Author`s Reply.

To the Editor,

Thank you for your interest on our case report (1). We appreciate your elaborate comments.

Electrocardiographic (ECG) ST elevation associated with left ventricular hypertrophy is due to delayed depolarization of the epicardium, which leads to discordant repolarization abnormalities. The ECG characteristics of left ventricular hypertrophy are ST elevation in right and septal precordial leads and ST depression in lateral leads (2). Generally, ST elevation is discordant with the QRS direction.

Hypertrophic cardiomyopathy has similar ECG findings with left ventricular hypertrophy. Apical variant of the hypertrophic cardiomyopathy (Yamaguchi syndrome) is frequently associated with deep symmetrical T wave inversion (giant T waves).

In our patient, apical hypertrophic cardiomyopathy was the least likely diagnosis. Echocardiographic image quality was good; left ventricular apex was clearly visible, left ventricular cavity mid and apical segments had normal thickness, and there was no gradient throughout the left ventricle.

Atrial fibrillation (AF) is quite common in the elderly. In addition to the advanced age (i.e., 68-years old), our patient also had long-standing hypertension. Advanced age and hypertension are the most common risk factors for the development of AF (3). Diastolic dysfunction is frequently observed in elderly women with hypertension. Our patient carries three major risk factors for the development of diastolic dysfunction: increased age, female sex, and hypertension. Biatrial dilatation is the hallmark finding of diastolic dysfunction. Therefore, we believe that there are enough risk factors for the development of AF, i.e., increased age, hypertension, diastolic dysfunction, and consequent biatrial dilatation.

In addition, the ECG presented in Figure 1 shows classic type 2 Brugada pattern and, ST elevation on V1 and V2, which were absent in the ECG performed in the previous year, which is presented in Figure 2. The case reports cited by the letter’s authors include ST segment elevations only in lateral leads. Both the presence of ST elevation on V1 and V2 and dynamic nature of the ST segment elevation in our patient make the diagnosis of apical hypertrophic cardiomyopathy much less likely. Our patient had a clearly visible notch on V3, which also favors early repolarization.

Figure 1

ECG shows atrial fibrillation. ST elevations are most prominent in V3, which also has a notch on the descending part of QRS compatible with early repolarization

Figure 2

ECG done in the last year showing similar findings