Management of EKG Findings in Adult Males with Borderline Abnormalities

Immediate Clinical Assessment

The European Society of Cardiology recommends that adult males with borderline EKG findings, such as left axis deviation, abnormal R-wave progression, and inferior T-wave abnormalities, should undergo cardiac evaluation with echocardiography and comparison to prior EKGs, as these patterns may represent early markers of structural heart disease or coronary artery disease 1, 2.
If the patient has symptoms such as chest pain, dyspnea, or syncope, they should be treated as potential acute coronary syndrome with immediate emergency department evaluation, 12-lead EKG, cardiac biomarkers, and risk stratification within 10 minutes 3.
Asymptomatic patients should proceed with systematic outpatient evaluation, though the combination of findings warrants timely assessment rather than routine follow-up 1, 4.

The American College of Cardiology states that left axis deviation between -30° and -45° is considered moderate and may indicate left anterior fascicular block, which often reflects underlying structural heart disease 5.
The European Heart Journal notes that isolated left axis deviation without other abnormalities may not require investigation in athletes if family history is negative, but when combined with other EKG abnormalities, it increases concern for pathology 1, 4, 5.
Early transition (R>S before V3) combined with poor R-wave progression constitutes a high-risk pattern highly indicative of cardiac disease, particularly left anterior descending coronary artery stenosis 2, 3.

The European Society of Cardiology recommends that transthoracic echocardiography is essential to assess left ventricular wall motion abnormalities, regional wall motion suggesting prior infarction, left ventricular hypertrophy, chamber dimensions, and ejection fraction 1, 2, 3.
Echocardiography can distinguish physiologic from pathologic left ventricular hypertrophy, according to the European Heart Journal 1.
Measuring troponin is necessary to exclude acute myocardial infarction, particularly if any symptoms are present, as recommended by the American College of Cardiology 2, 7.

The Journal of the American College of Cardiology advises that the term "borderline" does not mean benign—these findings require evaluation, and T-wave abnormalities may represent the only sign of inherited cardiomyopathy before structural changes become evident 3, 4, 6.
Abnormal EKG repolarization may identify subjects at risk for subsequent development of structural heart disease that may not be evident until years later, according to the European Heart Journal 4.

The American College of Cardiology recommends that serial EKGs and cardiac imaging are necessary to monitor for development of cardiomyopathy phenotype, and annual echocardiography is usually sufficient, but other imaging modalities should be used when images are suboptimal 3, 4, 7.
Continuing clinical surveillance with attention to development of symptoms is crucial, as emphasized by the European Society of Cardiology 3, 4.