Optimized electrocardiographic criteria for the detection of left ventricular hypertrophy in obesity patients

Are Electrocardiographic Criteria Reliable for Left Ventricular Hypertrophy Detection in Indian Adults?

BACKGROUND

Left ventricular hypertrophy (LVH) detection is vital to the risk stratification of adults at risk of adverse cardiovascular events such as coronary heart disease, cerebrovascular disease, and aortic aneurysms. Electrocardiogram (ECG), a non-invasive, cost-effective instrument has been widely used as a screening tool for LVH. The objective of this study was to determine the diagnostic accuracy of seven frequently used ECG criteria in high-risk Indian adults in comparison with echocardiography.

METHODS

ECG and transthoracic echocardiography were performed in adults older than 18 years with at least one cardiac risk factor (chronic hypertension, obesity, ischemic heart disease, and type 2 diabetes mellitus). Precision and accuracy were calculated for the various ECG criteria against LVH based on left ventricular mass index (LVMI) and cardiac remodeling by echocardiography.

RESULTS

A total of 220 participants were enrolled. Of these, 96 had LVH by echocardiography. There was marked variability in LVH detection by the different ECG criteria: 28 by Sokolow-Lyon criteria, 26 by Cornell criteria, 24 by Lewis criteria, 46 by Scott criteria, eight by Romhilt-Estes criteria, six by Modified Cornell criteria, and only two by Roberts criteria. Agreement statistics between ECG criteria and LVMI showed that none of them had a good agreement for LVH detection.

CONCLUSION

None of the ECG criteria were sensitive enough to rule out ventricular hypertrophy. In the context of cardiac remodeling, the ECG criteria had high sensitivity but low specificity and, hence, limited clinical relevance.

Evaluation of Different Criteria in the Diagnosis of Left Ventricular Hypertrophy by Electrocardiogram in Comparison With Echocardiogram

Left ventricular hypertrophy (LVH) is an adaptive mechanism of the cardiac muscle due to increased activity demand or functional overload. The echocardiogram (ECHO) presents a better performance in relation to the electrocardiogram (ECG) for the diagnosis of LVH. However, the ECG is a low-cost and easy-to-reproduce diagnostic alternative and can be useful in services and locations where the ECHO is not yet easily accessible. Recently, a new criterion for LVH was proposed by Peguero-Lo Presti. The aim of this article was to evaluate the electrocardiographic criteria for the diagnosis of LVH (Sokolow-Lyon, Cornell voltage, Romhilt-Estes, and Peguero-Lo Presti) in comparison to the diagnosis made by the ECHO. ECHO and ECG from 142 patients' medical records were analyzed. Patients were divided into three groups according to the ECHO - control, eccentric LVH, and concentric LVH. Sensitivity, specificity, PPV, NPV, and accuracy of the four electrocardiographic criteria were evaluated in three scenarios - (1) LVH vs control, (2) concentric LVH vs control, and (3) eccentric LVH vs control. Of the 142 patients included in the study, 100 (70.4%) had LVH. According to the type of hypertrophy, the 100 patients with LVH were divided into two groups - 41 (28.8%) had eccentric LVH and 59 (41.5%) had concentric LVH. Of all the scenarios, the Peguero-Lo Presti criteria obtained the best sensitivity (1, 41%; 2, 33,9%; 3, 51,2%) and accuracy (1, 56,3%; 2, 58,4%; 3, 69,8%). The Sokolow-Lyon criteria showed greater specificity in all analyses (100%). None of the electrocardiographic criteria obtained sensitivity values ​​that would justify the use of the electrocardiogram as a screening test for LVH. No differences were found for eccentric and concentric LVH in terms of diagnosis using electrocardiographic criteria. We recommend the use of these criteria to confirm the diagnosis of LVH, especially in low-complexity services that do not have image-based diagnostic tests.

Diagnostic Ability of Peguero-Lo Presti Electrocardiographic Left Ventricular Hypertrophy Criterion in Severe Aortic Stenosis

Traditional electrocardiographic (ECG) criteria for left ventricular hypertrophy (LVH), introduced in the pre-echocardiographic era of diagnosis, have a relatively low sensitivity (usually not exceeding 25–40%) in detecting LVH. A novel Peguero-Lo Presti ECG-LVH criterion was recently shown to exhibit a higher sensitivity than the traditional ECG-LVH criteria in hypertension. Our aim was to test the diagnostic ability of the novel Peguero-Lo Presti ECG-LVH criterion in severe aortic stenosis. We retrospectively analyzed 12-lead ECG tracings and echocardiographic records from the index hospitalization of 50 patients with isolated severe aortic stenosis (mean age: 77 ± 10 years; 30 women and 20 men). Exclusion criteria included QRS > 120 ms, bundle branch blocks or left anterior fascicular block, a history of myocardial infarction, more than mild aortic or mitral regurgitation, and significant LV dysfunction by echocardiography. We compared the agreement of the novel Peguero-Lo Presti criterion and traditional ECG-LVH criteria with echocardiographic LVH (LV mass index > 95 g/m² in women and >115 g/m² in men). Echocardiographic LVH was found in 32 out of 50 study patients. The sensitivity of the Peguero-Lo Presti criterion in detecting LVH was improved (55% vs. 9–34%) at lower specificity (72% vs. 78–100%) in comparison to 8 single traditional ECG-LVH criteria. Additionally, the positive predictive value (77% vs. 72%), positive likelihood ratio (2.0 vs. 1.5), and odds ratio (3.2 vs. 2.4) were higher for the Peguero-Lo Presti criterion versus the presence of any of these 8 traditional ECG-LVH criteria. Cohen’s Kappa, a measure of concordance between ECG and echocardiography with regard to LVH, was 0.24 for the Peguero-Lo Presti criterion, −0.01–0.13 for single traditional criteria, and 0.20 for any traditional criterion. However, by the receiver operating characteristics (ROC) curve analysis, the overall ability to discriminate between patients with and without LVH was insignificantly lower for the Peguero-Lo Presti versus Cornell voltage as a continuous variable (area under the ROC curve: 0.65 (95% CI, 0.48–0.81) vs. 0.71 (0.55–0.86), p = 0.5). In conclusion, our preliminary results suggest a slightly better, albeit still low, agreement of the novel Peguero-Lo Presti ECG criterion compared to the traditional ECG-LVH criteria with echocardiographic LVH in severe aortic stenosis.

Clinical applicability and diagnostic performance of electrocardiographic criteria for left ventricular hypertrophy diagnosis in older adults

Recently, a new ECG criterion, the Peguero-Lo Presti (PLP), improved overall accuracy in the diagnosis of left ventricular hypertrophy (LVH)—compared to traditional ECG criteria, but with few patients with advanced age. We analyzed patients with older age and examined which ECG criteria would have better overall performance. A total of 592 patients were included (83.1% with hypertension, mean age of 77.5 years) and the PLP criterion was compared against Cornell voltage (CV), Sokolow-Lyon voltage (SL) and Romhilt-Estes criteria (cutoffs of 4 and 5 points, RE4 and RE5, respectively) using LVH defined by the echocardiogram as the gold standard. The PLP had higher AUC than the CV, RE and SL (respectively, 0.70 vs 0.66 vs 0.64 vs 0.67), increased sensitivity compared with the SL, CV and RE5 (respectively, 51.9% [95% CI 45.4–58.3%] vs 28.2% [95% CI 22.6–34.4%], p < 0.0001; vs 35.3% [95% CI 29.2–41.7%], p < 0.0001; vs 44.4% [95% CI 38.0–50.9%], p = 0.042), highest F1 score (58.3%) and net benefit for most of the 20–60% threshold range in the decision curve analysis. Overall, despite the best diagnostic performance in older patients, the PLP criterion cannot rule out LVH consistently but can potentially be used to guide clinical decision for echocardiogram ordering in low-resource settings.

Peguero-Lo Presti criteria for the diagnosis of left ventricular hypertrophy: A systematic review and meta-analysis

Background

The Peguero-Lo Presti criteria are novel electrocardiographic (ECG) diagnostic criteria for the detection of left ventricular hypertrophy (LVH) and represent the sum of the amplitude of the deepest S wave in any lead with the S wave in lead V₄ (S_D+SV₄). The diagnostic efficacy of the Peguero-Lo Presti criteria in LVH is still debatable. We aimed to test the sensitivity and specificity of the Peguero-Lo Presti criteria and compared them with those of the Cornell voltage index to assess their overall performance in LVH diagnosis.

Methods

Electronic databases (e.g., Medline, Web of Knowledge, Embase, and the Cochrane Library) were searched from their inception until May 18, 2020. Trials written in English that investigated the Peguero-Lo Presti criteria for detecting LVH were included. Data were independently extracted and analyzed by two investigators.

Results

A total of 51 records were screened, and 6 trials comprising 13,564 patients were finally included. A bivariate analysis showed that the sensitivity of the Peguero-Lo Presti criteria (0.52, 95% confidence interval (CI) 0.46–0.58) was higher than that of the Cornell voltage index (0.29, 95% CI 0.23–0.36) and Sokolow-Lyon criteria (0.24, 95% CI 0.21–0.27); the diagnostic accuracy of the Peguero-Lo Presti criteria (0.69, 95% CI 0.65–0.73) was also higher than that of the Cornell voltage index (0.67, 95% CI 0.62–0.71) and Sokolow-Lyon criteria (0.28, 95% CI 0.25–0.32); and the specificity of the Peguero-Lo Presti criteria (0.85, 95% CI 0.79–0.90) was similar to that of the Cornell voltage index (0.92, 95% CI 0.89–0.95) and Sokolow-Lyon criteria (0.94, 95%CI 0.88–0.97). Two trials (including 12,748 patients) were discharged because they included partly healthy subjects and accounted for substantial heterogeneity. Pooled analysis of the remaining 4 trials (including 816 patients) showed that the sensitivity of the Peguero-Lo Presti criteria (0.56, 95% CI 0.51–0.61) was also higher than that of the Cornell voltage index (0.36, 95% CI 0.31–0.42) and Sokolow-Lyon criteria (0.24, 95% CI 0.18–0.31); the diagnostic accuracy of the Peguero-Lo Presti criteria (0.84, 95% CI 0.80–0.87) was also higher than that of the Cornell voltage index (0.54, 95% CI 0.50–0.58) and Sokolow-Lyon criteria (0.38, 95% CI 0.34–0.42); and the specificity of the Peguero-Lo Presti criteria (0.90, 95% CI 0.87–0.92) was similar to that of the Cornell voltage index (0.93, 95% CI 0.88–0.96) and Sokolow-Lyon criteria (0.97, 95% CI 0.90–0.99). Both the likelihood ratio and posttest probability of the Peguero-Lo Presti criteria and Cornell voltage index were moderate.

Conclusion

Based on this systematic review and meta-analysis, the Peguero-Lo Presti criteria-based ECG diagnostic method for LVH has high sensitivity, specificity and diagnostic accuracy and should be applied in clinical practice settings.

Electrocardiographic Risk Markers for Heart Failure in Women Versus Men

Heart failure (HF) is one of the leading causes of hospitalization in the Western world. Women have a lower HF hospitalization rate and mortality compared with men. The role of electrocardiography as a risk marker of future HF in women is not well known. We studied association of electrocardiographic (ECG) risk factors for HF hospitalization in women from a large middle-aged general population with a long-term follow-up and compared the risk profile to men. Standard 12-lead ECG markers were analyzed from 10,864 subjects (49% women), and their predictive value for HF hospitalization was analyzed. During the follow-up (30 ± 11 years), a total of 1,743 subjects had HF hospitalization; of these, 861 were women (49%). Several baseline characteristics, such as age, body mass index, blood pressure, and history of previous cardiac disease predicted the occurrence of HF both in women and men (p <0.001 for all). After adjusting for baseline variables, ECG sign of left ventricular hypertrophy (LVH) (p <0.001), and atrial fibrillation (p <0.001) were the only baseline ECG variables that predicted future HF in women. In men, HF was predicted by fast heart rate (p = 0.008), T wave inversions (p <0.001), abnormal Q-waves (p = 0.002), and atrial fibrillation (p <0.001). Statistically significant gender interactions in prediction of HF were observed in ECG sign of LVH, inferolateral T wave inversions, and heart rate. In conclusion, ECG sign of LVH predicts future HF in middle-aged women, and T wave inversions and elevated heart rate are associated with HF hospitalization in men.

Prognostic significance of body mass index-adjusted criteria for left ventricular hypertrophy

Electrocardiographic left ventricular hypertrophy (ECG-LVH) is associated with both cardiovascular and all-cause mortality. Obesity attenuates the sensitivity of several ECG-LVH criteria, so body mass index (BMI) adjusted criteria have been developed. However, the prognostic significance of BMI-adjusted ECG-LVH criteria is not known. This analysis included 7812 participants (59.8 ± 13.4 years, 53% women, 50% non-Hispanic-whites) from the Third National Health and Nutrition Examination Survey. The Cornell criteria (R in aVL + S in V3 ≥ 2800 µV in men or ≥2200 µV in women) and Sokolow-Lyon criteria (S in V1 + R in V5 or R in V6 ≥ 3500 µV) criteria were used for LVH. To account for the effects of obesity, the BMI-adjusted Cornell criteria (product of R in aVL + S in V3 and BMI > 60 400 µV kg m^-2 ) and the BMI-adjusted Sokolow-Lyon criteria (add 400 µV if overweight, add 800 µV if obese) were used. Compared to traditional ECG-LVH criteria, more participants met criteria for ECG-LVH with BMI-adjusted Cornell voltage (9.9% vs 2.9%) and BMI-adjusted Sokolow-Lyon (13.1% vs 6.4%) criteria. In multivariable-adjusted Cox proportional hazards models, the BMI-adjusted Sokolow-Lyon criteria performed no better than traditional criteria (HR 1.18, 95% CI 1.06-1.32 for all-cause, HR 1.38, 95% CI 1.17-1.62 for cardiovascular mortality) and the BMI-adjusted Cornell voltage criteria attenuated the association with all-cause (HR 1.16, 95% CI 1.03-1.32) and cardiovascular mortality (HR 1.34, 95% CI 1.13-1.60). Despite potential improvements in the detection of LVH using BMI-adjusted ECG-LVH criteria, adjusting for BMI may result in the loss of prognostic information.

Optimized electrocardiographic criteria for the detection of left ventricular hypertrophy in obesity patients

Background

Despite a generally high specificity, electrocardiographic (ECG) criteria for the detection of left ventricular hypertrophy (LVH) lack sensitivity, particularly in obesity patients.

Objectives

The aim of the study was to evaluate the accuracy of the most commonly used ECG criteria (Cornell voltage and Sokolow‐Lyon index), the recently introduced Peguero‐Lo Presti criteria and the correction of these criteria by body mass index (BMI) to detect LVH in obesity patients and to propose adjusted ECG criteria with optimal accuracy.

Methods

The accuracy of the ECG criteria for the detection of LVH was retrospectively tested in a cohort of obesity patients referred for a transthoracic echocardiogram based on clinical grounds (test cohort, n = 167). Adjusted ECG criteria with optimal sensitivity for the detection of LVH were developed. Subsequently, the value of these criteria was prospectively tested in an obese population without known cardiovascular disease (validation cohort, n = 100).

Results

Established ECG criteria had a poor sensitivity in obesity patients in both the test cohort and the validation cohort. The adjusted criteria showed improved sensitivity, with optimal values for males using the Cornell voltage corrected for BMI, (RaVL+SV3)*BMI ≥700 mm*kg/m²; sensitivity 47% test cohort, 40% validation cohort; for females, the Sokolow‐Lyon index corrected for BMI, (SV1 + RV5/RV6)*BMI ≥885 mm*kg/m²; sensitivity 26% test cohort, 23% validation cohort.

Conclusions

Established ECG criteria for the detection of LVH lack sufficient sensitivity in obesity patients. We propose new criteria for the detection of LVH in obesity patients with improved sensitivity, approaching known sensitivity of the most commonly used ECG criteria in lean subjects.