Left ventricular hypertrophy by Sokolow-Lyon voltage criterion predicts mortality in overweight hypertensive subjects

Prognostic factors in resistant hypertension: implications for cardiovascular risk stratification and therapeutic management

Resistant hypertension (RH) is defined as uncontrolled office blood pressure (BP) in spite of the use of at least three antihypertensive medications. Although its condition has a high prevalence, it is still understudied, and its prognosis is not well established. Some prospective studies evaluated the prognostic value of ambulatory BP monitoring, ECG and renal parameters. They pointed out that ambulatory BPs are important predictors of cardiovascular morbidity and mortality, whereas office BP has no prognostic value. The diagnosis of true RH and the nondipping pattern are also valuable predictors of cardiovascular outcomes. Moreover, several ECG (prolonged ventricular repolarization, serial changes in the strain pattern and left ventricular hypertrophy) and renal parameters (albuminuria and reduced glomerular filtration rate) are also powerful cardiovascular risk markers in RH. These markers and others yet unexplored, such as arterial stiffness and serum biomarkers, may improve cardiovascular risk stratification in these very high-risk patients.

Age- and gender-specific population attributable risks of metabolic disorders on all-cause and cardiovascular mortality in Taiwan

Background

The extent of attributable risks of metabolic syndrome (MetS) and its components on mortality remains unclear, especially with respect to age and gender. We aimed to assess the age- and gender-specific population attributable risks (PARs) for cardiovascular disease (CVD)-related mortality and all-cause mortality for public health planning.

Methods

A total of 2,092 men and 2,197 women 30 years of age and older, who were included in the 2002 Taiwan Survey of Hypertension, Hyperglycemia, and Hyperlipidemia (TwSHHH), were linked to national death certificates acquired through December 31, 2009. Cox proportional hazard models were used to calculate adjusted hazard ratios and PARs for mortality, with a median follow-up of 7.7 years.

Results

The respective PAR percentages of MetS for all-cause and CVD-related mortality were 11.6 and 39.2 in men, respectively, and 18.6 and 44.4 in women, respectively. Central obesity had the highest PAR for CVD mortality in women (57.5%), whereas arterial hypertension had the highest PAR in men (57.5%). For all-cause mortality, younger men and post-menopausal women had higher PARs related to Mets and its components; for CVD mortality, post-menopausal women had higher overall PARs than their pre-menopausal counterparts.

Conclusions

MetS has a limited application to the PAR for all-cause mortality, especially in men; its PAR for CVD mortality is more evident. For CVD mortality, MetS components have higher PARs than MetS itself, especially hypertension in men and waist circumference in post-menopausal women. In addition, PARs for diabetes mellitus and low HDL-cholesterol may exceed 20%. We suggest differential control of risk factors in different subpopulation as a strategy to prevent CVD-related mortality.

[Computerized interpretation of the electrocardiogram in the diagnosis of left ventricular hypertrophy. The ELECTROPRES project]

INTRODUCTION

Despite its low sensitivity, the electrocardiogram (ECG) is the tool used the most in the daily practice for detection of left ventricular hypertrophy (LVH). This study has aimed to assess the impact of the computerized interpretation of the ECG on the diagnosis of LVH in the practical clinical setting.

METHODS

ELECTROPRES is a project based on a free access computer platform that permits an online interpretation of the electrocardiogram. It includes 19 different left LVH criteria previously validated by echocardiography in a substudy. We analyzed the data from the first 669 patients with essential arterial hypertension (ATH) included in the ELECTROPRES platform from 21 primary care centers in 9 of the 17 Spanish autonomous communities.

RESULTS

Up to April 2010, a cohort of 669 hypertensive patients (51.7% women), with a mean age of 66.3±11.89 years, was analyzed. The mean evolution of the disease was 8 years, and the patients had been receiving an average of 2.4 antihypertensive agents. Systolic blood pressure was 139±17 mmHg and diastolic blood pressure 76±11. The ECG-known frequency of LVH was 3%. The prevalence of LVH increased up to 33.3% (P<0.001) with the ELECTROPRES platform. When all the criteria were independently examined, the Lewis index (R-I+S-III) and the Cornell product [(R-aVL+S-V3 (+6 for women)] were those in which the most cases of left ventricular hypertrophy were detected (24.8% and 13.3%, respectively). The Lewis index and the Cornell product were the criteria that detected more cases of left ventricular hypertrophy, regardless of the AHT stage and of the presence of cardiovascular complications.

CONCLUSIONS

The ECG computerized reading (ELECTROPRES platform) significantly increases detection of left ventricular hypertrophy in a population of essential hypertense subjects compared to conventional detection with the ECG by the physician in the usual clinical practice setting.

[Cardiovascular morbidity and mortality and electrocardiographic criteria of left ventricular hypertrophy in hypertensive patients treated in primary care]

FUNDAMENTALS AND OBJECTIVE: Electrocardiographic voltage criteria are the preferred method for diagnosis of left ventricular hypertrophy (LVH) in Primary Health Care (PHC). Several of these have been described as major adverse cardiovascular events (MACE) predictors. The aim of this study was to analyse the relationship between MACE occurrence in a cohort of hypertensive subjects in PHC and different electrocardiographic criteria recorded.

PATIENTS AND METHODS

265 hypertensive subjects attending PHC were randomly selected and followed up for 12 years. Standard 12-lead electrocardiograms were recorded at the beginning of the study. The occurrence of ischemic heart disease, heart failure, stroke, peripheral vascular disease, arrhythmia or cardiovascular death was considered as MACE. Electrocardiographic voltage criteria recorded were: Sokolow-Lyon, Minnesota code 3.1, Gubner and Ungerleider, Cornell voltage and Schillaci and Dalfó modifications. Data were analyzed using the life-table method and Cox regression models.

RESULTS

14,3% of patients lost to follow-up showed no differences in baseline characteristics from the rest of the cohort. The median follow-up was 10.1 years (IQR: 5.8-12.0). The cumulative survival rate was 53.5% (95% CI, 45.7-61.3%). The incidence of MACE was 5.85 (95% CI, 4.73-6.97) per 100 hypertensive patients-year. In the multivariate analysis none of the ECG criteria showed statistical association with the occurrence of MACE.

CONCLUSIONS

No association has been found between different electrocardiographic LVH criteria and the incidence of MACE in a cohort of hypertensive patients followed-up in a PHC setting for 12 years.

Prognostic impact of baseline and serial changes in electrocardiographic left ventricular hypertrophy in resistant hypertension

BACKGROUND

The prognostic value of electrocardiographic left ventricular hypertrophy (ECG-LVH) in resistant hypertension (RH) is unknown. The aim was to evaluate the importance of baseline and serial changes in ECG-LVH as predictors of cardiovascular morbidity and mortality in patients with RH.

METHODS

At baseline and during follow-up, 552 resistant hypertensive patients had 3 ECG-LVH criteria obtained: Sokolow-Lyon, Cornell voltage, and Cornell voltage-duration product. Primary end points were a composite of fatal and nonfatal cardiovascular events and all-cause and cardiovascular mortalities. Total strokes and coronary heart disease (CHD) events were secondary end points. Multiple Cox regression assessed the associations between time-varying ECG-LVH and subsequent end points.

RESULTS

After a median follow-up of 4.8 years, 70 patients died, 46 from cardiovascular causes; and 109 total cardiovascular events occurred, 46 strokes, and 44 CHD events. After adjustment for several cardiovascular risk factors, baseline Cornell voltage and product, but not Sokolow-Lyon voltage, were independent predictors of the composite end point and of all-cause and cardiovascular mortalities. Reductions of all ECG-LVH criteria were protective factors for the composite end point: a 1-SD (1.1 mV) reduction in Sokolow-Lyon voltage was associated with a 35% lower risk (95% CI 10%-53%) of cardiovascular events, whereas prevention or regression of Cornell product LVH criterion implied a 40% lower risk (95% CI 11%-60%). Baseline and serial changes in Sokolow-Lyon voltage were independent predictors of strokes, whereas Cornell voltage was predictive of CHD events.

CONCLUSIONS

Baseline and serial changes in ECG-LVH predict cardiovascular morbidity and mortality in RH patients. Antihypertensive treatment targeted at regression or prevention of ECG-LVH may improve prognosis.

The assessment of total cardiovascular risk in hypertensive subjects in primary care

BACKGROUND

Recently published guidelines emphasize that detection of any subclinical target organ damage in hypertensive subjects should be regarded as a sign of high cardiovascular risk.

AIM

To assess the ability of conventional multivariable cardiovascular disease risk prediction tools and high-sensitivity C-reactive protein (hs-CRP) to identify hypertensive subjects with target organ damage.

METHODS

Ankle-brachial index (ABI), estimated glomerular filtration rate (eGFR), electrocardiographically determined left ventricular hypertrophy (ECG-LVH), and base-line variables were measured in hypertensive subjects aged 45-70 years without established cardiovascular or renal disease or known diabetes.

RESULTS

Of the 495 subjects, 123 (24.8% (95% CI 21.1-28.9)) had ABI <1.00, 81 (16.4% (95% CI 13.2-19.9)) had ECG-LVH, and 41 (8.3% (95% CI 6.0-11.1)) had eGFR <60 mL/min/1.73 m(2). In patients with SCORE <5% or Framingham risk <20%, any sign of target organ damage was found in 46% and 49% of patients, respectively.

CONCLUSION

Assessment of ECG-LVH, ABI, and eGFR reclassifies a significant number of hypertensive patients to the high-risk category as compared to SCORE and Framingham risk prediction tools only.