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From:

DATE:05-10-2012

DR.VENUGOPAL.K

Post Graduate Student in M.D. (General medicine),

Department of General medicine,

Vijayanagar Institute of Medical Sciences, Bellary.

To

The Principal,

Vijayanagar Institute of Medical Sciences,

Bellary.

THROUGH PROPER CHANNEL

Respected Sir,

Subject: Acceptance of registration and forwarding of my dissertation topic.

With reference to the above subject, I, the undersigned studying Post Graduate Course in M.D.general medicine has been allotted the dissertation topic “ECG & ECHOCARDIAGRAPHIC STUDY OF LEFT VENTRICULAR HYPERTROPHY IN PATIENT WITH ESSENTIAL HYPERTENSION IN VIMS BELLARY”,

under the guidance of Dr. GADWALKAR SRIKANT.R. Professor, Department of General medicine , VIMS, Bellary.

I request you to kindly forward the dissertation topic in the prescribed form to the University for approval.

Thanking you,

Yours sincerely,

Signature of the guide :

(DR. GADWALKAR SRIKANT.R) (DR.VENUGOPAL.K )

Professor & HOD of General medicine, PG in General medicine,

Department of General medicine, VIMS,Bellary.

VIMS, Bellary.

FROM, DATE:05-10-2012

THE PROFESSOR AND HOD,

DEPARTMENT OF GENERAL MEDICINE,

VIMS, BELLARY.

TO,

The Registrar,

Rajiv Gandhi University of Health Sciences,

Bangalore.

THROUGH PROPER CHANNEL

Respected Sir,

As per the regulations of the University for registration of Dissertation topic, the following Post Graduate Student in MD General medicine has been alloted the dissertation topic as follows by the Official Registration Committee of all qualified and eligible guides of the Department of General medicine.

|NAME |TOPIC |GUIDE |

| |ECG & ECHOCARDIAGRAPHIC STUDY OF LEFT VENTRICULAR| |

|DR.VENUGOPAL.K |HYPERTROPHY IN PATIENT WITH ESSENTIAL |DR.GADWALKAR SRIKANT.R |

|Post Graduate Student in M.D. General medicine, |HYPERTENSION IN VIMS BELLARY |Professor and HOD, |

|VIMS, Bellary. | |Department of General medicine |

| | |VIMS, bellary. |

Therefore, I kindly request you to communicate the acceptance of the dissertation topic allotted to the PG student at an early date.

Thanking you,

Yours faithfully,

Signature of the guide :

(DR.GADWALKAR SRIKANT.R) (DR.GADWALKAR SRIKANT.R)

Professor & HOD Professor & HOD

Department of general medicine Department of general medicine

VIMS, Bellary. VIMS, Bellary

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

ANNEXURE – II

SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

| | | DR. VENUGOPAL.K |

|1 |Name of the candidate and Address |POST GRADUATE STUDENT |

| |( In Block letters ) |IN M.D.GENERAL MEDICINE |

| | |VIMS, BELLARY – 583104. |

| | | |

|2 |Name of the Institution |VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BELLARY |

| | | |

|3 |Course of study and subject |M.D.GENERAL MEDICINE |

| | | |

|4 |Date of admission to the course |30-05-2012 |

| | |

|5 |Title of topic: |

| |ECG & ECHOCARDIAGRAPHIC STUDY OF LEFT VENTRICULAR HYPERTROPHY IN PATIENT WITH ESSENTIAL HYPERTENSION IN VIMS BELLARY |

| | |

| |6 Brief resume of the intended work: |

| |6.1 Need for the Study: Left ventricular hypertrophy is no longer considered as an adaptive mechanism that compensates the pressure |

| |imposed on the heart and has been identified as an independent and significant risk factor for sudden death, acute myocardial infarction , |

| |congestive cardiac failure, and stroke . |

| |Structural changes in hypertensive heart extends beyond myocyte hypertrophy,they also includes medial hypertrophy of the intra myocardial |

| |coronary arteries and collagen deposition leads to cardiac fibrosis. |

| | |

| |Framingham heart study reveals that 1 in 10 individuals will have left ventricular hypertrophy in the age group of 65-69 years . |

| |Studies clarify strong relationship between left ventricular hypertrophy and adverse outcome and hence emphasize on the clinical importance |

| |for its detection. |

| |Electrocardiography in the assessment of cardiac dimension has lost its prominence in favour of imaging techniques that provide a |

| |multidimensional display of the heart, but secondary ST-Tchanges due to LVH .which are uniquely determined from the electrocardiography are |

| |know to increase the risk of cardiovascular morbidity and mortality. |

| |The increase in left ventricular mass represents a final pathway towards the adverse impact on cardiovascular system and higher vulnerability|

| |to complication . |

| | |

| |Left ventricular hypertrophy imposes a great cardiovascular risk, whether it is diagnosed by electrocardiography or 2D echocardiography. |

| |However, both these methods for detecting left ventricular hypertrophy have drawbacks .The electrocardiography is rather insensitive in |

| | |

| |detecting anatomical left ventricular hypertrophy. 2D echocardiography is more expensive and less available widely and is sometimes difficult|

| |to distinguish physiological from pathological left ventricular hypertrophy. |

| | |

| |Today, 2D echocardiography still demands considerably more time , cost ,technical skill of the operator and complexity of processing than |

| |routine 12 lead electrocardiography. |

| |This study is done to compare between electrocardiographic criteria’s for left ventricular hypertrophy, using echocardiography as standard. |

| | |

| |6.2 Review of Literature: |

| |Historical Background: Left ventricular hypertrophy is defined as an increase in muscle mass of the left ventricle. |

| |Hypertension , obesity , advanced age , valvular heart disease and other pathological disorders that cause an increase the hemodynamic |

| |burden can lead to LVH. |

| |LVH has been proven to be an extremely useful predictor of prognosis , regardless of whether it occurs in hypertensive patients or in the|

| |general population. |

| |Prevalence of left ventricular hypertrophy according to Framingham heart study is 1 in 10 in the age group of 65-69 years. 2 |

| | |

| | |

| | |

| |ELECTOCARDIGRAPHIC CRITERIA FOR LEFT VENTRICULAR HYPERTROPHY. |

| |Romhilt –esters scoring system for left ventricular hypertrophy.7 |

| |1 .R or S wave in any limb ≥ 2 mv 3 |

| |or S in V1 lead or V2 |

| |or R in lad V5 or V6 ≥ 3 mv |

| |2 left ventricular strain |

| |ST segment and T wave in opposite direction to QRS complex |

| |Without digitalis 3 |

| |With digitalis 1 |

| |3 Left atrial enlargement 3 |

| |Terminal negativity of P wave in lead V1 is ≥0.10 mv in depth |

| |and ≥0.04s in duration |

| |4 Left axis deviation ≥ 30 degree 2 |

| |5 QRS duration ≥0.09s 1 |

| |6 Intrinsicoid detectin in lead V5 or V6 ≥ 0.05s 1 |

| |Maximum score 13 |

| |Definite left ventricular hypertrophy -5 or more points |

| |Left ventricular hypertrophy, probably – 4 points |

| |Sokolow – lyon criteria for left ventricular hypertrophy.8 |

| |S wave in lead V1 plus R wave in lead in V5 or V6 ≥ 3.5 mv |

| |Or |

| |R wave in lead V5 or V6 ≥ 2.6 mv |

| | |

| |Cornell voltage criteria for left ventricular hypertrophy.9 |

| |Female - R wave in lead AVL plus S wave in V3 ≥ 2.00mv |

| |Male - R wave in lead AVL plus S wave in V3 ≥ 2.8mv |

| |Cornell regression equation : risk of LVH=1/(1+e-exp)+ |

| |Cornell voltage duration measurements |

| |Qrs duration * cornell voltage >2436mm/sec |

| |Qrs duration * sum of voltage in all leads >1742mm/sec |

| | |

| |Better quantification of LVH was obtained by estimating left ventricular mass , first derived from M- mode ECHO by various groups in the |

| |early 1970s .This is done by estimating the volume of LV myocardial “Shell”, which is the difference between the external volume of left |

| |ventricle and left ventricular chamber volume .LV mass obtained by multiplying the estimated LV myocardial volume by 1.04, the specific |

| |gravity of myocardium .Formulas such as that of Troy et al, were used widely in early LV mass studies, but not validated by anatomic |

| |correlation. |

| |Devereux and Reicheck.10 were first to correlate echocardiography LV mass estimates with LV specimen of the same heart at autopsy. They |

| |tested various geometric formulas and different methods of measuring wall thickness and LVID and found that anatomic LV mass correlated best |

| |with LV measurements { penn convention (r=0.96) } using the following empirical equqtion: |

| |LVM =1.04[(IVST+LVID+PWT) 3 – (LVID) 3 ] -13.6g |

| |Where LVID - left ventricular diameter during diastole. |

| | |

| |LVPWT - left ventricular posterior wall thickness in diastole. |

| |IVST - interventricular septal thickness in diastole. |

| |Using American society of echocardiography (ASE) method of measuring septal and left ventricular wall thickness ,Devereux and Woytholer et |

| |al ., found a good correlation between ECHO and anatomic LV mass (r=0.9 and 0.81 respectively)11 |

| | |

| |CRITERIA FOR LVH BY ECHOCARDIOGRAPHY |

| |LV mass: Male > 115 g/m2 |

| |Female > 95 g/m2 |

| |LV posterior wall thickness ( Diastole ) : Male > 10 mm |

| |Female > 9 mm |

| | |

| |6.3 AIMS AND OBJECTIVES: |

| |To identify the left ventricular hypertrophy . |

| | |

| |To assess the prognostic importance of left ventricular hypertrophy in a patient with |

| | |

| |essential hypertension. |

| | |

| |To assess any correlation between left ventricular hypertrophy with the peripheral |

| | |

| |vascular disease, coronary artery disease, acute myocardial infarction and stroke. |

| | |

| | |

| | |

|7 |Materials And Methods: |

| |7.1 Source of Data: |

| |Patients attending the outpatient department and those who will be admitted in the medicine wards of vijayanagar institute of Medical |

| |sciences, BELLARY from january 2013 to june2014 will be the study subjects. |

| |Sample Size: 100 |

| | |

| |7.2 Method of Collection of Data: |

| |The data will be collected from the patients by the detailed clinical history, clinical examination of the patients and relevant |

| |investigation in a specially designed proforma. |

| |Case History: |

| |1. Patients will be assigned a case number, and their name, age, sex, occupation socio- economic status will be noted. |

| |2.. Total duration of hypertension , the medication used will be recored. |

| |3. History of smoking, or tobacco in any other form, alcohol consumption will be specifically noted in the personal history. |

| |4. Family history of hypertension, ischemic heart disease will be specifically noted. |

| | |

| |Investigation: |

| |1.Blood—Hbg%, total counts (TC), differential counts (DC), Blood Urea, Serum Creatinine, random blood sugar (RBS) |

| |2. Chest Xray. |

| |3. ECG. |

| |4. Echocardiography with colour doppler. |

| | |

| |Inclusion Critera All cases of essential hypertension, irrespective of duration of hypertension and type of treatment received will be |

| |included in the study. |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Exclusion Criteria |

| |Secondary hypertension |

| |Ischemic heart disease/Myocardial infarction |

| |Ischemic cardiomyopathy |

| |Congenital heart disease |

| |Valvular heart disease. |

| | |

| |7.3 Does the study requires any investigations or interventions to be conducted on patients or other humans or animals ? If so please |

| |describe briefly. |

| | |

| |Yes, the study involves the following investigation/ interventions on the patients. |

| | |

| |1.Blood—Hbg%, TC, DC, Blood Urea, RBS, Serum Creatinine. |

| |2.. Chest Xray. |

| |3. ECG. |

| |4. Echocardiography with colour Doppler. |

| | |

| | |

| |7.4 Has ethical clearance been obtained from your Institution in case of 7.3 ? |

| |YES, Ethical clearance has been obtained from VIMS INSTITUTIONAL ETHICS COMMITTEE, Bellary. |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |8 REFERENCES : |

| | |

| |Braunwald’s heart disease. A text book of cardiovascular medicine 9th edition. |

| |Echocardiography – Harvey feigenbaum 5th edition. |

| |Levy D. Prognostic implication of echocardiographically determined left ventricular mass in the Framingham heart study. N Engl J med 1990; |

| |322: 1561-6. |

| |Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison’s Principles of Internal Medicine. 18 edition, vol. 2: McGraw Hill, 2008; 1552. |

| |McLenachen JM, Dargie HJ. Ventricular in hypertensive arrhythmias LVH: Am J Hypertens 1990; 3: 735-40. |

| |Ghali JK,Kadakia S, Cooper R. Impact of LVH on ventricular arrhythmias in the absence of coronary artery disease. J Am Coll Cardiol 1992; 19:|

| |1277-82. |

| |Szlachcic J, Tubau JF, O’KellyB. What is the role of silent coronary artery disease and LVH in the genesis of ventricular arrhythmias in men |

| |with essential hypertension? J Am Coll Cardiol 1992; 19: 803-8. |

| |Casale PN, Devereux RB, Milner M. Value of echocardiographic measurements of |

| |LV mass in predicting cardiovascular morbid events in hypertensive men. Ann Intern med 1986; 105: 173-8. |

| |Levy D, Garrison RH, Savage DD. Prognostic implications of echocardiographically determined LV mass in The Framingham Heart Study. N Engl J |

| |Med 1990; 322: 1561-6. |

| |William J. Ettiott, Wayne Alexander. The pathophysiologic of systemic arterial hypertension. In: Hurst’s The Heart, 11th edition, vol. 2. |

| |McGraw-Hill Companies, 2004; 1533-7, 1543. |

| |Nathaniel Reichek, Richard B. Devereux. Left ventricular hypertrophy relationship of anatomic, echocardiographic, electrocardiographic |

| |findings. Circulation 1981; 83: |

| | |

| |Leo Schamroth- Introduction to Electrocardiography, 7th edition, 67-77. |

| | |

| |Romhilt DW, Estes EH. A point score system for ECG diagnosis of LVH. Am Heart J 1968; 75: 752. |

| |Dennis M Krikler. Historical aspect of ECG. Cardiol Clin 5 (3): 349-55. |

| |Ivan AD, Cruz. Left Ventricular Hypertrophy. In: Text Book of ECHO anatomy, Appleton and Lange USA, 1995; 355-80. |

| |Braunwald Ziper, Libby. A textbook of Cardiovascular Medicine, 8th ed, W. B Saunders Company, 2008; 949. |

| | | |

|9 |Signature of the candidate : | |

| | |RECOMMENDED AND FORWARDED |

|10 |Remarks of the guide : | |

| | | |

|11 |Name and Designation of : |DR.GADWALKAR SRIKANT.R |

| |( In Block Letters) |Department of GENERAL MEDICINE, |

| |11.1 Guide: |VIMS, Bellary. |

| | | |

| |11.2 Signature | |

| | | |

| |11.3 Co – Guide, if any | |

| | | |

| |11.4 Signature | |

| | | |

| |11.5 Head of the Department |DR.GADWALKAR SRIKANT.R |

| | |Professor and Head of the Department, |

| | |Department of GENERAL MEDICINE, |

| | |VIMS, Bellary. |

| | | |

| |11.6 Signature | |

| |12.1 Remarks of Chairman and Principal | |

|12 | | |

| | | |

| |12.2 Signature | |

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