Image Based Question-67136

A patient presented with fatigue,dyspnea and ankle edema.ECG shows the following picture.What can be the most probable diagnosis?

A. Hypertrophic Cardiomyopathy

B. Restrictive Cardiomyopathy

C. Dilated Cardiomyopathy

D. COPD

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Correct Answer » C Explanation

Ans:C. Dilated Cardiomyopathy.

ECG in the image shows:

• There is marked LVH (S wave in V2 > 35 mm) with dominant S waves in V1-4.

• Right axis deviation suggests associated right ventricular hypertrophy (i.e. biventricular enlargement).

• There is evidence of left atrial enlargement (deep, wide terminal portion of the P wave in V1).

• There are peaked P waves in lead II suggestive of right atrial hypertrophy (not quite 2.5mm in height).

Dilated Cardiomyopathy

• It is a myocardial disease characterised by ventricular dilatation and global myocardial dysfunction (ejection fraction < 40%).

• Patients usually present with symptoms of biventricular failure, e.g. fatigue, dyspnoea, orthopnoea, ankle oedema.

• Associated with a high mortality due to progressive cardiogenic shock or ventricular dysrhythmias (sudden cardiac death).

Causes:

• Can be divided into ischaemic and non-ischaemic.

Ischaemic

• Dilated cardiomyopathy commonly occurs following massive anterior MI due to extensive myocardial necrosis and loss of contractility.

Non-ischaemic

• Most cases are idiopathic.

• Up to 25% are familial (primarily autosomal dominant, some types are X-linked) .

A very small proportion may occur with:

• Viral myocarditis (coxsackie B / adenovirus).

• Alcoholism.

• Toxins (e.g. doxorubicin).

• Autoimmune disease.

• Pregnancy (peripartum cardiomyopathy).

Common ECG associations with DCM.

• The most common ECG abnormalities are those associated with atrial and ventricular hypertrophy —

• typically, left sided changes are seen but there may be signs of biatrial or biventricular hypertrophy.

• Interventricular conduction delays (eg. LBBB) occur due to cardiac dilatation.

• Diffuse myocardial fibrosis may lead to reduced voltage QRS complexes, particularly in the limb leads.

• There may be a discrepancy of QRS voltages with signs of hypertrophy in V4-6 and relatively low voltages in the limb leads.

• Left axis deviation.

• Poor R-wave progression with QS complexes in V1-4 (“pseudo-infarction” pattern).
  Frequent ventricular ectopics and ventricular bigeminy (seen with severe DCM).

• Ventricular dysrhythmias (VT / VF).