Electrocardiographic parameters of left ventricular hypertrophy and prediction of mortality in hemodialysis patients

The prevalence and risk of mortality associated with intradialytic hypertension among patients with end-stage kidney disease on haemodialysis: A systematic review and meta-analysis

INTRODUCTION

Intradialytic hypertension (IDHTN) is a common but less frequently recognised complication of haemodialysis. However, it is associated with increased overall mortality in patients on haemodialysis. This systematic review and meta-analysis aimed to determine the prevalence of IDHTN and associated mortality risk in the global haemodialysis population.

METHOD

A systematic search of PubMed and EMBASE was undertaken to identify articles with relevant data published between 1990 and 2023. The pooled prevalence of IDHTN in the global haemodialysis population was determined using the DerSimonian-Laird random-effects meta-analysis. The pooled hazards ratio for mortality in patients with IDHTN was also computed from the studies that reported mortality among haemodialysis patients with IDHTN. The study protocol was registered with PROSPERO (CRD42023388278).

RESULTS

Thirty-two articles from 17 countries were included, with a pooled population of 127,080 hemodialysis patients (median age 55.1 years, 38.2% females). Most studies had medium methodological quality (53.1%, n = 17). The overall pooled prevalence of IDHTN was 26.6% [(95% CI 20.2-33.4%), n = 27 studies, I2 = 99.3%, p<0.001 for heterogeneity], with significant differences depending on the definition used. The pooled proportion of haemodialysis sessions with IDHTN was 19.9% [(95% 12.5-28.6%, n = 8 studies, I2 = 99.3%, p<0.001 for heterogeneity)] with significant differences across the different definition criteria. The p-value for the Begg test was 0.85. The median pre-dialysis blood pressure was not significantly associated with IDHTN. The pooled hazard ratio for mortality was 1.37 (95% CI 1.09-1.65), n = 5 studies, I2 = 13.7%, and p-value for heterogeneity = 0.33.

CONCLUSION

The prevalence of IDHTN is high and varies widely according to the definition used. A consensus definition of IDHTN is needed to promote uniformity in research and management. The increased mortality risk forecasted by IDHTN highlights the need for optimal blood pressure control in patients on hemodialysis.

Do We Need New Electrocardiographic Criteria for Left Ventricular Hypertrophy? The Case of the Peguero-Lo Presti Criterion. A Narrative Review

The cardiovascular risk associated with left ventricular hypertrophy (LVH) in the community and, particularly, in the hypertensive fraction of the general population, represents the rationale for its timely and accurate identification in order to implement adequate preventive strategies. Although electrocardiography (ECG) is the first-line and most economical method of diagnosing LVH its accuracy is largely suboptimal. Over the last 70 years, dozens of different ECG criteria, mostly based on measurements of QRS voltages, have been proposed. In this long journey, a few years ago Peguero et al. developed a novel ECG voltage criterion, currently recognized as Peguero-Lo Presti (PLP) suggesting that it has greater sensitivity than traditional ECG-LVH criteria. Considering that in the last 5 years numerous studies have investigated the diagnostic value of this new index, this review aimed to summarize the data published so far on this topic focusing both on the accuracy in identifying the presence of LVH compared with imaging techniques such as echocardiography (ECHO) and magnetic resonance imaging (MRI) and the value in predicting hard outcomes. The evidence in favor of the greater diagnostic accuracy of the PLP criterion in detecting LVH, phenotyped by ECHO or MRI, and in the stratification of hard outcomes compared with traditional ECG criteria does not appear to be sufficiently proven. Given that the diagnosis of LVH by all ECG criteria (including the PLP) exclusively based on the QRS amplitude is largely imprecise, the development of new multiparametric ECG criteria based on artificial intelligence could represent a real improvement in the diagnostic capacity of the ECG.

Automatic ECG-based detection of left ventricular hypertrophy and its predictive value in haemodialysis patients

Objective.Left ventricular hypertrophy (LVH) is one of the most severe risk factors in patients with end-stage kidney disease (ESKD) regarding all-cause and cardiovascular mortality. It contributes to the risk of sudden cardiac death which accounts for approximately 25% of deaths in ESKD patients. Electrocardiography (ECG) is the least expensive way to assess whether a patient has LVH, but manual annotation is cumbersome. Thus, an automated approach has been developed to derive ECG-based LVH parameters. The aim of the current study is to compare automatic to manual measurements and to investigate their predictive value for cardiovascular and all-cause mortality.Approach.From the 12-lead 24 h ECG measurements of 301 ESKD patients undergoing haemodialysis, three different LVH parameters were calculated. Peguero-Lo Presti voltage, Cornell voltage, and Sokolow-Lyon voltage were automatically derived and compared to the manual annotations. To determine the agreement between manual and automatic measurements and their predictive value, Bland-Altman plots were created and Cox regression analysis for cardiovascular and all-cause mortality was performed.Main results.The median values for the automatic assessment were: Peguero-Lo Presti voltage 1.76 mV (IQR 1.29-2.55), Cornell voltage 1.14 mV (IQR 0.721-1.66), and Sokolow-Lyon voltage 1.66 mV (IQR 1.08-2.23). The mean differences when compared to the manual measurements were -0.027 mV (0.21 SD), 0.027 mV (0.13 SD) and -0.025 mV (0.24 SD) for Peguero-Lo Presti, Cornell, and Sokolow-Lyon voltage, respectively. The categorial LVH detection based on pre-defined thresholds differed in only 13 cases for all indices between manual and automatic assessment. Proportional hazard ratios only differed slightly in categorial LVH detection between manually and automatically determined LVH parameters; no differences could be found for continuous parameters.Significance.This study provides evidence that automatic algorithms can be as reliable in LVH parameter assessment and risk prediction as manual measurements in ESKD patients undergoing haemodialysis.

Prognostic values of left ventricular mass index progression in incident peritoneal dialysis patients : a prospective cohort study

BACKGROUND

Left ventricular hypertrophy (LVH) is common among patients undergoing dialysis. However, the dynamic structural changes of LV are rarely discussed. The study aimed to investigate the prognostic significance of left ventricular mass index (LVMI)-progression in incident peritoneal dialysis (PD) patients, and explore risks factors for LVMI-progression.

METHODS

Incident PD patients between February 2008 and July 2018 were recruited. Echocardiography was performed yearly to collect LVMI and evaluate its changes. Participants were divided into three subgroups: group with LVMI-regression, group with LVMI stable and group with LVMI-progression. The end points include all-cause mortality, cardiovascular mortality and cardiovascular events. Cox regression models were performed to identify the associations between LVMI-progression and these endpoints. Multivariate logistic regression was conducted to identify risk factors for LVMI-progression.

RESULTS

A total of 216 PD patients (130 men,60.2%) with a mean age of 54.3 ± 16.8 years were recruited. LVMI-progression was identified in 72 patients (33.3%) after PD initiation. The cohort was followed for a median duration of 65.9 months. Multivariable Cox regression analysis revealed that LVMI-progression was an independent predictor of all-cause mortality (HR, 1.419; 95% CI, 1.016-1.982; p = 0.040), cardiovascular mortality (HR, 1.836; 95%CI, 1.084-3.108; p = 0.024), and cardiovascular events (HR, 1.494; 95%CI, 1.063-2.099; p = 0.021). Multivariable logistic regression showed that hemoglobin, ferritin, blood pressure and fibrinogen were significantly associated with LVMI-progression.

CONCLUSION

Early LVMI-progression was independently associated with all-cause mortality and cardiovascular outcomes in PD patients. The dynamic monitoring of LVMI might therefore help identify high-risk patients.