECG recording) tracing of a patient with hypertrophic cardiomyopathy and preexcitation
pattern (WPW syndrome) shows nonsustained ventricular tachycardia (VT) attack .

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ECG 1b. The same Holter recording also showed ventricular premature contraction (VPC) and atrial premature contraction
(APC) .

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ECG 1c. The same patient's 12-lead ECG shows delta wave and ST segment and T wave changes in many leads . This patient
does not have coronary artery obstruction.

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ECG 2. The ECG above belongs to a 40 years-old woman with hypertrophic cardiomyopathy. ST segment depression and
T wave changes are NOT due to obstructive coronary artery disease.

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ECG 3. Above is the ECG of another patient with hypertrophic cardiomyopathy showing nonspecific T wave changes , voltage
criteria for left ventricular hypertrophy and atriyal abnormality pattern .

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ECG 4. The ECG above belongs to a patient with APICAL hypertrophic cardiomyopathy. Deeply negative T waves in precordial
leads , ST segment depression and voltage criteria for left ventricular hypertrophy suggested a diagnosis of apical hypertrophic
cardiomyopathy. The increased R wave amplitude in right precordial leads (C1-C3) and a blood pressure of 110/70 mmHg
further supported the diagnosis which was later confirmed by echocardiography. Deeply (>1.0 mV) negative T waves are more
frequently observed in the APICAL type of hypertrophic cardiomyopathy. Coronary angiography did not reveal any obstruction
in the coronary arteries.

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ECG 5a. The ECG above belongs to a 40 years-old woman with hypertrophic cardiomyopathy.
Echocardiography showed MIDVENTRICULAR HYPERTROPHY.

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ECG 5b. The same patient's Holter recording showed attacks of non-sustained ventricular tachycardia.
Because of syncopal attacks, an ICD (implantable cardioverter defibrillator) was implanted.

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ECG 6a. The ECG above belongs to a 10 years-old boy with hypertrophic cardiomyopathy.
The voltage is so high that to accomodate QRS complexes, limb leads were recorded at a calibration of 5 mm/mV
while precordial leads were recorded at 2.5 mm/mV.

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Figure 1a. His ECHOcardiogram at the age of 10 years showed a thickened interventricular septum of 3.8cm
with a thickened left ventricular posterior wall (2.8 cm).



ECG 6b. Above is the ECG of the same patient at 27 years of age. QRS is wide and there is intraventricular conduction defect.
P waves show signs of atrial abnormality.

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Figure 1b. His ECHOcardiogram at the age of 27 years shows a dilated left ventricle and no midventricular obstruction.


The 2 ECGs and 2 ECHOcardiograms above have been used with the permission of Anatolian Journal of Cardiology and
AVES Publishing.

Click here to read the relevant article by Dr. Ugur Canpolat et al.




ECG 7. The ECG above belongs to a 12 days-old newborn with hypertrophic cardiomyopathy (septal involvement).

Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.

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EGG 8. The ECG above belongs to a 58 years-old man with hypertrophic cardiomyopathy.
All the leads other than aVR, V1 and V2 show q waves. The patient did not have previous myocardial infarction.
Abnormal q waves may be observed in patients with hypertrophic cardiomyopathy but without previous myocardial infarction.
There is also left anterior fascicular block.

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EGG 9. The ECG above belongs to a 69 years-old man with APICAL hypertrophic cardiomyopathy.
Deep negative T waves and ST segment depression is seen in the precordial leads.




ECG 10. Above is the ECG of a 73 years-old woman with apical hypertrophic cardiomyopathy.
Chest leads show deeply negative T waves.

The ECG above has been used with the permission of Texas Heart Institute Journal.

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Click here to go to the relevant article of the Texas Heart Institute Journal




ECG 11. Above is the ECG of a 65-year-old obese, nondiabetic, normotensive woman with exertional angina of 4 years' duration.
The ECG showed poor precordial R-wave progression with Q waves in leads V1 through V6, II, III, and aVF, and T inversions
in the precordial leads. She reported no history that suggested acute coronary syndrome.
Coronary angiography showed normal coronary arteries. Injection of contrast medium into the LV revealed hypercontractile
mid-LV myocardium and a spherical, calcified cavity that projected outward and communicated with the LV apex.
Apical aneurysm in the absence of epicardial coronary artery disease is a rare sequela of apical hypertrophic cardiomyopathy.
High intraventricular pressures, local abnormalities of cardiac contraction, and intramural coronary artery abnormalities may
lead to a chronically ischemic state of the apical myocardium and to aneurysm formation.

The ECG above has been used with the permission of Texas Heart Institute Journal.

Click here for a more detailed ECG

Click here to go to the relevant article of the Texas Heart Institute Journal




ECG 12. The ECG above belongs to a 30 years-old man with hypertrophic cardiomyopathy. He has normal blood pressure.
ECHOcardiography showed diffuse (concentric) hypertrophy of the left ventricle.
The above ECG was recorded at a standard calibration of 10 mm/mV and at a paper speed of 25 mm/second.
It shows increased voltage. The height of the R wave in lead V5 is about 67 mm.
The overlapping R and S waves create bold deflections, giving the impression of pacemaker spike at first glance.
He does not have cardiac pacemaker.

Esra Dogan has donated the above ECG to our website.

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ECG 13. The ECG above belongs to a patient with biventricular hypertrophic cardiomyopathy.

Dr. Magda Carvalho has donated the above ECG to our website.

Click here to see the Twitter link of this patient's ECHO video

Below is an image from this patient's ECHOcardiography examination.