Electrocardiographic identification of increased left ventricular mass by simple voltage-duration products

Malignant left ventricular hypertrophy and risk of cognitive impairment in SPRINT MIND trial

BACKGROUND

The association of malignant left ventricular hypertrophy (LVH), a specific subphenotype of LVH characterized by elevated levels of high-sensitivity cardiac troponin (hs-cTnT) or N-terminal pro-B-type natriuretic peptide (NT-proBNP), with cognitive decline remains understudied.

METHODS

This post-hoc analysis included a total of 8,027 (67.9 ± 9.3 years) SPRINT MIND trial participants who had with at least 1 follow-up cognitive assessment. Participants were classified into 6 groups on the basis of LVH status on electrocardiogram (ECG), and elevations in levels of hs-cTnT ≥14 ng/L or NT-proBNP ≥125 pg/mL at baseline visit. Multivariate Cox proportional hazard models were used to examine the association of LVH/biomarker groups with incident probable dementia, mild cognitive impairment (MCI) and a composite of MCI/probable dementia.

RESULTS

Over a median follow-up period of 5 years, there were 306, 597, and 818 incidents of MCI, probable dementia and a composite of MCI/probable dementia, respectively. Compared with participants without LVH and normal biomarker levels, those with concomitant LVH and elevated levels of both biomarkers were associated with a higher risk of probable dementia (HR, 2.50; 95% CI (1.26-4.95), MCI (HR, 1.78; 95% CI (0.99-3.23) and the composite of MCI/ probable dementia (HR, 1.89; 95% CI, 1.16-3.10).

CONCLUSIONS

Among SPRINT participants, malignant LVH is associated with incident probable dementia and mild cognitive impairment. These findings underscore the potential utility of measuring hs-cTnT and NT-proBNP levels when LVH is detected on ECG, aiding in the differentiation of individuals with a favorable risk for cognitive impairment from those with a higher risk.

Searching for the Best Machine Learning Algorithm for the Detection of Left Ventricular Hypertrophy from the ECG: A Review

Background: Left ventricular hypertrophy (LVH) is a powerful predictor of future cardiovascular events. Objectives: The objectives of this study were to conduct a systematic review of machine learning (ML) algorithms for the identification of LVH and compare them with respect to the classical features of test sensitivity, specificity, accuracy, ROC and the traditional ECG criteria for LVH. Methods: A search string was constructed with the operators "left ventricular hypertrophy, electrocardiogram" AND machine learning; then, Medline and PubMed were systematically searched. Results: There were 14 studies that examined the detection of LVH utilizing the ECG and utilized at least one ML approach. ML approaches encompassed support vector machines, logistic regression, Random Forest, GLMNet, Gradient Boosting Machine, XGBoost, AdaBoost, ensemble neural networks, convolutional neural networks, deep neural networks and a back-propagation neural network. Sensitivity ranged from 0.29 to 0.966 and specificity ranged from 0.53 to 0.99. A comparison with the classical ECG criteria for LVH was performed in nine studies. ML algorithms were universally more sensitive than the Cornell voltage, Cornell product, Sokolow-Lyons or Romhilt-Estes criteria. However, none of the ML algorithms had meaningfully better specificity, and four were worse. Many of the ML algorithms included a large number of clinical (age, sex, height, weight), laboratory and detailed ECG waveform data (P, QRS and T wave), making them difficult to utilize in a clinical screening situation. Conclusions: There are over a dozen different ML algorithms for the detection of LVH on a 12-lead ECG that use various ECG signal analyses and/or the inclusion of clinical and laboratory variables. Most improved in terms of sensitivity, but most also failed to outperform specificity compared to the classic ECG criteria. ML algorithms should be compared or tested on the same (standard) database.

Electrocardiographic manifestations in female team handball players: analyzing ECG changes in athletes

Introduction

Long-term intense training leads to structural, functional, and electrical remodeling of the heart. How different sports affect the heart has not been fully investigated, particularly for female athletes. The aim of the present study was to investigate the morphology of 12-lead resting electrocardiogram (ECG) in elite female handball players compared to non-athlete female subjects. Potential changes will be explored to see if they could be explained by differences in cardiac dimensions and exercise hours.

Materials and methods

A cross-sectional study of 33 elite female team handball players compared to 33 sex and age-matched, non-athletic controls (age range 18-26 years) was performed. All participants underwent a resting 12-lead ECG and an echocardiographic examination. ECG variables for left ventricular hypertrophy and durations were evaluated and adjusted for cardiac dimensions and exercise hours using ANCOVA analysis. A linear regression analysis was used to describe relation between echocardiographic and ECG measures and exercise hours.

Results

The female handball players had larger cardiac dimensions and significantly lower heart rate and QTc duration (Bazett's formula) as well as increased QRS and QT durations compared to controls. The 12-lead sum of voltage and the 12-lead sum of voltage ∗ QRS were significantly higher among handball players. Changes in ECG variables reflecting the left ventricle could in part be explained by left ventricular size and exercise hours. Correlation with exercise hours were moderately strong in most of the echocardiographic measures reflecting left ventricular (LV), left ventricular mass (LVM), left atrium (LA) and right atrium (RA) size. Poor to fair correlations were seen in the majority of ECG measures.

Conclusions

Female team handball players had altered ECGs, longer QRS and QT durations, higher 12-lead sum of voltage and 12-lead sum of voltage ∗ QRS as well as shorter QTc (Bazett's formula) duration compared to non-athletic controls. These findings could only partly be explained by differences in left ventricular size. Despite larger atrial size in the athletes, no differences in P-wave amplitude and duration were found on ECG. This suggest that both structural, and to some degree electrical remodeling, occur in the female team handball players' heart and highlight that a normal ECG does not rule out structural adaptations. The present study adds knowledge to the field of sports cardiology regarding how the heart in female team handball players adapts to this type of sport.

Factors associated with electrocardiographic left ventricular hypertrophy among patients with hypertension in Thailand

BACKGROUND

Left ventricular hypertrophy (LVH) strongly predicts cardiovascular diseases (CVD) and death. One-fourth of Thai adults suffer from hypertension. Nevertheless, the information on LVH among Thai patients with hypertension is not well characterized. We aimed to identify the prevalence and factors associated with electrocardiographic LVH (ECG-LVH) among patients with hypertension in Thailand.

METHODS

The present study obtained the dataset from the Thailand Diabetes Mellitus/Hypertension study, which included hypertension patients aged 20 years and older receiving continuous care at outpatient clinics in hospitals nationwide in 2011-2015 and 2018. Meanwhile, those without a record of 12-lead electrocardiography (ECG) were excluded from the analysis. ECG-LVH was defined as the LVH noted regarding ECG interpretation in the medical records. Multivariable logistic regression analysis was utilized for determining factors associated with ECG-LVH and presented as the adjusted odds ratio (AOR) and 95% confidence interval (CI).

RESULTS

From 226,420 hypertensive patients in the Thailand Diabetes Mellitus/Hypertension study, 38,807 individuals (17.1%) with ECG data recorded were included in the analysis. The mean age was 64.8 ± 11.5 years, and 62.2% were women. Overall, 1,557 study participants had ECG-LVH, with an estimated prevalence of 4.0% (95% CI, 3.8-4.2%). Age-adjusted ECG-LVH prevalence among women and men was 3.4 and 5.1%, respectively (P < 0.001). Multivariable analysis determined factors associated with ECG-LVH, including being men (AOR, 1.49; 95% CI, 1.31-1.69), individuals aged 70 to 79 years (AOR, 1.56; 95% CI, 1.20-2.02) and ≥ 80 years (AOR, 2.10; 95% CI, 1.58-2.78) compared to individuals aged less than 50 years, current smokers (AOR, 1.26; 95% CI, 1.09-1.46) compared to those who never smoked, systolic blood pressure ≥ 140 mmHg and diastolic blood pressure ≥ 90 mmHg (AOR, 1.58; 95% CI, 1.30-1.92) compared to systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg.

CONCLUSIONS

The current study illustrated the prevalence of ECG-LVH among Thai patients with hypertension who had ECG recorded and identified high-risk groups who tended to have ECG-LVH. The findings underscore the need for targeted interventions, particularly among high-risk groups such as older individuals, men, and current smokers, to address modifiable factors associated with ECG-LVH.

Pediatric ECG-Based Deep Learning to Predict Left Ventricular Dysfunction and Remodeling

BACKGROUND

Artificial intelligence-enhanced ECG analysis shows promise to detect ventricular dysfunction and remodeling in adult populations. However, its application to pediatric populations remains underexplored.

METHODS

A convolutional neural network was trained on paired ECG-echocardiograms (≤2 days apart) from patients ≤18 years of age without major congenital heart disease to detect human expert-classified greater than mild left ventricular (LV) dysfunction, hypertrophy, and dilation (individually and as a composite outcome). Model performance was evaluated on single ECG-echocardiogram pairs per patient at Boston Children's Hospital and externally at Mount Sinai Hospital using area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC).

RESULTS

The training cohort comprised 92 377 ECG-echocardiogram pairs (46 261 patients; median age, 8.2 years). Test groups included internal testing (12 631 patients; median age, 8.8 years; 4.6% composite outcomes), emergency department (2830 patients; median age, 7.7 years; 10.0% composite outcomes), and external validation (5088 patients; median age, 4.3 years; 6.1% composite outcomes) cohorts. Model performance was similar on internal test and emergency department cohorts, with model predictions of LV hypertrophy outperforming the pediatric cardiologist expert benchmark. Adding age and sex to the model added no benefit to model performance. When using quantitative outcome cutoffs, model performance was similar between internal testing (composite outcome: AUROC, 0.88, AUPRC, 0.43; LV dysfunction: AUROC, 0.92, AUPRC, 0.23; LV hypertrophy: AUROC, 0.88, AUPRC, 0.28; LV dilation: AUROC, 0.91, AUPRC, 0.47) and external validation (composite outcome: AUROC, 0.86, AUPRC, 0.39; LV dysfunction: AUROC, 0.94, AUPRC, 0.32; LV hypertrophy: AUROC, 0.84, AUPRC, 0.25; LV dilation: AUROC, 0.87, AUPRC, 0.33), with composite outcome negative predictive values of 99.0% and 99.2%, respectively. Saliency mapping highlighted ECG components that influenced model predictions (precordial QRS complexes for all outcomes; T waves for LV dysfunction). High-risk ECG features include lateral T-wave inversion (LV dysfunction), deep S waves in V1 and V2 and tall R waves in V6 (LV hypertrophy), and tall R waves in V4 through V6 (LV dilation).

CONCLUSIONS

This externally validated algorithm shows promise to inexpensively screen for LV dysfunction and remodeling in children, which may facilitate improved access to care by democratizing the expertise of pediatric cardiologists.

[Functional methods of amyloid cardiomyopathy diagnostic in practice and in expert centers: A review]

The article is a set of recommendations for the interpretation of electrocardiography and echocardiography data in patients with suspected amyloidosis of the heart. Amyloid cardiomyopathy is a progressive disease characterized by a detailed picture of congestive heart failure, poor quality of life and poor prognosis. Currently, medications have appeared that can improve the prognosis in patients with amyloidosis of the heart. Therefore, raising awareness of specialists about specific instrumental signs of the disease is an important and urgent task.

Modulation of cardiac ventricular conduction: Impact on QRS duration, amplitude and dispersion

Alterations in cardiac impulse conduction may exert both beneficial and detrimental effects. The assessment of ventricular conduction properties is of paramount importance both in clinical and in experimental settings. Currently the duration of the QRS complex is regarded as hallmark of in-vivo assessment of global ventricular conduction time. In addition, the amplitude of the QRS complex has been suggested to reflect ventricular conduction time in man and in rats. Here, for the first time, we systematically investigated the relationship between QRS duration ("QRS") and QRS amplitude ("RS-height"; RSh) in the murine ECG obtained during anesthesia. In mice harbouring a homozygous knockout of the transmembrane protein podoplanin (PDPN-/-; n = 10) we found both a shorter QRS and a greater RSh than in wild-type animals (n = 13). In both genotypes cumulative i.p. administration of 5 mg/kg and 10 mg/kg of the Na channel blocker flecainide resulted in dose-dependent QRS increase and RSh decrease, whereby the drug-induced changes in RSh were greater than in QRS. In both genotypes the flecainide-induced changes in QRS and in RSh were significantly correlated with each other (R = -0.56, P = 0.004). Whereas dispersion of QRS and RSh was similar between genotypes, dispersion of the ratio QRS/RSh was significantly smaller in PDPN-/- than in wild-types. We conclude that in the murine ECG QRS is inversely related to RSh. We suggest that both parameters should be considered in the analysis of ventricular conduction time in the murine ECG.

A Left ventricle remodeling in patients with bicuspid aortic valve

PURPOSE

We assessed the impact of bicuspid aortic valve (BAV), aortic stenosis (AS), and regurgitation (AR) on the metrics of left ventricular (LV) remodeling, as measured by electrocardiogram (ECG), transthoracic echocardiography (TTE), and cardiac magnetic resonance (CMR).

METHODS

This retrospective CMR study included 11 patients with both AS and AR (BAV-ASR), 30 with AS (BAV-AS), 28 with AR (BAV-AR), 47 with neither AS nor AR (BAV-no_AS/AR), and 40 with trileaflet aortic valve (TAV-no_AS/AR). CMR analysis included the LV end-diastolic volume index (LVEDVi), mass index (LVMi), and extracellular volume fraction (ECV). The Sokolow-Lyon and Cornell products by ECG and TTE-derived E/e' were measured.

RESULTS

There were no differences in the ECG, TTE, and CMR parameters between BAV-no_AS/AR and TAV-no_AS/AR. However, the presence of aortic valve dysfunction resulted in an elevated Sokolow-Lyon product for BAV-ASR (p = 0.017) and BAV-AR (p = 0.001), as well as increased Cornell product (p = 0.04) and E/e' (p < 0.001) for BAV-AS compared with BAV-no_AS/AR. LVEDVi and LVMi were elevated in patients with BAV-ASR and BAV-AR compared with those with BAV-no_AS/AR (LVEDVi: 101 ± 29 ml/m² and 112 ± 32 ml/m² vs. 74 ± 15 ml/m², p = 0.005 and p < 0.001, LVMi: 75 ± 7 g/m² and 64 ± 14 g/m² vs. 47 ± 9 g/m², respectively; p < 0.001). There was no difference in ECV between the BAV and TAV-no_AS/AR subgroups.

CONCLUSION

Normally functioning BAV did not result in LV remodeling. However, concomitant AV dysfunction was associated with statistically significant morphological remodeling.

Blood pressure variability and the development of hypertensive organ damage in the general population

Increasing blood pressure variability (BPV) has been reported to be a strong predictor of cardiovascular events in patients with hypertension. However, the effects of BPV in the general population have not been intensively studied. The present study was designed to investigate a possible relationship between year-to-year BPV and hypertensive target organ damage (TOD) in a relatively low-risk general population. A total of 5489 consecutive patients (mean age 58.6 ± 10.7 years) who visited our hospital for an annual physical checkup for five consecutive years during 2008-2013 were enrolled in this study. The average systolic and diastolic blood pressures and pulse pressure were calculated, as well as standard deviation, coefficient of variation, and average real variability in blood pressures. Cross-sectional analysis was conducted and subjects without TOD at baseline (n = 3115) were followed up (median 1827 days) with the endpoint of TOD, defined as left ventricular hypertrophy on electrocardiogram or declining glomerular filtration rate. At baseline, BPV was closely associated with TOD. During follow-up, left ventricular hypertrophy and declining glomerular filtration rate developed in 189 and 400 subjects, respectively. Although the standard deviation for systolic blood pressure and pulse pressure predicted future development of TOD in a univariate analysis, BPV was not a significant determinant of incident TOD in adjusted Cox hazard models. These results suggest that year-to-year BPV is a marker of the presence of TOD in the general population but does not independently predict future TOD.

Utility and pitfalls of the electrocardiogram in the evaluation of cardiac amyloidosis

BACKGROUND

Cardiac amyloidosis is a protein misfolding disorder involving deposition of amyloid fibril proteins in the heart. The associated fibrosis of the conduction tissue results in conduction abnormalities and arrhythmias. "Classical" electrocardiogram (ECG) findings in cardiac amyloidosis include that of low voltage complexes with increased left ventricular wall thickness on echocardiography. However, this "classical" finding is neither sensitive nor specific. As cardiac amyloidosis is associated with a generally poor prognosis, the need for early recognition of this disease is important given the availability of new treatment options. In this review, we highlight 3 cases of patients with cardiac amyloidosis. Although presenting with typical clinical signs and symptoms, ECG for all 3 patients was not consistent with the classical findings described. They underwent further diagnostic tests which clinched the diagnosis of cardiac amyloidosis, allowing patients to receive targeted treatment. Through the review of the literature, we will highlight the different ECG patterns in patients with different types of cardiac amyloidosis and clinical scenarios, as well as the pitfalls of using ECG to identify the condition. Lastly, we also emphasize the current paradigms in diagnosing cardiac amyloidosis through the non-invasive methods of echocardiography, cardiac magnetic resonance imaging, and nuclear technetium-pyrophosphate imaging.

CONCLUSIONS

Electrocardiogram is often the first investigation used in evaluating many cardiac disorders, including cardiac amyloidosis. However, classical features of cardiac amyloidosis on ECG are often not present. A keen understanding on the ECG features of cardiac amyloidosis and knowledge of the diagnostic workflow is important to diagnose this condition.

Influence of shift work on cardiovascular disease risk in Southern African long-distance truck drivers: a cross-sectional study

OBJECTIVES

Cardiovascular disease (CVD) is a major problem globally. Truck drivers have an increased risk of CVD due to a sedentary lifestyle, irregular working hours and behavioural choices. We aimed to get insight into the contribution of night shift work to CVD risk in long-distance truck drivers in South Africa.

DESIGN

A cross-sectional study.

SETTING

Enrolment took place at three South African truck stop locations in two provinces; Bloemfontein (Free State), Pomona Road (Gauteng) and Soweto (Gauteng).

PARTICIPANTS

607 males aged ≥18 years with full-time employment as a long-distance truck driver were included. The criteria for inclusion were willingness and being able to provide informed consent and to complete the study procedures.

PRIMARY AND SECONDARY OUTCOME MEASURES

Information was collected on sociodemographics, occupational and health characteristics. Physical measurements, an ECG and carotid intima-media thickness (CIMT) measurements were taken. A night shift was defined as working at least 3 hours between 22:00 and 6:00 hours once a week. CVD risk was defined with the Framingham Risk Score (FRS), the Atherosclerotic Cardiovascular Disease (ASCVD) risk algorithm, left ventricular hypertrophy (LVH) and CIMT.

RESULTS

In total, 607 truck drivers were included of which 305 (50.2%) worked in day shifts only and 302 (49.8%) worked day and night shifts. There was a high prevalence of CVD risk factors in both groups as 33% were hypertensive, 28% obese and 37% had abnormal lipid levels. Working day and night shifts compared with working only day shifts did not result in differences in FRS, ASCVD risk or LVH. No difference was found in CIMT measurements, except for the maximum bulb thickness which was higher in day shift workers.

CONCLUSIONS

CVD risk factors are considerably present in male truck drivers in South Africa. CVD risk does not differ between dayshift and day-night shift workers in this cross-sectional analysis.

Incident atrial fibrillation and heart failure in treated hypertensive patients with left ventricular hypertrophy. The LIFE Study

Aim: The present study investigated the appearance and severity of atrial fibrillation (AF) and heart failure (HF) in 8,702 hypertensive patients with left ventricular hypertrophy (LVH) receiving antihypertensive treatment in a prospective trial. Methods: Patients who had a history of AF or HF were not included, and the participants had sinus rhythm when they were randomly allocated to blinded study medication. Endpoints were adjudicated. Results: Incident AF occurred in 679 patients (7.8%) and HF in 246 patients (2.8%) during 4.7 ± 1.1 years mean follow-up. Incident AF was associated with a > 4-fold increased risk of developing subsequent HF [hazards ratios (HRs) = 4.7; 95% confidence intervals (CIs), 3.1–7.0; P < 0.001] in multivariable Cox analyses adjusting for age, sex, race, randomized treatment, standard cardiovascular risk factors and incident myocardial infarction. The development of HF as a time-dependent variable was associated with a multivariable-adjusted 3-fold increase of the primary study endpoint (HRs = 3.11; 95% CIs, 1.52–6.39; P < 0.001) which was a composite of myocardial infarction, stroke or cardiovascular death. Incident HF was associated with a > 3-fold increased risk of developing subsequent AF (HRs = 3.3; 95% CIs, 2.3–4.9; P < 0.001). This development of AF was associated with a > 2-fold increase of the composite primary study endpoint in multivariable Cox analysis (HRs = 2.26; 95% CIs, 1.09–4.67; P = 0.028). Conclusions: Incident atrial fibrillation and heart failure are associated with increased risk of the other in treated hypertensive patients with left ventricular hypertrophy. Such high-risk hypertensive patients who subsequently develop both atrial fibrillation and heart failure have particular high risk of composite myocardial infarction, stroke or cardiovascular death (ClinicalTrials.gov identifier: NCT00338260).

Patient contrastive learning: A performant, expressive, and practical approach to electrocardiogram modeling

Supervised machine learning applications in health care are often limited due to a scarcity of labeled training data. To mitigate the effect of small sample size, we introduce a pre-training approach, Patient Contrastive Learning of Representations (PCLR), which creates latent representations of electrocardiograms (ECGs) from a large number of unlabeled examples using contrastive learning. The resulting representations are expressive, performant, and practical across a wide spectrum of clinical tasks. We develop PCLR using a large health care system with over 3.2 million 12-lead ECGs and demonstrate that training linear models on PCLR representations achieves a 51% performance increase, on average, over six training set sizes and four tasks (sex classification, age regression, and the detection of left ventricular hypertrophy and atrial fibrillation), relative to training neural network models from scratch. We also compared PCLR to three other ECG pre-training approaches (supervised pre-training, unsupervised pre-training with an autoencoder, and pre-training using a contrastive multi ECG-segment approach), and show significant performance benefits in three out of four tasks. We found an average performance benefit of 47% over the other models and an average of a 9% performance benefit compared to best model for each task. We release PCLR to enable others to extract ECG representations at https://github.com/broadinstitute/ml4h/tree/master/model_zoo/PCLR.

ECGs are a rich source of cardiac health information. Many recent works have shown that deep learning can extract new information from ECGs when there are a sufficient number of labeled data. However, when there are not enough labeled data or a clinician scientist does not have the resources to train a deep learning model from scratch, options are limited. We introduce Patient Contrastive Learning of Representations (PCLR), an approach to train a neural network that extracts representations of ECGs. The only labels required to train PCLR are which ECG comes from which patient. The resulting ECG representations can be used directly in linear models for new tasks without needing to finetune the neural network. We show PCLR is better than using a set of handpicked features for four tasks, and better than three other deep learning approaches for three out of four tasks evaluated. Furthermore, PCLR is better than training a neural network from scratch when training data are limited. PCLR is one of the first attempts at releasing and evaluating a pre-trained ECG model with the purpose of accelerating deep learning ECG research.

Performance of the Electrocardiogram in the Diagnosis of Left Ventricular Hypertrophy in Older and Very Older Hypertensive Patients

BACKGROUND

Left ventricular hypertrophy (LVH) is an important cardiovascular risk factor, regardless of arterial hypertension. Despite the evolution of imaging tests, the electrocardiogram (ECG) is still the most used in the initial evaluation, however, with low sensitivity.

OBJECTIVE

To evaluate the performance of the main electrocardiographic criteria for LVH in elderly and very elderly hypertensive individuals.

METHODS

In a cohort of hypertensive patients, ECGs and doppler echocardiographies (ECHO) were performed and separated into three age groups: <60 years, Group I; 60-79 years Group II; and ≥80 years, Group III. The most used electrocardiographic criteria were applied for the diagnosis of LVH: Perugia; Pegaro-Lo Presti; Gubner-Ungerleider; Narita; (Rm+Sm) x duration; Cornell voltage; Cornell voltage duration; Sokolow-Lyon voltage; R of aVL ≥11 mm; RaVL duration. In evaluating the performance of these criteria, in addition to sensitivity (Sen) and specificity (Esp), the "Diagnostic Odds Ratios" (DOR) were analyzed. We considered p-value <0.05 for the analyses, with two-tailed tests.

RESULTS

In 2,458 patients, LVH was present by ECHO in 781 (31.7%). In Groups I and II, the best performances were for the criteria of Narita, Perugia, (Rm+Sm) x duration, with no statistical differences between them. In Group III (very elderly) the Perugia criteria and (Rm+Sm) x duration had the best performances: Perugia [44,7/89.3; (Sen/Esp)] and (Rm+Sm) duration [39.4%/91.3%; (Sen/Esp), p<0.05)], with the best PAIN results:6.8. This suggests that in this very elderly population, these criteria have greater discriminatory power to separate patients with LVH.

CONCLUSION

In very elderly hypertensive patients, the Perugia electrocardiographic criteria and (Rm+Sm) x duration showed the best diagnostic performance for LVH.

Discrepancy between left ventricular hypertrophy by echocardiography and electrocardiographic hypertrophy: clinical characteristics and outcomes

Background

The clinical significance of the discrepancy between left ventricular hypertrophy (LVH) by echocardiography and ECG remains to be elucidated.

Methods

After excluding patients who presented with pacemaker placement, QRS duration ≥120 ms and cardiomyopathy and moderate to severe valvular disease, we retrospectively analysed 3212 patients who had undergone both scheduled transthoracic echocardiography (echo) and ECG in a hospital-based population. Cornell product >2440 mm · ms was defined as ECG-based LVH; left ventricular mass index >115 g/m² for men and >95 g/m² for women was defined as echo-based LVH. The study population was categorised into four groups: patients with both ECG-based and echo-based LVH (N=131, 4.1%), those with only echo-based LVH (N=156, 4.9%), those with only ECG-based LVH (N=409, 12.7%) and those with no LVH (N=2516, 78.3%).

Results

The cumulative 3-year incidences of a composite of all-cause death and major adverse cardiovascular events were 32.0%, 33.8%, 19.2% and 15.7%, respectively. After adjusting for confounders, the HRs relative to that in no LVH were 1.63 (95% CI 1.16 to 2.28), 1.68 (95% CI 1.23 to 2.30) and 1.09 (95% CI 0.85 to 1.41) in patients with both ECG-based and echo-based LVH, those with only echo-based LVH, and those with only ECG-based LVH, respectively.

Conclusions

Echo-based LVH without ECG-based LVH was associated with a significant risk of adverse clinical events, and the risk was comparable to that in patients with both echo-based and ECG-based LVH.

The association between ECG criteria and Echo criteria for left ventricular hypertrophy in a general Chinese population

BACKGROUND

Several ECG criteria have been widely used for diagnosis of left ventricular hypertrophy (LVH) in clinical practice. However, their performance in a general Chinese population is limited.

METHODS AND RESULTS

A multi-stage, stratified cluster sampling across China was performed and 7415 representative Chinese adults aged 18-85 years were analyzed. ECG was collected by using GE MAC 5500 machine. The association between five ECG-LVH criteria (i.e., Peguero-Lo Presti, Cornell, Cornell product, Sokolow-Lyon and Sokolow-Lyon product) and echocardiographic LVH (Echo-LVH) was assessed by Pearson's correlation, diagnostic statistics like predictive values, and receiver operating characteristics (ROC) curve. We found that the prevalence of the Echo-LVH was 11% while ECG-LVH ranged from 3% to 27%. All ECG-LVH criteria had high negative predictive value (NPV) (89%) and specificity (73-96%) but low positive predictive value (PPV) (12-24%) and sensitivity (4-29%). The newly Peguero-Lo Presti criteria had higher sensitivity (29%) but lower specificity (73%) and accuracy (68%) compared with other criteria. Cornell product had the best diagnostic performance (AUC: 0.59), as well as the highest specificity (96%) and accuracy (86%) but lowest sensitivity (4%). Among single-lead components of ECG criteria, R_aVL voltage and QRS duration performed relatively better than others. Hypertensive and older individuals had higher sensitivity but lower specificity and accuracy than their counterparts.

CONCLUSION

ECG-LVH criteria had high NPV to detect Echo-LVH. Though with higher sensitivity, Peguero-Lo Presti criteria did not have better diagnostic performance to detect Echo-LVH. R_aVL and QRS duration had stronger association with Echo-LVH among all single-lead components.

Peguero-Lo Presti criteria modified by body surface area for the electrocardiographic diagnosis of left ventricular hypertrophy in Thai patients

Background

Several electrocardiographic (ECG) criteria are used to diagnose left ventricular hypertrophy (LVH); however, they have low sensitivity.

Objective

To assess the sensitivity of LVH diagnosis using Peguero-Lo Presti criteria modified by body surface area (BSA).

Methods

This study used retrospective data from 9,438 patients who attended the Central Chest Institute of Thailand from January 2017 to December 2017 with available echocardiography, and who were categorized into those with and without LVH to determine diagnostic accuracy. We randomly selected 317 patients after excluding others based on various conditions. The left ventricular mass of the 317 patients was estimated using echocardiography. Peguero-Lo Presti criteria were modified by dividing original criteria by BSA. The accuracy of the modified criteria was compared with that of the original Peguero-Lo Presti, Sokolow-Lyon, and Cornell voltage criteria. A McNemar test was used to determine the agreement of all ECG criteria examined with LV mass index. The area under a receiver operating characteristic curve (AUC) was used to assess the performance of the criteria.

Results

LVH was diagnosed in 164 of the 317 patients using echocardiography. The sensitivity of modified Peguero-Lo Presti criteria was 50.6% (95% confidence interval [CI] 42.7% to 58.5%), and specificity was 88.2% (95% CI 82.0% to 92.9%), with an AUC of 0.67 (95% CI 0.61-0.73).

Conclusions

Peguero-Lo Presti criteria modified by dividing them by BSA can improve sensitivity with acceptable specificity for the diagnosis of LVH compared with other ECG criteria examined, at least in selected Thai patients. The modified Peguero-Lo Presti criteria have accuracy similar to that for the original criteria.

Prevalence and associated factors of electrocardiographic left ventricular hypertrophy in a rural community, central Thailand

Left ventricular hypertrophy (LVH) is considered a cardiac condition with life-threatening complications. Detected LVH is a strong predictor of cardiovascular diseases and death. This condition is normally diagnosed at offices. We aimed to determine the prevalence and associated factors of electrocardiographic-LVH (ECG-LVH) among adults in a Thai rural community. A cross-sectional study was conducted in Na-Yao rural community of Thailand in 2020. A total of 638 individuals aged ≥ 20 years were interviewed using standardized structured questionnaires related to demographic information, risk behaviors, comorbidities and anthropometric measurements. LVH was determined by Sokolov-Lyon and Cornell criteria based on the collected electrocardiograms. The prevalence of ECG-LVH among adults was 6.6%. The factors independently associated with ECG-LVH were being male (AORs 2.04, 95% CI 1.05–3.98), history of diabetes mellitus (AORs 1.01, 95% CI 1.01–1.02), and hypertensive crisis ≥ 180/110 mmHg (AORs 7.24, 95% CI 1.31–39.92). However, resting heart rate was negatively associated with ECG-LVH (p < 0.05). Our data emphasized that LVH was one of the significant health problems among adults in a rural community. This condition could lead to severe complications. Thus, effective detection and public health interventions should be provided at the community level.

Diagnostic Accuracy of the Electrocardiography Criteria for Left Ventricular Hypertrophy (Cornell Voltage Criteria, Sokolow-Lyon Index, Romhilt-Estes, and Peguero-Lo Presti Criteria) Compared to Transthoracic Echocardiography

Objective/Aim: We aimed to evaluate the diagnostic utility of the widely used left ventricular hypertrophy (LVH) electrocardiography (ECG) criteria (Cornell Voltage Criteria [CVC], Sokolow-Lyon Index [SLI], Romhilt-Estes [REC], and Peguero-Lo Presti [PLP] Criteria) compared with the left ventricular mass measured by echocardiography.

Methods: In this prospective diagnostic accuracy study, we screened all consecutive adults (18 to 65 years) who presented to our academic emergency department (ED) with increased blood pressure (≥130/85 mmHg) between January 2016 and January 2017, and we enrolled a convenience sample of 165 patients in our study. The attending emergency physician managed all patients as per their primary complaint. The consulting cardiologist performed a transthoracic echocardiogram (TTE) of the patient and calculated the left ventricular mass (LVM) according to the American Society of Echocardiography (ASE) formula. After completing the patient recruitment phase, researchers evaluated all ECGs and calculated scores for SLI, CVC, REC, and PLP. We used contingency tables to calculate the diagnostic utility metrics of all ECG criteria.

Results: The prevalence of LVH by TTE was 31.5%. CVC, SLI, REC, and PLP criteria correctly identified (true positive rate) abnormal LVM in only 3.9%, 1.9%, 9.6%, and 19.2% of the patients, respectively. CVC, SLI, REC score and PLP criteria performed poorly with extremely low sensitivities (3.9%, 1.9%, 10%, 19.2%) and poor accuracies (67.3%, 64.9%, 57.7%, 69.7%).

Conclusion: ECG voltage criteria's clinical utility in estimating LVM and LVH is low, and it should not be used for this purpose.

Comparisons of traditional electrocardiographic criteria for left and right ventricular hypertrophy in young Asian women: The CHIEF heart study

The performance of electrocardiographic (ECG) voltage criteria to identify left and right ventricular hypertrophy (LVH and RVH) in young Asian female adults have not been clarified so far.In a sample of 255 military young female adults, aged 25.2 years on average, echocardiographic LVH was respectively defined as the left ventricular mass (LVM) indexed by body surface area (BSA) (≥88 g/m) and by height (≥41 g/m), and RVH was defined as anterior right ventricular wall thickness >5.2 mm. The performance of ECG voltage criteria for the echocardiographic LVH and RVH were assessed by area under curve (AUC) of receiver operating characteristic (ROC) curve to estimate sensitivity and specificity.For the Sokolow-Lyon (the maximum of SV1 or SV2 + RV5 or RV6) and Cornell (RaVL + SV3) voltage criteria with the LVM/BSA ≥88 g/m, the AUC of ROC curves were 0.66 (95% confidence intervals [CI]: 0.52-0.81, P = .039) and 0.61 (95% CI: 0.44-0.77, P = .18), respectively. For these 2 ECG voltage criteria with the LVM/height ≥41 g/m, the AUC of ROC curves were 0.64 (95% CI: 0.52-0.75, P = 0.11) and 0.73 (95% CI: 0.61-0.85, P = 0.0074), respectively. The best cut-off points selected for the Sokolow-Lyon and Cornell voltage criteria with echocardiographic LVH in young Asian females were 26 mm and 6 mm, respectively. In contrast, all the AUC of ROC curves were less than 0.60 and not significant according to the Sokolow-Lyon (the maximum of RV1 + SV5 or V6) and Myers' voltage criteria (eg, the voltage of R wave in V1 and the ratios of R/S in V1, V5 and V6) with echocardiographic RVH.There was a suggestion that the ECG voltage criteria to screen the presence of LVH should be adjusted for the young Asian female adults, and with regard to RVH, the ECG voltage criteria were found ineffective.

Performance of Electrocardiographic Criteria for Echocardiographically Diagnosed Left Ventricular Hypertrophy in Chinese Hypertensive Patients

BACKGROUND

Performance of electrocardiographic (ECG) criteria for echocardiographically diagnosed left ventricular hypertrophy (LVH) in Chinese hypertensive patients is not well known. We investigated the accuracy of various ECG criteria for the diagnosis of the echocardiographic LVH according to the new cutoff values of left ventricular mass (LVM) index (>115 g/m² for men and >95 g/m² for women) in Chinese hypertensive patients.

METHODS

Our study included 702 consecutive hypertensive inpatients including 92 (13.1%) concentric and 121 (17.2%) eccentric LVH on standard echocardiography. Diagnostic accuracy of 7 ECG criteria was evaluated by calculating sensitivity and specificity and by using the receiver operating characteristic curves.

RESULTS

The ECG criteria for the detection of the echocardiographically defined LVH had a sensitivity of 15%–31.9% and specificity of 91.6%–99.2% overall, 20.7%–43.5% and 91.6%–99.2% concentric, and 7.4%–23.1% and 91.6%–99.2% eccentric. ECG diagnosis of LVH defined as the positive diagnosis of any of 4 ECG criteria including Sokolow–Lyon voltage, Cornell voltage, Cornell product, and RavL voltage had a sensitivity of 54% and specificity of 86.3% overall, 71.7% and 86.3% concentric, and 40.5% and 86.3% eccentric. After adjustment for confounding factors, various ECG criteria were significantly correlated with LVM, with standardized β coefficients from 0.20 to 0.39 (P < 0.001) and the highest coefficient for the Cornell product criterion.

CONCLUSIONS

All ECG LVH indexes had low sensitivity and high specificity in Chinese hypertensive patients. Combination of 4 or all ECG criteria might improve sensitivity without any loss of specificity.

The value of electrocardiography and echocardiography in distinguishing Fabry disease from sarcomeric hypertrophic cardiomyopathy

BACKGROUND

Screening for Fabry disease is sub-optimal in non-specialised centres.

AIM

To assess the diagnostic value of electrocardiographic scores of left ventricular hypertrophy and a combined electrocardiographic and echocardiographic model in Fabry disease.

METHODS

We retrospectively reviewed the electrocardiograms and echocardiograms of 61 patients (mean age 55.6±11.5 years; 57% men) with Fabry disease and left ventricular hypertrophy, and compared them with those from 59 patients (mean age 44.8±18.3 years; 66% men) with sarcomeric hypertrophic cardiomyopathy. Six electrocardiography criteria for left ventricular hypertrophy were specifically analysed: Sokolow-Lyon voltage index; Cornell voltage index; Gubner index; Romhilt-Estes score; Sokolow-Lyon product (voltage index×QRS duration); and Cornell product (voltage index×QRS duration).

RESULTS

Right bundle branch block was more frequent in patients with Fabry disease (54% vs. 22%; P=0.001). QRS duration, Gubner score and Sokolow-Lyon product were significantly higher in patients with Fabry disease. Maximal wall thickness was higher in patients with sarcomeric hypertrophic cardiomyopathy (21.9±5.1 vs. 15.5±2.9mm; P<0.001). Indexed sinus of Valsalva diameter was larger in patients with Fabry disease. After multivariable analysis, right bundle branch block, Sokolow-Lyon product, maximal wall thickness and aortic diameter were independently associated with Fabry disease. A model including these four variables yielded an area under the receiver operating characteristic curve of 0.918 (95% confidence interval 0.868-0.968) for Fabry disease.

CONCLUSION

Our model combining easy-to-assess electrocardiographic and echocardiographic variables may be helpful in improving screening and reducing diagnosis delay in Fabry disease.

On-treatment HDL cholesterol predicts incident atrial fibrillation in hypertensive patients with left ventricular hypertrophy

Purpose: Hypertensive patients are at increased risk of atrial fibrillation (AF). Although low baseline high density lipoprotein (HDL) cholesterol has been associated with a higher risk of AF, this has not been verified in recent population-based studies. Whether changing levels of HDL over time are more strongly related to the risk of new AF in hypertensive patients has not been examined.Material and methods: Incident AF was examined in relation to baseline and on-treatment HDL levels in 8267 hypertensive patients with no history of AF, in sinus rhythm on their baseline electrocardiogram, randomly assigned to losartan- or atenolol-based treatment. HDL levels at baseline and each year of testing were categorised into quartiles according to baseline HDL levels.Results: During 4.7 ± 1.10 years of follow-up, 645 patients (7.8%) developed new AF. In univariate Cox analyses, compared with the highest quartile of HDL levels (>1.78 mmol/l), patients with on-treatment HDL in the lowest quartile (≤ 1.21 mmol/l) had a 53% greater risk of new AF. Patients with on-treatment HDL in the second and third quartiles had intermediate increased risks of AF. Baseline HDL in the lowest quartile was not a significant predictor of new AF (hazard ratio (HR): 1.14, 95% confidence interval (CI): 0.90-1.43). In multivariable Cox analyses adjusting for multiple baseline and time-varying covariates, the lowest quartile of on-treatment HDL remained associated with a nearly 54% increased risk of new AF (HR: 1.54, 95% CI: 1.16-2.05) whereas a baseline HDL≤ ⩽1.21 mmol/l was not predictive of new AF (HR: 1.01, 95% CI: 0.78-1.31).Conclusion: Lower on-treatment HDL is strongly associated with risk of new AF. These findings suggest that serial assessment of HDL can estimate AF risk better than baseline HDL in hypertensive patients with left ventricular hypertrophy. Future studies may investigate whether therapies that increase HDL can lower risk of developing AF.Clinical Trials Registration: http://clinicaltrials.gov/ct/show/NCT00338260?order=1.

Association of Alk1 and Endoglin Polymorphisms with Cardiovascular Damage

Cardiovascular diseases are associated to risk factors as obesity, hypertension and diabetes. The transforming growth factor-β1 receptors ALK1 and endoglin regulate blood pressure and vascular homeostasis. However, no studies relate the association of ALK1 and endoglin polymorphisms with cardiovascular risk factors. We analysed the predictive value of the ALK1 and endoglin polymorphisms on cardiovascular target organ damage in hypertensive and diabetic patients in 379 subjects with or without hypertension and diabetes in a Primary Care setting. The ALK1 rs2071219 polymorphism (AA genotype) is associated with a lower presence of diabetic retinopathy and with the absence of altered basal glycaemia. Being carrier of the ALK1 rs3847859 polymorphism (G allele) is associated with lower basal heart rate and with higher LDL-cholesterol levels. The endoglin rs3739817 polymorphism (AA genotype) is associated with higher levels of LDL-cholesterol, and being carrier of the endoglin rs10987759 polymorphism (C allele) is associated with higher haemoglobin levels and with an increased heart rate. Summarizing, several ALK1 and endoglin gene polymorphisms increase the risk of cardiovascular events. The analysis of these polymorphisms in populations at risk, in combination with the determination of other parameters and biomarkers, could implement the diagnosis and prognosis of susceptibility to cardiovascular damage.

Indices of left ventricular voltage on electrocardiogram are closely associated with serum cardiac troponin I levels in normotensive Japanese individuals

The high-sensitivity cardiac troponin I (hs-cTnI) in serum can increase due to an increase in left ventricular (LV) overload in individuals with hypertension. Since LV voltage on an electrocardiogram (ECG) reflects LV load, it is possible that LV voltage is closely associated with hs-cTnI in individuals without hypertension. This study investigated the association between LV voltage indices and serum hs-cTnI levels in normotensive Japanese individuals.Subjects who visited the Enshu Hospital for a health check-up were screened for their eligibility. Subjects with renal dysfunction, cancer, active inflammatory disease, or a history of cardiovascular events were excluded, as were subjects with obvious ST segment or T wave abnormality, Wolff-Parkinson-White syndrome, pacemaker implantation, or frequent arrhythmia in the ECG. Exclusion of individuals with hypertension left 803 subjects (54.8 ± 11.3 years) for final inclusion. The R wave voltage in lead V5 (RV5 voltage), the Sokolow-Lyon voltage (a sum of the QRS wave (a complex wave consists of Q, R, and S wave) of the S wave voltage in lead V1 and the R wave voltage in lead V5), and the Cornell product (a product of QRS duration and QRS voltage) were evaluated by ECG as LV voltage indices. Laboratory measurements included serum hs-cTnI levels. Possible associations between indices of LV voltage on ECG and serum hs-cTnI levels were cross-sectionally investigated in the normotensive subjects.The median values [interquartile range] of hs-cTnI and BNP were and 2.1 [1.4-3.0] and 13.8 [7.7-24.9] pg/mL, respectively. Multivariate regression analysis identified that the levels of hs-cTnI, but not BNP, were significantly associated with RV5 voltage (β 0.090, P = .0087), Sokolow-Lyon voltage (β 0.112, P = .0009), and Cornell product (β 0.101, P = .039) after adjustment for possible confounding factors. Moreover, the RV5 voltage, Sokolow-Lyon voltage, and Cornell product were significantly associated with the hs-cTnI levels after adjustment for possible confounding factors including ECG findings (β 0.109, P = .0075; β 0.125, P = .0010; and β 0.096, P = .0116, respectively).Indices of LV voltage in ECG had close associations with serum hs-cTnI levels in normotensive subjects. These findings support that the ECG findings of LV voltage have significant associations with slight myocardial micro-damage even in normotensive subjects.

Automatic image analyser to assess retinal vessel calibre (ALTAIR). A new tool to evaluate the thickness, area and length of the vessels of the retina

BACKGROUND AND OBJECTIVES

The examination of the fundus allows to evaluate retinal the microcirculation in vivo. We assess the reliability and validity of ALTAIR software, and to evaluate its clinical relevance by the association of thickness, area and length of the retinal vessels with other measures of vascular structure and function, target organ damage and cardiovascular risk.

METHODS

Cross-sectional study involving a total of 250 subjects aged 62 ± 9 years, 51 % males. In a random subsample of 60 subjects (118 retinographies), we estimated the intraobserver, interobserver and interdevice intraclass correlation coefficients (ICC) of the measurements of retinal vascular thickness, area and length in 3 concentric circles. Concurrent validity was assessed with all 250 subjects (495 retinographies), analysing the relationship to age, blood pressure, target organ damage, vascular structure and function, and cardiovascular risk.

RESULTS

Of the sample, 69 % were diagnosed with hypertension and 17 % with diabetes. Intraobserver ICC ranged from 0.640 for venous length to 0.906 for arterial area. Interobserver ICC ranged from 0.809 for arterial length to 0.916 for venous area, and interdevice ICC for arteriovenous ratio (AVR) was 0.887, thickness of arteries 0.590 and vein thickness 0.677. We found a moderate correlation between retinal vascular parameters and vascular structure and function, and target organ damage. In multiple linear regression analysis, the association with blood pressure, albumin/creatinine ratio, carotid intima-media thickness and cardiovascular risk is maintained.

CONCLUSION

The ALTAIR tool has been useful for analysing the thickness, area and length of retinal vessels, with adequate reliability and a concomitant association of retinal vessel measurements with other cardiovascular parameters and cardiovascular risk. Therefore, in addition to thickness, the area and length of retinal vessels could also play a role in the prediction of cardiovascular risk.

Optimal measuring point for ST deviation in chest pain patients with possible acute coronary syndrome

INTRODUCTION

In the ECG, significant ST elevation or depression according to specific amplitude criteria can be indicative of acute coronary syndrome (ACS). Guidelines state that the ST amplitude should be measured at the J point, but data to support that this is the optimal measuring point for ACS detection is lacking. We evaluated the impact of different measuring points for ST deviation on the diagnostic accuracy for ACS in unselected emergency department (ED) chest pain patients.

MATERIAL AND METHODS

We included 14,148 adult patients with acute chest pain and an ECG recorded at a Swedish ED between 2010 and 2014. ST deviation was measured at the J point (STJ) and at 20, 40, 60 and 80 ms after the J point. A discharge diagnosis of ACS or not at the index visit was noted in all patients.

RESULTS

In total, 1489 (10.5%) patients had ACS. ST amplitude criteria at STJ had a sensitivity of 28% and a specificity of 92% for ACS. With these criteria, the highest positive and negative predictive values for ACS were obtained near the J point, but the optimal point varied with ST deviation, age group and sex. The overall best measuring points were STJ and ST20.

CONCLUSIONS

This study indicates that the diagnostic accuracy of the ECG criteria for ACS is very low in ED chest pain patients, and that the optimal measuring point for the ST amplitude in the detection of ACS differs between ST elevation and depression, and between patient subgroups.

Renin Angiotensin Aldosterone System Blockades Does Not Protect Residual Renal Function in Patients with Hemodialysis at 1 Year After Dialysis Initiation: A Prospective Observational Cohort Study

The beneficial effects of renin angiotensin aldosterone system (RAAS) blockade on residual renal function (RRF) in patients who have just initiated hemodialysis (HD) have been inconclusive. In this study, 935 patients with incident HD from a nationwide prospective observational cohort in Korea were included for analysis. The primary outcome showed that RRF as demonstrated by urine volume changes over 0, 3, and 12 months differed between the RAAS blockade and control groups. Mixed-effects linear regression was used to compare RRF between the groups. Patients in the RAAS group had a greater proportion of higher urine volume at study enrollment compared to the control group, but there was no difference in baseline characteristics, heart function, and dialysis-related indices. After adjusting for confounding factors, the RAAS group did not provide a significant benefit to RRF in a mixed-effects linear regression (p = 0.51). Male gender, high Charlson comorbidity index, diuretic use, and high weekly ultrafiltration volume were associated with faster decline in RRF. The RAAS group failed to provide a protective effect for the development of anuria 1 year after initiating dialysis based on the multivariate logistic regression (OR 0.73 95% CI 0.25-2.13, p = 0.57). In Korean patients with incident HD, RAAS blockade did not provide a protective effect for RRF after 1 year. Further research is needed to clarify the optimal treatment for preserving RRF in HD patients.

Diagnostic performance of electrocardiographic criteria in echocardiographic diagnosis of different patterns of left ventricular hypertrophy

Background

Electrocardiogram (ECG) is considered the initial screening method for the detection of left ventricular hypertrophy (LVH) despite its low sensitivity. However, there are no data on how ECG criteria for LVH perform in patients with concentric (cLVH) and eccentric LVH (eLVH).

Methods

In the setting of the Corinthia cross‐sectional study, ECGs were analyzed in 1,570 participants of the study. Seven ECG LVH criteria were calculated (Sokolow–Lyon voltage, index, and product, sex‐specific Cornell voltage and product, Lewis voltage, and the Framingham), whereas LVH was defined, based on echocardiographic data, as left ventricular mass indexed for body surface area (BSA) of at least 125 g/m² in men and at least 110 g/m² in women.

Results

Regarding the frequency encountered for each ECG LVH criterion, there was no difference between eLVH and cLVH. However, when ECG criteria were compared as continuous variables between LVH groups, Cornell voltage and product were higher in cLVH individuals, with a value of Cornell voltage >13.95 mV having 61% sensitivity and 62% specificity to differentiate cLVH from eLVH (p = .05). Even after adjustment for age, sex, body mass index, and hypertension, the occurrence of Cornell voltage or product increased the odds of cLVH by 1.6 times (p = .001).

Conclusion

Cornell voltage and product criteria disclosed a superior discriminative ability for the detection of LVH via ECG. When further categorizing LVH as concentric and eccentric, Cornell product depicted the higher discriminative ability for cLVH.

Cross-sectional study of the health of southern African truck drivers

OBJECTIVES

Lifestyle and working conditions of truck drivers predisposes them to risk-factors associated with communicable and non-communicable diseases, but little is known about the health status of African truck driver. This study aims to assess a cross-section of truckers in South Africa to describe their health information.

SETTING

The study took place across three truck-stop rest areas in the South African provinces of Free State and Gauteng.

PARTICIPANTS

Eligibility criteria included being males aged 18 years and older, full-time employment as a long-distance truck driver. A total of 614 male truck drivers participated; 384 (63%) were Zimbabwean and 325 (55%) completed high-school.

PRIMARY AND SECONDARY OUTCOME MEASURES

The trucker survey explored demographics; working conditions; sexual, eating and sleeping behaviours; mental health status, medical history and cardiac risk-factors. Medical assessments included physical measurements, glucose and lipid measurements, ECG, carotid intima-media thickness (CIMT) and cardiac ultrasound.

RESULTS

In the previous month, 554 (91%) participants were sexually active; 522 (86%) had sex with a regular partner; 174 (27%) with a casual partner; 87 (14%) with a sex worker. Average time driving was 10 hours/day, 20 days/month, 302 (50%) never worked night shifts and 74 (12%) worked nights approximately four times per week. 112 (18%) experienced daytime sleepiness and 59 (10%) were ever hospitalised from an accident. Forty-seven (8%, 95% CI 5.3 to 9.5) were HIV-positive, with half taking antiretrovirals. Forty-eight (8%) truckers had some moderate depression, while 21 (4%) suffered from post-traumatic stress disorder. Reported tuberculosis, myocardial infarction, and diabetes were <3%. Prominent cardiac risk-factors included smoking (n=63, 11%), consuming alcohol (>15 drinks/week) (n=54, 9%), overweight/obesity (n=417, 69%), and hypertension (n=220, 36%,95% CI 32.1 to 39.7). ECG results showed 23 (4.9%) and 29 (5.3%) drivers had left ventricular hypertrophy using the Cornell criterion and product, respectively. CIMT measurements indicated nine (4.2%) drivers had a carotid atherosclerotic plaque.

CONCLUSION

This first holistic assessment of health among southern African male truck drivers demonstrates substantial addressable cardiovascular risk factors, mental health issues and sexual risk behaviours.

Electrocardiographic Detection of Left Ventricular Hypertrophy; Adding Body Mass Index and Spatial QRS-T Angle: A Cross-Sectional Study

Introduction

We investigated improvement of electrocardiographic LVH detection by adding measures of adiposity and/or novel electrocardiographic measures. Left ventricular hypertrophy (LVH) is an important risk factor for adverse cardiovascular outcomes. Improvement of electrocardiographic criteria for LVH is desirable, since electrocardiography is widely used.

Methods

We included 1091 participants of the Netherlands Epidemiology of Obesity Study (NEO) who underwent cardiac magnetic resonance imaging (MRI). Performance of Sokolow–Lyon and Cornell voltage and product criteria was assessed. Stepwise regression analysis was performed with each conventional electrocardiographic criterion and age, sex, body mass index (BMI), waist circumference, and waist:hip ratio (p-entry < 0.05, p-removal > 0.10). T-wave abnormalities or the spatial QRS-T angle (SA) were added to the improved models.

Results

The study population had a mean (SD) age of 56 (6) years, BMI of 26.1 (4.0) kg/m² and 46% were men. MRI-LVH was present in 10% of participants. The c-statistic for Sokolow–Lyon voltage was 0.58, R² was 0.02 and sensitivity at 90% specificity was 16%, for Sokolow–Lyon product this was 0.62, 0.02, and 21%, for Cornell voltage 0.65, 0.04, and 28% and for Cornell product 0.67, 0.04, and 25%. Best performing models were obtained by addition of both BMI and SA (Sokolow-Lyon voltage: c-statistic 0.74, R² 0.11, sensitivity of 41% at 90% specificity; Sokolow-Lyon product: 0.75, 0.12, 42%; Cornell voltage: c-statistic 0.70, R² 0.08, sensitivity of 38% at 90% specificity; Cornell product: c-statistic 0.72, R² 0.08, sensitivity of 44% at 90% specificity).

Conclusions

Electrocardiographic detection of LVH improved by adding BMI and SA to a model with conventional electrocardiographic criteria. This approach would require little extra effort and application in clinical practice is feasible. However, results should first be replicated in high-risk populations.

Electronic supplementary material

The online version of this article (10.1007/s40119-019-00151-9) contains supplementary material, which is available to authorized users.

Noninvasive validation of central and peripheral augmentation index estimated by a novel wrist-worn tonometer

BACKGROUND

The validation of new blood pressure devices with easier use and more rapid data collection may facilitate the incorporation of these measures into clinical practice. We analyze the reliability and validity of Pulse Wave Analysis as reported by a novel wrist-worn device, easy and quick to use, comparing central and peripheral augmentation index (AIx) with the same measures from the SphygmoCor. Additionally, we analyzed clinical relevance through the association of the Pulse Wave Analysis, as reported by a novel wrist-worn device, with other cardiovascular parameters.

METHODS

Cross-sectional study including 254 participants. Mean age was 51.9 ± 13.4 years and 53% were women.

MEASUREMENTS

peripheral AIx (PAIx) and central AIx (CAIx) by the wrist-worn device and SphygmoCor (MM3); carotid-femoral (cf) pulse wave velocity (PWV) by SphygmoCor (MM3); cardioankle-vascular index (CAVI), ankle-brachial index (ABI) and brachial-ankle (ba) PWV by the Vasera device and carotid-intima media thickness (IMT) by ultrasonography.

RESULTS

Intra-observer intra-class correlation coefficient (ICC) for PAIx was 0.886 (95% CI 0.803-0.934) and for CAIx 0.943 (95% CI 0.901-0.968) with Bland Altman limits of agreement -0.75 (-23.8 to 21.8) and 0.08 (-15.7 to 15.9), respectively. Inter-observer ICC for PAIx was 0.952 (95% CI 0.915-0.972) and CAIx 0.893 (95% CI 0.811-0.939) with limits of agreement -0.45 (-13.7 to 12.8) and 0.43 (-17.7 to 18.5), respectively. Comparing the wrist-worn device with SphygmoCor, the ICC was 0.849 (95% CI 0.798-0.887) for PAIx, and 0.783 (95% CI 0.711-0.838) for CAIx. In Bland-Altman, limits of agreement for PAIx 1.03 (-20.67 to 22.73), and for CAIx -2.14 (-24.79 to 20.50). PAIx and CAIx, from the wrist-worn device, correlated with age, CAVI, ABI, baPWV, cfPWV, IMT, glomerular filtration and cardiovascular risk.

CONCLUSION

AIx measurements by wrist-worn device shows a good intra-observer and inter-observer reliability, inter-device noninvasive reliability and validity when compared with SphygmoCor, and clinical relevance by association with measures of vascular structure and function, end-organ damage and cardiovascular risk.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02623894; https://clinicaltrials.gov/ct2/show/NCT02623894.

Antihypertensive therapy prevents new-onset atrial fibrillation in patients with isolated systolic hypertension: the LIFE study

Aims: Atrial fibrillation (AF) is associated with increased cardiovascular risk and the incidence increases with age, hypertension and left ventricular hypertrophy (LVH). Reducing in-treatment systolic blood pressure (SBP) prevents new-onset AF but has previously not been studied in patients with isolated systolic hypertension (ISH). We aimed to investigate the effect on preventing new-onset AF by decreased in-treatment SBP in patients with ISH compared to patients with non-ISH. Methods and results: Double-blind, randomized, parallel-group study of 1320 patients with ISH and electrocardiographic (ECG) LVH, included among the 9193 patients in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study. Annual ECGs were Minnesota coded centrally, and new-onset AF was evaluated in 1248 ISH patients and compared with 7583 non-ISH patients during mean 4.8 ± 0.9 years follow-up. Cox regression analyses were used to assess the effect of reduced in-treatment SBP. New-onset AF occurred in 61 (4.9%) ISH patients and 292 (3.9%) non-ISH patients. In multivariate analysis lower in-treatment SBP was associated with 17% risk reduction (p = 0.008) for new-onset AF in ISH patients and 9% risk reduction (p = 0.006) in non-ISH patients per 10 mmHg decrease in in-treatment SBP, independent of treatment modality, baseline risk factors, baseline SBP and in-treatment heart rate and ECG-LVH. There was a significant interaction (p = 0.041) in favor of SBP reduction and AF prevention in ISH vs. non-ISH patients. Conclusion: Our data suggest that the effect of in-treatment SBP reduction in preventing new-onset AF is stronger in ISH compared to non-ISH patients with hypertension and ECG-LVH. However, the principal findings were the same in ISH and non-ISH patients.

The relationship of all-cause mortality to average on-treatment systolic blood pressure is significantly related to baseline systolic blood pressure: implications for interpretation of the Systolic Blood Pressure Intervention Trial study

BACKGROUND

The SPRINT study demonstrated that targeting systolic blood pressure (SBP) less than 120 mmHg was associated with lower cardiovascular event and mortality rates. In the LIFE study, however, a lower achieved SBP was associated with increased mortality. Mean baseline SBP in SPRINT was 140 mmHg and a third of the population had a baseline SBP 132 mmHg or less, raising the question of whether the lower baseline SBP in SPRINT could in part account for these differences.

METHODS

All-cause mortality during 4.8 ± 0.9 years follow-up was examined in relation to tertiles of achieved on-treatment average SBP in patients with baseline SBP of 25th percentile or less versus greater than 25th percentile value of 164 mmHg in 7998 nondiabetic hypertensive patients with ECG left ventricular hypertrophy randomly assigned to losartan-based or atenolol-based treatment. Average on-treatment SBP less than 142 mmHg (lowest tertile) and average SBP 142 mmHg to less than 152 mmHg (middle tertile) were compared with average SBP at least 152 mmHg (highest tertile and reference group).

RESULTS

In the overall population, there was a significant interaction between baseline SBP 164 mmHg or less and average on-treatment SBP less than 142 mmHg in Cox analysis (χ = 15.48, P < 0.001). Among patients with baseline SBP greater than 164 mmHg, in multivariate Cox analyses adjusting for other potential predictors of mortality and a propensity score for having baseline SBP 164 mmHg or less and compared with average on-treatment SBP at least 152 mmHg, average on-treatment SBP less than 142 mmHg was associated with 32% higher mortality (hazard ratio 1.32, 95% CI 1.01-1.65), whereas average SBP of 142 mmHg to less than 152 mmHg was associated with 24% lower mortality (hazard ratio 0.76, 95% CI 0.59-0.98). In contrast, among patients with baseline SBP 164 mmHg or less, both average on-treatment SBP less than 142 mmHg (hazard ratio 0.60, 95% CI 0.36-0.99) and average SBP of 142 mmHg to less than 152 mmHg (hazard ratio 0.51, 95% CI 0.30-0.89) were associated with significantly lower mortality compared with average SBP of at least 152 mmHg.

CONCLUSION

Achievement of an average SBP less than 142 mmHg was associated with reduced mortality in patients with baseline SBP 164 mmHg or less but with increased mortality in those with higher baseline SBP in LIFE. These findings suggest that the lower mortality associated with a lower targeted SBP in SPRINT may not be applicable to patients with considerably higher baseline SBP than SPRINT patients. Further study is necessary to better understand these findings.

CLINICAL TRIALS REGISTRATION

http://clinicaltrials.gov/ct/show/NCT00338260?order=1.

Cornell product is an ECG marker of heart failure with preserved ejection fraction

Objective

ECG markers of heart failure (HF) with preserved ejection fraction (HFpEF) are lacking. We hypothesised that the Cornell product (CP) is a risk marker of HFpEF and has prognostic utility in HFpEF.

Methods

CP =[(amplitude of R wave in aVL+depth of S wave in V3)×QRS] was measured on baseline 12-lead ECG in a prospective Asian population-based study of 606 healthy controls (aged 55±10 years, 45% men), 221 hypertensive controls (62±9 years, 58% men) and 242 HFpEF (68±12 years, 49% men); all with EF ≥50% and followed for 2 years for all-cause mortality and HF hospitalisations.

Results

CP increased across groups from healthy controls to hypertensive controls to HFpEF, and distinguished between HFpEF and hypertension with an optimal cut-off of ≥1800 mm*ms (sensitivity 40%, specificity 85%). Age, male sex, systolic blood pressure (SBP) and heart rate were independent predictors of CP ≥1800 mm*ms, and CP was associated with echocardiographic E/e' (r=0.27, p<0.01) and left ventricular mass index (r=0.46, p<0.01). Adjusting for clinical and echocardiographic variables and log N-terminal pro B-type natriuretic peptide (NT-proBNP), CP ≥1800 mm*ms was significantly associated with HFpEF (adjusted OR 2.7, 95% CI 1.0 to 7.0). At 2-year follow-up, there were 29 deaths and 61 HF hospitalisations, all within the HFpEF group. Even after adjusting for log NT-proBNP, clinical and echocardiographic variables, CP ≥1800 mm*ms remained strongly associated with a higher composite endpoint of all-cause mortality and HF hospitalisations (adjusted HR 2.1, 95% CI 1.2 to 3.5).

Conclusion

The Cornell product is an easily applicable ECG marker of HFpEF and predicts poor prognosis by reflecting the severity of diastolic dysfunction and LV hypertrophy.

Improved scoring system for the electrocardiographic diagnosis of left ventricular hypertrophy

BACKGROUND

Left ventricular hypertrophy (LVH) is a common manifestation of cardiovascular disease and a risk factor for cardiovascular morbidity and mortality, but available methods for its electrocardiographic (ECG) diagnosis have limited accuracy.

AIM

To investigate findings associated with LVH on ECG and developed an improved system for the diagnosis of LVH.

METHODS

A cohort study comparing ECG data acquired within 30 days of transthoracic echocardiography (TTE) was performed. Multivariate regression analysis identified ECG findings associated with increased LV mass and mass index. A scoring system was derived and performance compared to established criteria for LVH.

RESULTS

Data from 5486 outpatients with TTEs and corresponding ECGs were included in the derivation cohort, 333 (6.1%) of whom had LVH by TTE. In the primary regression analysis, findings associated with LVH were amplitudes of Q in V3, R in V6, S in V3, T in V6, P’ in V1, P in V6, as well as R and T-axis discordance, R peak time in V6, QRS duration, weight, height, sex, and age. From this we derived a score consisting of 5 criteria, and validated it in an independent cohort of 910 patients. With a threshold of 1.5 points, sensitivity and specificity were 67.9% and 81.4%, and 62.5% and 83.2% in the derivation and validation cohorts, respectively. With a threshold of 2 points, sensitivity and specificity were 42.3% and 93.0%, and 37.5% and 93.4% in these cohorts.

CONCLUSIONS

This score had superior sensitivity for detection of LVH by ECG while making a modest sacrifice in specificity compared to conventional criteria.

Consistency of left ventricular hypertrophy diagnosed by electrocardiography and echocardiography: the Northern Shanghai Study

Background

Left ventricular hypertrophy (LVH) is one of the preclinical manifestations of hypertensive target organ damage (TOD). However, it remains unclear which electrocardiographic criterion perform better in diagnosing LVH.

Purpose

To investigate the consistency of LVH diagnosed by electrocardiography (ECG) and echocardiography (ECHO). Taking LVH by ECHO as reference, to compare three different ECG criteria (Sokolow-Lyon, Cornell and Cornell Product criteria) and find the best ECG indicator for identifying LVH in community-based elderly Chinese.

Patients and methods

Echocardiography and electrocardiography were applied to define LVH in 1789 elderly Chinese aged >65 years old in communities located at the northern Shanghai. Echocardiographic LVH (ECHO-LVH) was defined by left ventricular mass indexed for Body Surface Area (LVM/BSA) or for height^2.7 (LVM/height^2.7). Electrocardiographic LVH (ECG-LVH) was defined by Sokolow-Lyon (SL), Cornell and Cornell Product (CP) criteria. ECHO-LVH was defined by LVM/BSA≥125 g/m² in male or ≥110 g/m² in female (LVH1); LVM/BSA≥115 g/m² in male, or ≥95 g/m² in female (LVH2) and LVM/height^2.7 ≥51 g/m^2.7 in male or ≥47 g/m^2.7 in female (LVH3).

Results

As compared with SL and Cornell criteria, CP had the greatest correlation coefficient in the association with echocardiography-defined LVH, except for LVM/BSA in men. Of note, CP criterion had the greatest area under curve of ROC than Cornell criterion and the SL index, not only in total population but also in subgroups classified by blood pressure.

Conclusion

In ECG-LVH criteria, CP criterion complies better than SL index and Cornell criterion in assessing cardiac hypertrophy.

Optimal duration and predictors of diagnostic utility of patient-activated ambulatory ECG monitoring

Objective

We studied the optimal duration of ambulatory event monitors for symptomatic patients and the predictors of detected events.

Methods

Patients with palpitations or dizziness received a patient-activated handheld event monitor which records 30 s single-lead ECG strips. Patients were monitored in an ambulatory setting for a range of 1-4 weeks and ECG strips interpreted by five independent electrophysiologists. Event pick-up rates and clinical covariates were analysed.

Results

Of 335 consecutive adults (age 50±16 years, 58% female) with palpitations (94%) and dizziness (25%) monitored, 286 patients (85%) reported events, and clinically significant events were detected in 86 (26%) patients. Of these 86 patients, 26% had ≥2 significant events, and 73% had events detected in the first 3 days. No significant events were detected after 12 days. The most common ECG abnormalities detected were premature ventricular ectopy (38%), premature atrial ectopy (37%) and atrial fibrillation (AF)/atrial flutter (34%). A history of AF (adjusted OR (AOR) 4.2, 95% CI 1.1 to 15.8), previous arrhythmia (AOR 2.8, 95% CI 2.3 to 5.9) and previous abnormal ambulatory monitoring (AOR 3.4, 95% CI 1.0 to 9.4) were associated with detection of clinically significant events. Patients older than 50 years were 82% more likely to have a clinically significant event (OR 1.8, 95% CI 1.3 to 3.6).

Conclusion

Patient-activated ambulatory event monitoring for 7 days may be sufficient in the diagnosis of symptomatic patients as significant events first detected beyond 10 days were rare. Patients with a history of AF, arrhythmia or previous abnormal ambulatory monitoring may require even shorter monitoring periods.

Cornell product in an electrocardiogram is related to reduced LV regional wall motion

Electrocardiographic left ventricular hypertrophy (LVH) diagnosed by Cornell product and the Sokolow-Lyon voltage are associated with anatomical LVH; therefore, we investigated whether Cornell product and the Sokolow-Lyon voltage were associated with echocardiographic regional wall motion (measured by 2D-strain imaging). We reviewed data on 288 consecutive hypertensive patients who underwent both echocardiography and electrocardiography. Electrocardiographic LVH was calculated as follows: Cornell voltage, S in lead V3 + R in lead aVL; Cornell product, Cornell voltage (+0.6 mV for females) × QRS duration; and Sokolow-Lyon voltage, S in lead V1 + R in lead V5. The mean age of the subjects was 64.3 ± 13.2 years; 47.9% were men, and 65.2% were taking antihypertensive medications. Both Cornell product (r = 0.392, P < 0.001) and the Sokolow-Lyon voltage (r = 0.315, P < 0.001) were significantly related to left ventricular mass index (LVMI), and the relationship between Cornell product and LVMI (beta = 0.24, P = 0.001) was independent of the Sokolow-Lyon voltage (beta = 0.25, P < 0.001). In multivariate linear regression analysis in which the two ECG-LVH were included together, Cornell product was related to global longitudinal strain (beta = 0.24, P = 0.002), even after adjusting for the Sokolow-Lyon voltage (P = 0.835). Additionally, the Cornell voltage was related to the inner/outer ratio of circumferential strain (beta = 0.17, P = 0.033) after adjusting for the Sokolow-Lyon voltage (P = 0.318). By contrast, the Sokolow-Lyon voltage was related to the relative wall thickness and E/e' on tissue Doppler imaging, even after adjusting for Cornell product. In conclusion, Cornell product and voltage were associated with longitudinal regional wall motion and with the transmurality of regional wall motion in the short axis direction.

Effect of Renin-Angiotensin-Aldosterone System Blockade on Outcomes in Patients With ESRD: A Prospective Cohort Study in Korea

Introduction

Conflicting results still exist regarding the benefit of renin-angiotensin-aldosterone system (RAAS) blockade on clinical outcomes in dialysis patients. The aim of this study was to evaluate the effects of RAAS blockade on survival in Korean patients with end-stage renal disease (ESRD).

Methods

Our analysis was based on the data of 5223 patients enrolled from the Clinical Research Center for ESRD, a nationwide prospective observational cohort. Multivariate Cox regression was applied for risk factor analysis with the cumulative duration of RAAS blockade use as time-varying covariate. The risks for mortality from all causes and major cardiovascular event-free survival were estimated.

Results

Compared to the control group, patients in the RAAS group were younger but had a higher proportion of diabetes mellitus, had higher systolic blood pressure, required a greater number of prescribed antihypertensive drugs, and had a longer dialysis duration. On multivariate time-varying Cox regression analysis, the RAAS group with cumulative duration of >90 days was significantly associated with a lower risk of mortality from all causes after adjustment for confounding (hazard ratio [HR] = 0.45, 95% confidence interval [CI] = 0.35-0.58, P < 0.0001). Major cardiovascular event-free survival was also better for the RAAS group than for the control group on multivariate analysis (HR = 0.27, 95% CI = 0.20-0.37, P < 0.0001), considering the cumulative duration of RAAS blockade use.

Conclusion

In Korean patients with ESRD, we reported a specific benefit of RAAS blockade in improving overall survival after adjustment for confounding factors from real-world data.

Association of QRS duration with left ventricular volume and ejection fraction after anterior myocardial infarction assessed by gated single photon emission computed tomography

BACKGROUND

Even intermediate QRS prolongation without bundle branch block is associated with worse clinical outcome after myocardial infarction (MI). We assessed the association of QRS duration with left ventricular (LV) volume and ejection fraction after anterior MI by using quantitative gated single photon emission computed tomography (SPECT).

METHODS

Eighty-two patients with prior anterior MI were enrolled. Intermediate QRS prolongation was defined as QRS duration ≥100 ms without bundle branch block. Quantitative analysis of thallium SPECT was performed on the redistribution image. LV end-diastolic volume (LVEDV), end-systolic volume (LVESV) and ejection fraction (LVEF) were obtained.

RESULTS

There were 25 patients with intermediate QRS prolongation and 57 patients with normal QRS duation. Compared to patients with normal QRS duration, patients with intermediate QRS prolongation had larger LVEDV (137.4 ± 75.1 ml vs 87.9 ± 43.6 ml, p = .004), larger LVESV (89.9 ± 69.6 ml vs 49.2 ± 35.5 ml, p = .009) and lower LVEF (39.3 ± 14.6% vs 47.6 ± 12.0%, p = .02). QRS duration was positively associated with LVEDV (r = 0.49, p < .001) and LVESV (r = 0.47, p < .001), and was inversely associated with LVEF (r= -0.32, p < .001). Multivariate analysis showed that male sex (β = 0.22, p = .04), QRS duration (β = 0.34, p = .002) and number of abnormal Q waves (β = 0.37, p < .001) were associated with LVEDV. QRS duration (β= -0.32, p = .003) and number of abnormal Q waves (β = -0.40, p < .001) were associated with LVEF.

CONCLUSIONS

Our results suggest that QRS duration as well as number of abnormal Q waves is independently associated with LV volume and ejection fraction after anterior MI.

Limited Relationship of Voltage Criteria for Electrocardiogram Left Ventricular Hypertrophy to Cardiovascular Mortality

BACKGROUND

Numerous methods have been proposed for diagnosing left ventricular hypertrophy using the electrocardiogram. They have limited sensitivity for recognizing pathological hypertrophy, at least in part due to their inability to distinguish pathological from physiological hypertrophy. Our objective is to compare the major electrocardiogram-left ventricular hypertrophy criteria using cardiovascular mortality as a surrogate for pathological hypertrophy.

METHODS

This study was a retrospective analysis of 16,253 veterans < 56 years of age seen at a large Veterans Affairs Medical Center from 1987 to 1999 and followed a median of 17.8 years for cardiovascular mortality. Receiver operating characteristics and Cox hazard survival techniques were applied.

RESULTS

Of the 16,253 veterans included in our target population, the mean age was 43 years, 8.6% were female, 33.5% met criteria for electrocardiogram-left ventricular hypertrophy, and there were 744 cardiovascular deaths (annual cardiovascular mortality 0.25%). Receiver operating characteristic analysis demonstrated that the greatest area under the curve (AUC) for classification of cardiovascular death was obtained using the Romhilt-Estes score (0.63; 95% confidence interval, 0.61-0.65). Most of the voltage-only criteria had nondiagnostic area under the curves, with the Cornell being the best at 0.59 (95% confidence interval, 0.57-0.62). When the components of the Romhilt-Estes score were examined using step-wise Wald analysis, the voltage criteria dropped from the model. The Romhilt-Estes score ≥ 4, the Cornell, and the Peguero had the highest association with cardiovascular mortality (adjusted hazard ratios 2.2, 2.0, and 2.1, consecutively).

CONCLUSION

None of the electrocardiogram leads with voltage criteria exhibited sufficient classification power for clinical use.

Relationship between QRS measurements and left ventricular morphology and function in asymptomatic individuals

BACKGROUND AND AIM

QRS amplitude and duration are associated with increased left ventricular (LV) volume, mass and dysfunction. However, the diagnostic concordance between QRS measurements and LV morphology and function, as shown by Doppler echocardiography, is not well established. We investigated the relationships of QRS duration and amplitude with echocardiographic measurements of LV morphology and systolic and diastolic function in normal individuals.

METHODS

Individuals without signs or symptoms of coronary artery disease or heart failure, who underwent clinical examination as a part of a cross-sectional survey for the prevalence of coronary risk factors, randomly selected from the population list in Caltanissetta, Italy, were included in the study. QRS duration and amplitude were automatically measured using inbuilt software. LV ejection and filling patterns were studied using Doppler echocardiography.

RESULTS

We studied 184 individuals (96 men and 88 women), mean age 55.9 (11.3). QRS duration increased by 5.4 ms for every 100 g increase in LV mass, and by 4.6 ms for each 10 mm increase in LV end-diastolic diameter. The amplitude increased by 0.8 mm for every 100 g increase in LV mass. There was no relationship with LV dimensions. A nonlinear correlation was found between QRS amplitude and indexes of global dyssynchrony. The time-voltage QRS area correlated with LV mass, dimensions and indexes of dyssynchrony. There was no relationship between QRS measurements and ejection fraction.

CONCLUSIONS

QRS prolongation and increase in amplitude are strongly influenced by LV increased mass and volume, as well as by dyssynchrony, independently of ejection fraction.

Combining ECG Criteria for Left Ventricular Hypertrophy Improves Risk Prediction in Patients With Hypertension

BACKGROUND

Patients with hypertension with ECG left ventricular hypertrophy (LVH) have higher cardiovascular morbidity and mortality, but single ECG criteria may underestimate risk. Whether continued presence or new development of ECG LVH by 2 criteria can further concentrate risk during blood pressure lowering is unclear.

METHODS AND RESULTS

Incident stroke, myocardial infarction, cardiovascular death, the composite of these outcomes, and all-cause mortality were examined in relation to the presence of on-treatment ECG LVH by Cornell product and/or Sokolow-Lyon voltage during a mean of 4.8±0.9 years follow-up in 9193 patients with hypertension randomized to losartan- or atenolol-based regimens. Patients were categorized into 4 groups according to the presence or absence of ECG LVH by each criterion at baseline and yearly during the study. At baseline, LVH by both criteria was present in 960 patients (10.4%). Compared with the absence of ECG LVH by both criteria, persistence or development of ECG LVH by both criteria entered as a time-varying covariate was associated with >3-fold increased risks of events in multivariable Cox analyses adjusting for randomized treatment, baseline risk factors, and on-treatment heart rate and systolic and diastolic blood pressures. Patients with ECG LVH by either Cornell product or Sokolow-Lyon voltage had 45% to 140% higher risks of all end points.

CONCLUSIONS

Persistence or development of ECG LVH by both Cornell product and Sokolow-Lyon voltage criteria during antihypertensive therapy is associated with markedly increased risks of cardiovascular end points and all-cause mortality. Further study is indicated to determine whether additional therapy in these patients can reduce their risk.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00338260.