The relationship between electrocardiographic left ventricular hypertrophy criteria and echocardiographic mass in patients undergoing transcatheter aortic valve replacement

Electrocardiography versus Echocardiography in Severe Aortic Stenosis with the Consideration of Coexistent Coronary Artery Disease

(1) Background: Coexistent coronary artery disease (CAD) might influence the ability of electrocardiogram (ECG) to identify echocardiographic left ventricular hypertrophy (ECHO-LVH) in patients with aortic stenosis (AS). We aimed to assess the relation between ECG-LVH (by the Sokolov-Lyon or Cornell criteria) and ECHO-LVH considering coexistent CAD. (2) Methods: We retrospectively analyzed the medical records of 74 patients (36 males) with severe AS who were hospitalized in the University Hospital in Cracow from 2021 to 2022. (3) Results: ECHO-LVH was present in 49 (66%) patients, whereas 35 (47.3%) patients had ECG-LVH. There was no difference between the rate of ECG-LVH in patients with vs. without ECHO-LVH. Single-vessel and multi-vessel CAD were diagnosed by invasive coronary angiography in 18% and 11% of patients, respectively. The sensitivity of the classical ECG-LVH criteria with regard to ECHO-LVH was low, reaching at best 41% for the Sokolov-Lyon and Cornell criteria. The results were similar and lacked a pattern when considering patients without significant stenosis, with single- and multi-vessel disease separately. Correlations between the left ventricular mass index and ECG-derived parameters were weak and present solely for the Lewis index (r = 0.31), R wave's amplitude >1.1 mV in aVL (r = 0.36), as well as the Cornell (r = 0.32) and Sokolov-Lyon (r = 0.31) voltage criteria (p < 0.01). The presence, location of stenoses, and CAD extent were not associated with the presence of either ECHO-LVH or ECG-LVH, irrespective of individual ECG-LVH criteria. (4) Conclusions: The sensitivity of classical ECG criteria for echocardiographic LVH in severe AS is low, regardless of coexistent CAD or its angiographic extent.

Implication of Different ECG Left Ventricular Hypertrophy in Patients Undergoing Transcatheter Aortic Valve Replacement

Background

Various ECG criteria for left ventricular hypertrophy (LVH) have been proposed, but their association with clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement is unknown. We investigated the prevalence of ECG LVH according to different criteria and its prognostic impact on clinical outcomes after transcatheter aortic valve replacement.

Methods and Results

In this prospective observational cohort, we evaluated 700 patients who underwent transcatheter aortic valve replacement between March 2010 and December 2019. Baseline preprocedural LVH was defined by 3 ECG criteria—Sokolow‐Lyon, Romhilt‐Estes, and Cornell voltage criteria. The primary outcome was major adverse cardiac or cerebrovascular event (MACCE; composite of death, myocardial infarction, stroke, or rehospitalization from cardiovascular cause); the key secondary outcome was all‐cause and cardiovascular mortality. Among 596 eligible patients, the prevalence of LVH was determined as 56.3% by Sokolow‐Lyon, 31.1% by Romhilt‐Estes, and 48.1% by Cornell criteria. Regardless of the criteria, patients with ECG LVH had more severe aortic stenosis hemodynamics and higher left ventricular mass index. After multivariate adjustment, the presence of LVH by the Cornell criteria was significantly associated with lower risks of MACCE (adjusted hazard ratio [HR], 0.68; 95% CI, 0.51–0.91; P=0.009), all‐cause mortality (adjusted HR, 0.55; 95% CI, 0.34–0.90 [P=0.017]), and cardiovascular mortality (adjusted HR, 0.40; 95% CI, 0.20–0.79 [P=0.008]). However, this association was absent with the Sokolow‐Lyon and Romhilt‐Estes criteria.

Conclusions

ECG LVH by Cornell criteria only was significantly associated with lower risks of MACCE and all‐cause or cardiovascular mortality.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03298178.

Electrocardiographic Versus Echocardiographic Left Ventricular Hypertrophy in Severe Aortic Stenosis

Although ECG used to be a traditional method to detect left ventricular hypertrophy (LVH), its importance has decreased over the years and echocardiography has emerged as a routine technique to diagnose LVH. Intriguingly, an independent negative prognostic effect of the "electrical" LVH (i.e., by ECG voltage criteria) beyond echocardiographic LVH was demonstrated both in hypertension and aortic stenosis (AS), the most prevalent heart valve disorder. Our aim was to estimate associations of the ECG-LVH voltage criteria with echocardiographic LVH and indices of AS severity. We retrospectively manually analyzed ECG tracings of 50 patients hospitalized in our center for severe isolated aortic stenosis, including 32 subjects with echocardiographic LVH. The sensitivity of single traditional ECG-LVH criteria in detecting echocardiographic LVH was 9-34% and their respective specificity averaged 78-100%. The ability to predict echocardiographic LVH was higher for S-waves than R-waves (mean area under the receiver operating curve (AUC): 0.62-0.70 vs. 0.58-0.65). Among combinations of R- and S-waves, the discriminating ability was highest for the Cornell voltage (AUC: 0.71) compared to the Sokolow-Lyon, Romhilt and Gubner-Ungerleider voltage (AUC: 0.62-0.68). By multiple regression, peak aortic pressure gradient was positively related to the Sokolow-Lyon (β = 1.7 ± 0.5, p = 0.002) and Romhilt voltage (β = 1.3 ± 0.5, p = 0.01), but not Cornell (0.5 ± 0.3, p = 0.2) or Gubner-Ungerleider voltage (β = 0.0 ± 0.5, p > 0.9), regardless of LV mass index. In conclusion, echocardiographic LVH and stenosis severity appear to have distinct associations with traditional ECG-LVH criteria in AS. A moderate diagnostic superiority of the Cornell voltage criterion with regard to anatomic LVH might result from its unique ability to include depolarization vectors in both the frontal and horizontal plane with consequent lesser sensitivity to the confounding effect of obesity.

The electrocardiogram: Still a useful marker for LV fibrosis in aortic stenosis

Left ventricular (LV) strain on the electrocardiogram (ECG) (down-sloping, convex ST-segment depression with asymmetric T-wave inversion in leads V5 and V6) reflects fibrosis as a result of subendocardial ischemia. It is associated with a significantly increased risk of cardiovascular events independent of the presence of LV hypertrophy on the echocardiogram or cardiac magnetic resonance (CMR) scan. Ongoing studies of early aortic valve replacement in asymptomatic patients with severe aortic stenosis are using ECG changes as a marker of possible fibrosis shown by midwall late gadolinium enhancement on CMR. However, until these studies report, it is still reasonable to respond to LV strain on the ECG by tightening control of systemic hypertension and consider intervention in cases where indications are otherwise in borderline.

Electrocardiographic criteria for left ventricular hypertrophy in aortic valve stenosis: Correlation with echocardiographic parameters

BACKGROUND

Aortic valve stenosis (AS) generates a chronic pressure overload that induces left ventricular hypertrophy (LVH). The aim of this study was to assess the prevalence of the electrocardiographic criteria for LVH in patients with clinically significant AS and to evaluate the relationship between the ECG criteria for LVH and echocardiographic parameters.

METHODS

The clinical data of 95 patients with moderate to severe AS were retrospectively analyzed. Eight ECG criteria for LVH were used and compared to the results of transthoracic echocardiography (TTE).

RESULTS

In 59% of patients, at least one of the ECG criteria for LVH was found. These patients had a greater LVMI (142.1 ± 35.6 vs. 124.1 ± 22.5 g/m² , p = 0.01) and peak aortic jet velocity (4.2 ± 0.8 vs. 3.8 ± 0.9 m/s, p = 0.01) along with smaller aortic valve area (0.72 ± 0.28 vs. 0.86 ± 0.22 cm² , p = 0.02) compared to patients with a negative ECG for LVH. The ECG parameters had a low sensitivity (6%-36.9%) with a specificity of up to 100%. The Cornell Voltage criteria had the best sensitivity with a specificity of 63.6% and the highest correlation with the LVMI (r = 0.38, p < 0.001). All of the ECG parameters correlated positively with the peak aortic jet velocity as well as with the mean aortic gradient.

CONCLUSION

The electrocardiographic criteria for LVH in patients with moderate or severe AS have a poor sensitivity in identifying LVH confirmed by TTE. The values of the selected ECG criteria for LVH correlate weakly with both the TTE indices of LVH and the markers of AS severity.

Possible predictive role of electrical risk score on transcatheter aortic valve replacement outcomes in older patients: preliminary data

Objectives

To evaluate the predicative power of the electrical risk score (ERS), a noninvasive and inexpensive test obtained by means of a standard 12-lead electrocardiogram (ECG), in a cohort of elderly patients who had undergone transcatheter aortic valve replacement (TAVR).

Methods

Survivors and non-survivors after TAVR at 1-year follow-up were compared in respect to the pre-procedural ERS as well as a number of other clinical and instrumental variables. ERS is composed of seven simple ECG markers: heart rate (>75 bpm); QRS duration (>110 ms); left ventricular hypertrophy (Sokolow–Lyon criteria); delayed QRS transition zone (≥ V4); frontal QRS-T angle (>90°); long QT_Bazett (>450 ms for men and >460 in women) or JT_Bazett (330 ms for men and >340 ms for women); and long Tpeak to Tend interval (T_p-e) (>89 ms). The trial was registered in ClinicalTrials.gov as NCT03145376.

Results

A total of 40 patients were evaluated. During the follow-up, the all-cause mortality rate was 25% (ten patients) with 15% of cardiovascular death (six patients). The ERS was the strongest predictor of all-cause (odds ratio 3.73, 95% CI: 1.44–9.66, P<0.05) or cardiovascular (odds ratio 3.95, 95% CI: 1.09–14.27, P<0.05) mortality. Receiver operating characteristic curves showed that ERS had the widest significant sensitivity-specificity area under the curve (AUC) predicting all-cause (AUC: 0.855, P<0.05) or cardiovascular mortality (AUC: 0.908, P<0.05).

Conclusion

ERS seems to be a useful noninvasive tool able to stratify the risk of mortality in 1-year follow-up of TAVR patients. These findings, however, require larger trials to be confirmed.

Diagnostic utility of biomarkers of left ventricular stress in patients with aortic stenosis and preserved left ventricular ejection fraction

INTRODUCTION

Aortic stenosis (AS) is the most common acquired valvular heart disease. The early identification of patients with severe AS is crucial. NT-proBNP is a well-known biomarker of pressure overload, and its role in patients with AS has been demonstrated in previous studies. Another, less well-known biomarker of pressure overload is sST2 protein, and its role in AS is unclear.

AIM

To evaluate the utility of sST2 protein, NT-proBNP and selected clinical parameters in the assessment of degenerative AS severity in a population with preserved left ventricular ejection fraction (LVEF).

MATERIAL AND METHODS

Sixty-nine consecutive patients (mean age: 68.42 ±12.58 years, 55.07% male) with symptomatic degenerative AS and preserved LVEF ≥ 45% were prospectively included. At enrollment complete transthoracic echocardiographic examination, ECG analysis, and standard laboratory tests including NT-proBNP were performed and blood samples for sST2 were obtained.

RESULTS

There were 43 (62.32%) patients with severe AS. The multivariate stepwise linear regression models revealed that only systolic blood pressure (SBP), Sokolow-Lyon index and left ventricular end-diastolic diameter (LVEDD) were independently associated with severe AS. Spearman correlation coefficients analysis showed no correlations between sST2 levels and a mild to moderate correlation between NT-proBNP concentration and parameters of AS severity. However, levels of NT-proBNP (p = 0.1857) and sST2 (p = 0.7851) did not differentiate patients according to severity of AS.

CONCLUSIONS

In the study population with degenerative AS and preserved LVEF neither the NT-proBNP nor sST2 concentrations can be used to differentiate patients according to the severity of AS.

Diffuse Myocardial Fibrosis Reduces Electrocardiographic Voltage Measures of Left Ventricular Hypertrophy Independent of Left Ventricular Mass

Background

Myocardial fibrosis quantified by myocardial extracellular volume fraction (ECV) and left ventricular mass (LVM) index (LVMI) measured by cardiovascular magnetic resonance might represent independent and opposing contributors to ECG voltage measures of left ventricular hypertrophy (LVH). Diffuse myocardial fibrosis can occur in LVH and interfere with ECG voltage measures. This phenomenon could explain the decreased sensitivity of LVH detectable by ECG, a fundamental diagnostic tool in cardiology.

Methods and Results

We identified 77 patients (median age, 53 [interquartile range, 26–60] years; 49% female) referred for contrast‐enhanced cardiovascular magnetic resonance with ECV measures and 12‐lead ECG. Exclusion criteria included clinical confounders that might influence ECG measures of LVH. We evaluated ECG voltage‐based LVH measures, including Sokolow‐Lyon index, Cornell voltage, 12‐lead voltage, and the vectorcardiogram spatial QRS voltage, with respect to LVMI and ECV. ECV and LVMI were not correlated (R²=0.02; P=0.25). For all voltage‐related parameters, higher LVMI resulted in greater voltage (r=0.33–0.49; P<0.05 for all), whereas increased ECV resulted in lower voltage (r=−0.32 to −0.57; P<0.05 for all). When accounting for body fat, LV end‐diastolic volume, and mass‐to‐volume ratio, both LVMI (β=0.58, P=0.03) and ECV (β=−0.46, P<0.001) were independent predictors of QRS voltage (multivariate adjusted R²=0.39; P<0.001).

Conclusions

Myocardial mass and diffuse myocardial fibrosis have independent and opposing effects upon ECG voltage measures of LVH. Diffuse myocardial fibrosis quantified by ECV can obscure the ECG manifestations of increased LVM. This provides mechanistic insight, which can explain the limited sensitivity of the ECG for detecting increased LVM.

Longitudinal associations between adiponectin and cardiac structure differ by hypertensive status: Coronary Artery Risk Development in Young Adults

OBJECTIVE

We studied the longitudinal association between adiponectin and cardiac structure and function 10 years later stratified by hypertension status.

METHODS

Multicenter longitudinal study of black and white men and women that began in 1985-1986, when participants were 18-30 years old. Adiponectin was measured at year 15(2000-2001). Echocardiograms were completed at year 25(2010-2011). Participants were stratified by the presence of hypertension. Risk factor-adjusted echocardiographic variables were compared across adiponectin quintiles. Linear and quadratic regression models were also derived for risk factor-adjusted echocardiographic variables.

RESULTS

Relative to the lowest quintile of adiponectin, participants from the highest quintile had a 6% lower LV mass index (LVMi) among normotensives, and an 8% higher LVMi among hypertensives. Among normotensive participants, regression analysis demonstrated a linear inverse relationship between adiponectin and LV mass, LVMi, posterior wall thickness (PWT) and ventricular septal thickness (VST) (all p≤0.05). Among hypertensive participants, regression analysis demonstrated a U-shaped relationship between adiponectin and LV mass, LVMi, PWT and VST (p≤0.005 for all quadratic terms).

CONCLUSIONS

Among normotensive participants, higher adiponectin may be a useful marker of less adverse future cardiac structure. Further study is required to see if adiponectin receptor agonists may provide a benefit among these individuals. Among hypertensive participants, further study is required to assess the prognostic and therapeutic use of adiponectin.