Are Electrocardiographic Criteria Reliable for Left Ventricular Hypertrophy Detection in Indian Adults?

BACKGROUND: Left ventricular hypertrophy (LVH) detection is vital to the risk stratification of adults at risk of adverse cardiovascular events such as coronary heart disease, cerebrovascular disease, and aortic aneurysms. Electrocardiogram (ECG), a non-invasive, cost-effective instrument has been widely used as a screening tool for LVH. The objective of this study was to determine the diagnostic accuracy of seven frequently used ECG criteria in high-risk Indian adults in comparison with echocardiography. METHODS: ECG and transthoracic echocardiography were performed in adults older than 18 years with at least one cardiac risk factor (chronic hypertension, obesity, ischemic heart disease, and type 2 diabetes mellitus). Precision and accuracy were calculated for the various ECG criteria against LVH based on left ventricular mass index (LVMI) and cardiac remodeling by echocardiography. RESULTS: A total of 220 participants were enrolled. Of these, 96 had LVH by echocardiography. There was marked variability in LVH detection by the different ECG criteria: 28 by Sokolow-Lyon criteria, 26 by Cornell criteria, 24 by Lewis criteria, 46 by Scott criteria, eight by Romhilt-Estes criteria, six by Modified Cornell criteria, and only two by Roberts criteria. Agreement statistics between ECG criteria and LVMI showed that none of them had a good agreement for LVH detection. CONCLUSION: None of the ECG criteria were sensitive enough to rule out ventricular hypertrophy. In the context of cardiac remodeling, the ECG criteria had high sensitivity but low specificity and, hence, limited clinical relevance.

An Unusual Clinical Presentation of Scrub Typhus.

Scrub typhus is still underdiagnosed despite a resurgence in incidence as the clinical presentation is often atypical leading to low index of suspicion among clinicians. We report a case of a young girl presenting as lobar pneumonia and diagnosed as scrub typhus. Despite such a classical picture of community-acquired pneumonia on clinical presentation and radiological findings the patient was found to have scrub typhus serologically thereby posing a diagnostic dilemma. Upon serological confirmation, doxycycline therapy was initiated followed by a rapid and complete resolution of pneumonia, both clinically and radiographically. This case report highlights the importance of recognizing an uncommon clinical presentation of this common tropical disease and its prompt diagnosis and treatment.

Combined ST Elevation in a Case of Acute Myocardial Infarction: How to Identify the Infarct-related Artery?

Combined ST elevation in anterior and inferior ECG leads in acute myocardial infarction is not a rarity. It is both interesting and challenging to indentify the infarct related culprit artery. We report the case of a middle aged male with acute myocardial infarction whose admission ECG shows ST elevation in lead II, III, aVF as well as from V1-V3. 90% of such cases are due to single vessel occlusion - majority due to proximal RCA occlusion and the remaining due to mid to distal LAD occlusion. ECG features to differentiate between these two vascular occlusions are discussed. In this case at hand, lead III ST elevation of 2.5 mm and V2/V3≥ 1 indicates proximal RCA as the IRA and the same has been confirmed by pre-discharge coronary angiogram .

Inadvertent Skipping of Steroids in Septic Shock Leads to a Diagnosis of Adult Onset Still's Disease.

Adult onset Still's disease is uncommon in middle-aged and elderly individuals and can rarely present with shock; shock is usually associated with disseminated intravascular coagulation, multiorgan dysfunction syndrome or acute respiratory distress syndrome. We report a post-menopausal woman with arthritis, fever, pneumonitis and hypotension which was managed as septic shock. Steroids were inadvertently missed during the second day of hospitalization in the intensive care unit. Persistence of hypotension on inotropes, with normal renal, hepatic and neurological function and recurrence of fever when steroids were skipped, led to suspicion of an inflammatory disorder. A diagnosis of Still's disease may be entertained in postmenopausal women with polyarthritis, rash, and fever with leukocytosis. Sepsis is mimicked, and multiple antibiotics use is common before the diagnosis of such an entity is made. Shock is rare in adult onset Still's disease and is not necessarily associated with disseminated intravascular coagulation, acute respiratory distress syndrome, or multiorgan dysfunction.

A dangerous twist of the 'T' wave: A case of Wellens' Syndrome.

Wellens' syndrome is a condition in which electrocardiographic (ECG) changes indicate critical proximal left anterior descending artery narrowing occurring during the chest pain-free period. Due to the severity of the obstruction, if such cases are managed by early invasive revascularisation therapy, a major threat in the form of a massive myocardial infarction or sudden death may be averted. We present the case of a patient with previous chest pain, whose ECG showing subtle ischemic changes was initially overlooked. A repeat ECG taken during the painless period showed a biphasic T wave, suggestive of Wellen's' syndrome. This was confirmed by an immediate coronary angiogram.