Continuous prolonged generalized weakness, lightheadedness, and presyncope. What might you suspect from the ECG?

A young man presented with continuous prolonged generalized weakness, lightheadedness, and presyncope. There was some dyspnea but no chest pain.  Here is his ECG.  This shows LVH, with high voltage.LVH can have very thick-walled ventricles and a correspondingly small LV cavity.  LVH is a common etiology of heart failure with preserved ejection fraction, as it may results in a stiff ventricle with poor diastolic relaxation.See this articles: Heart Failure with Preserved Ejection Fraction (NEJM review)One etiology of LVH on the ECG is Hypertrophic Cardiolmyopathy (HOCM), and sometimes ECGs in patients with HOCM are specific for HOCM.  But this ECG is NOT specific for HOCM.However, it isatypical for LVH: most ECGs with LVH that manifest as precordial high voltage have deep S-waves in V1-V3. This one has very early transition: the only lead with a deep S-wave is lead V1.See Ken ' s excellent tutorial on the ECG in HOCM below.Case continuedWe did a chart review and, indeed, this patient had known HOCM and an implanted ICD.  It was present during sinus rhythm with normal heart rate; therefore, the ICD not interrogated.We did a bedside echo (original quality was not so good, and this is moreover an iPhone video of the screen -- but it is good enough):Notice how small the LV cavity is.  It is only a slit.  This is because of the large LV myocardial mass due to HOCM.  There is very little filling, and thus very...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs