Left Ventricular Aneursym Overview
- Persistent ST elevation following an acute myocardial infarction.
- Following an acute STEMI, the ST segments return towards baseline over a period of two weeks, while the Q waves persist and the T waves usually become flattened or inverted.
- However, some degree of ST elevation remains in 60% of patients with anterior STEMI and 5% of patients with inferior STEMI.
- The mechanism is thought to be related to incomplete reperfusion and transmural scar formation following an acute MI.
- This ECG pattern is associated with paradoxical movement of the ventricular wall on echocardiography (ventricular aneurysm).
ECG Features of LV Aneurysm
- ST elevation seen > 2 weeks following an acute myocardial infarction.
- Most commonly seen in the precordial leads.
- May exhibit concave or convex morphology.
- Usually associated with well-formed Q- or QS waves.
- T-waves have a relatively small amplitude in comparison to the QRS complex (unlike the hyperacute T-waves of acute STEMI).
The pattern of persistent anterior ST elevation (> 2 weeks after STEMI) plus pathological Q waves has a sensitivity of 38% and a specificity of 84% for the diagnosis of ventricular aneurysm.
- Ventricular arrhythmias and sudden cardiac death (myocardial scar tissue is arrhythmogenic).
- Congestive cardiac failure.
- Mural thrombus and subsequent embolisation.
Differentiation from acute STEMI
Factors favouring left ventricular aneurysm
- ECG identical to previous ECGs (if available).
- Absence of dynamic ST segment changes.
- Absence of reciprocal ST depression.
- Well-formed Q waves.
Factors favouring acute STEMI
- New ST changes compared with previous ECGs.
- Dynamic / progressive ECG changes — the degree of ST elevation increases on serial ECGs.
- Reciprocal ST depression.
- High clinical suspicion of STEMI — ongoing ischaemic chest pain, sick-looking patient (e.g. pale, sweaty), haemodynamic instability.
Other discriminating features
The ratio of T-wave to QRS complex amplitude has been proposed as an additional means of differentiating between LV aneurysm and acute STEMI:
- T-wave/QRS ratio < 0.36 in all precordial leads favours LV aneurysm.
- T-wave/QRS ratio > 0.36 in any precordial lead favours anterior STEMI.
- Minimal ST elevation in V1-3 associated with deep Q waves and T-wave inversion.
- This is a LV aneurysm secondary to a prior anteroseptal STEMI.
- Old inferior STEMI with persistent ST elevation (LV aneurysm morphology).
- ECG is reproduced from Dr Smith’s ECG Blog.
- Edhouse J, Brady WJ, Morris F. ABC of clinical electrocardiography: Acute myocardial infarction-Part II. BMJ. 2002 Apr 20;324(7343):963-6. Review. [PMID: 11964344] [Full text]
- Smith SW. T/QRS ratio best distinguishes ventricular aneurysm from anterior myocardial infarction. Am J Emerg Med. 2005 May;23(3):279-87. [PMID: 15915398]
- Left ventricular aneurysm vs. acute anterior STEMI from EMS-12 lead.
- Some more cases of left ventricular aneurysm from Dr Smith’s ECG Blog.
- Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography
- Hampton, JR. The ECG In Practice, 6e
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric, 6e
- Wagner, GS. Marriott’s Practical Electrocardiography 12e
- Chan, TC. ECG in Emergency Medicine and Acute Care
- Mattu, A. ECG’s for the Emergency Physician
LITFL Further Reading
- ECG BASICS — Waves, Intervals, Segments and Clinical Interpretation
- ECG A to Z by diagnosis –alphabetical diagnostic approach to the ECG
- ECG CLINICAL CASES — ECG’s placed in clinical context with a challenging Q&A approach
- 100 ECG Quiz — Self-assessment tool for examination practice
- ECG Reference SITES and BOOKS — the best of the rest
- LITFL ECG IMAGE Database — Searchable database of LITFL ECG’s
- ECG and Cardiology Eponymous Syndromes — Cheats guide to eponymous emancipation
- ECG Exam Template — a framework for answering ECG exam questions.