The electrocardiogram: Still a useful marker for LV fibrosis in aortic stenosis

Left ventricular (LV) strain on the electrocardiogram (ECG) (down-sloping, convex ST-segment depression with asymmetric T-wave inversion in leads V5 and V6) reflects fibrosis as a result of subendocardial ischemia. It is associated with a significantly increased risk of cardiovascular events independent of the presence of LV hypertrophy on the echocardiogram or cardiac magnetic resonance (CMR) scan. Ongoing studies of early aortic valve replacement in asymptomatic patients with severe aortic stenosis are using ECG changes as a marker of possible fibrosis shown by midwall late gadolinium enhancement on CMR. However, until these studies report, it is still reasonable to respond to LV strain on the ECG by tightening control of systemic hypertension and consider intervention in cases where indications are otherwise in borderline. •In aortic stenosis (AS), increased total left ventricular (LV) impedance due to valvular resistance, hypertension and arterial stiffness, leads to LV hypertrophy and an increased risk of adverse events.•Left ventricular strain on the electrocardiogram (ECG) reflects midwall fibrosis.•In patients with AS, ECG can improve risk prediction and provide incremental prognostic information.