Accuracy and prognostic significance of electrocardiographic markers of left ventricular hypertrophy in a general population: findings from the Pressioni Arteriose Monitorate E Loro Associazioni population

Electrocardiographic abnormalities in patients with sickle cell disease: A systematic review and meta-analysis

BACKGROUND

Previous studies have documented that electrocardiography (ECG) can reveal a range of abnormalities, offering valuable insights into the cardiac evaluation of patients with sickle cell disease (SCD). The objective of this study is to assess the patterns of ECG abnormalities observed in these patients with SCD, and to determine their prevalence.

METHOD

We systematically reviewed the literature using online databases of PubMed, Scopus, Web of Science, Embase, and Google Scholar to identify original studies that reported findings of standard ECG assessments in patients with SCD. Statistical analyses were performed using the random effects model. Additional analyses including sensitivity analysis and subgroup analysis were also conducted.

RESULTS

Analysis of data from 59 studies involving 897,920 individuals with SCD revealed that 75% of these patients had abnormal ECG findings (67%-81%), which were predominantly nonspecific ST-T changes, left ventricular hypertrophy, T-wave changes, prolonged corrected QT (QTc) interval, and ischemic changes. Besides, it was shown that these patients had significantly higher odds of having any ECG abnormalities (OR of 17.50, 4.68-65.49), right atrial enlargement (6.09, 1.48-25.09), left ventricular hypertrophy (3.45, 1.73-6.89), right ventricular hypertrophy (7.18, 2.28-22.57), biventricular hypertrophy (10.11, 1.99-51.38), prolonged QTc interval (5.54, 2.44-12.59), ST depression (3.34, 1.87-5.97), and T-wave changes (5.41, 1.43-20.56). Moreover, the mean of QTc interval was significantly higher among those with SCD (23.51 milliseconds, 16.08-30.94).

CONCLUSION

Our meta-analysis showed a higher prevalence of abnormal ECG findings among individuals with SCD. A significant proportion of these patients had various ECG abnormalities, suggesting a potential need for regular ECG assessments for patients with SCD.

Comparison of electrocardiographic versus echocardiographic detection of left ventricular mass changes over time and evaluation of new onset left ventricular hypertrophy

We assessed the value of 3 electrocardiographic (EKG) voltage criteria in detecting variations of left ventricular mass (LVM) over time, taking echocardiographic (ECHO) LVM as reference, in the Pressioni Arteriose Monitorate E Loro Associazioni study. In 927 subjects (age 47 ± 13 years on entry, 49.9% men) an ECHO evaluation of LVM and EKG suitable for measurement of EKG-LVH criteria (Sokolow-Lyon voltage, Cornell voltage and R-wave voltage in aVL) were available at baseline and at a 2^nd evaluation performed 10 years later. Δ (delta) LVM, Δ LVMI, and Δ EKG parameters values were calculated from 2^nd evaluation to baseline. The sensitivity of the EKG criteria in the diagnosis of LVH, poor at baseline, becomes even worse after 10 years, reaching very low values. Only the sensitivity of R-wave amplitude exhibited slight increase over time but with unsatisfactory absolute values. Despite the prevalence of ECHO-LVH at the 2^nd evaluation was threefold increased compared to baseline (29.3% and 33.7% for LVM indexed to BSA and height^2.7 , respectively), the prevalence of EKG-LVH was unchanged when evaluated by Sokolow-Lyon criteria, significantly reduced when assessed by Cornell voltage index, while significantly increased using R-wave voltage in aVL criteria. Despite an ECHO-LVM increase over the time, mean EKG changes were of opposite sign, except for R-wave amplitude in aVL. Our study highlights the discrepancy between ECHO and EKG in monitoring LVM changes over the time, especially for Sokolow-Lyon and Cornell voltage. Thus, EKG is an unsuitable method for the longitudinal evaluation of LVM variations.

Prevalence and long-term prognostic implications of prolonged QRS duration in left ventricular hypertrophy: a population-based observational cohort study

OBJECTIVES

ECG left ventricular hypertrophy (ECG-LVH) has been associated with left ventricular dysfunction and adverse prognosis, but little is known about the prevalence and prognostic significance of different levels of QRS duration in the presence of ECG-LVH in a general population.

DESIGN

Population-based observational prospective cohort study.

PARTICIPANTS

Nationally representative random cluster of Finnish adult population.

METHODS

We assessed the prevalence and long-term (median 15.9 years) prognostic significance of QRS duration in ECG-LVH, and compared the risk to individuals without ECG-LVH in a predominantly middle-aged random sample of 6033 Finnish subjects aged over 30 years (mean age 52.2, SD 14.6 years), who participated in a health examination including a 12-lead ECG.

MAIN OUTCOME MEASURES

Cardiovascular and all-cause mortality, incidence of heart failure (HF).

RESULTS

ECG-LVH was present in 1337 (22.2%) subjects; 403 of these (30.1%) had QRS duration ≥100 ms and 100 (7.5%) had ≥110 ms. The increased risk of mortality in ECG-LVH became evident after a QRS threshold of ≥100 ms. After controlling for known clinical risk factors, QRS 100-109 ms was associated with increased cardiovascular (HR 1.38, 95% CI 1.01 to 1.88, p=0.045) and QRS≥110 ms with cardiovascular (1.74, 95% CI 1.07 to 2.82, p=0.025) and all-cause mortality (1.52, 95% CI 1.02 to 2.25, p=0.039) in ECG-LVH. The risk of new-onset HF was two-fold in subjects with QRS 100-109 ms and threefold in subjects with QRS ≥110 ms, even after adjustment for incident myocardial infarction within the follow-up. When the prognosis was compared with subjects without ECG-LVH, subjects with ECG-LVH but QRS duration <100 ms displayed similar mortality rates with or without ECG-LVH but higher rates of incident HF.

CONCLUSIONS

In ECG-LVH, the risk of excess mortality and new-onset HF markedly increases with longer QRS duration, but even QRS duration within normal limits in ECG-LVH carried a risk of HF compared with the risk in individuals without ECG-LVH.

Complementary value of ECG and echocardiographic left ventricular hypertrophy for prediction of adverse outcomes in the general population

OBJECTIVE

To investigate whether ECG left ventricular hypertrophy (ECG-LVH) has prognostic value independent of echocardiography LVH (Echo-LVH).

METHODS

Participants (N = 9744, mean age, 53.81 ± 10.49 years and 45.5% male) from the Northeast China Rural Cardiovascular Health Study were included. Associations between Echo-LVH (sex-specific left ventricular mass normalized to BSA) and ECG-LVH (diagnosed using the Cornell-voltage duration product) and adverse outcomes were evaluated using Cox regression. The value of ECG-LVH for predicting adverse events was evaluated by reclassification and discrimination analyses.

RESULTS

Median follow-up was 4.65 years; 563 participants developed incident stroke or coronary heart disease (CHD) and 402 died. Compared with participants without either condition, those with both Echo-LVH and ECG-LVH had a significantly increased risk of incident stroke or CHD (hazard ratio, 2.42; 95% confidence interval, 1.82-3.22) and mortality (2.58; 1.85-3.60). ECG-LVH remained an independent risk factors for both outcomes when ECG-LVH and Echo-LVH were included in the model as separate variables [incident stroke or CHD (1.43; 1.14-1.79); mortality (1.41; 1.08-1.84)]. Reclassification and discrimination analyses indicated ECG-LVH addition could improve the conventional model for predicting adverse outcomes within 4 years. These relationships persisted after excluding participants with cardiovascular disease history or taking antihypertension drugs or upon applying other ECG-LVH and Echo-LVH diagnostic criteria.

CONCLUSION

Our study provides strong evidence that ECG-LVH is associated with adverse outcomes, independent of Echo-LVH. Clinically, ECG-LVH could be considered as a consequential factor, especially in those with Echo-LVH. These findings have potential clinical relevance for risk stratification.

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.

Predictive value of electrocardiographic left ventricular hypertrophy in the general population: A meta-analysis

BACKGROUND

Conflicting results have been reported on the predictive value of the electrocardiographic left ventricular hypertrophy (LVH) in the general population. This meta-analysis sought to compare the predictive value of different electrocardiographic criteria of LVH in the general population.

METHODS

We comprehensively searched PubMed and Embase databases until May 9, 2020 to identify observational studies investigating the predictive value of different electrocardiographic criteria for LVH (Sokolow-Lyon voltage, Cornell voltage or Cornell product) in the general population. Outcome measures were major adverse cardiovascular events (MACEs), cardiovascular or all-cause mortality.

RESULTS

Ten studies enrolling 58,400 individuals were included. Comparison with and without electrocardiographic LVH, the pooled risk ratio (RR) of MACEs was 1.62 (95% confidence interval [CI] 1.40-1.89) for the Sokolow-Lyon voltage criteria, 1.70 (95% CI 1.27-2.29) for the Cornell voltage criteria, and 1.56 (95% CI 1.17-2) for the Cornell product criteria. The pooled RR of all-cause mortality was 1.47 (95% CI 1.10-1.97) for the Sokolow-Lyon voltage criteria and 1.87 (95% CI 1.29-2.71) for the Cornell voltage criteria. Furthermore, the pooled RR of cardiovascular mortality was 1.38 (95% CI 1.19-1.60) for the Sokolow-Lyon criteria, 1.66 (95% CI 1.24-2.33) for the Cornell voltage criteria, and 1.82 (95% CI 0.65-5.09) for the Cornell product criteria.

CONCLUSIONS

Different electrocardiographic criteria for evaluating LVH had a similar value in predicting MACEs among the general population. LVH detected by the Cornell voltage appeared to have a stronger predictive value in prediction of cardiovascular or all-cause mortality.

Additional prognostic value of electrocardiographic left ventricular hypertrophy in traditional cardiovascular risk assessments in chronic kidney disease

BACKGROUND

Left ventricular hypertrophy (LVH) is a common predictor of the cardiovascular prognosis in chronic kidney disease (CKD). However, whether or not electrocardiography-derived LVH (ECG-LVH) has prognostic value in patients with various degrees of CKD and improves the cardiovascular risk stratification based on traditional risk factors remains unclear.

METHODS

A total of 7206 participants at least 40 years of age who were free from cardiovascular events in a general population were followed for the incidence of cardiovascular events. CKD was confirmed by either the presence of a reduced estimated glomerular filtration rate (eGFR) (<60 ml/min per 1.73 m) or albuminuria, defined as a urinary albumin-to-creatinine ratio (UACR) of at least 30 mg/g Cr.

RESULTS

A total of 1886 (26.2%) had CKD, of which 1471 (78.0%) had a preserved eGFR (CKD stage 1-2). After an average 11.3 years of follow-up, the adjusted hazard ratio for the incidence of cardiovascular events significantly increased for ECG-LVH according to the Sokolow--Lyon voltage, Cornell voltage, or Cornell voltage product among participants with CKD (hazard ratio 1.47, P = 0.002), in contrast to those without CKD (hazard ratio 1.15, P = 0.210). The inclusion of any ECG-LVH parameters improved the accuracy of reclassification in any risk prediction model based on the eGFR, UACR, or Framingham 10-year risk score in the CKD participants (net reclassification improvement = 0.13-0.32, all P values <0.040).

CONCLUSION

In patients with CKD stage 1-5, ECG-LVH is useful for predicting the risk of future cardiovascular events and adds prognostic information to traditional cardiovascular risk assessments.

Correction of QRS voltage for body mass index does not improve the prediction of fatal and nonfatal cardiovascular events. The Moli-sani study

BACKGROUND AND AIMS

The diagnosis of LVH by ECG may particularly difficult in obese individuals. The aim of this study was to prospectively investigate whether the correction for body mass index (BMI) might improve the prognostic significance for cerebro and cardiovascular events of two electrocardiographic (ECG) criteria for left ventricular hypertrophy (LVH) in a large cohort of Italian adults.

METHODS AND RESULTS

In 18,330 adults (54 ± 11 years, 55% women) from the Moli-sani cohort, obesity was defined using the ATPIII criteria. The Sokolow-Lyon (SL) and Cornell Voltage (CV) criteria were used for ECG-LVH. In overweight and obese subjects, as compared with normal weight, the prevalence of ECG-LVH by the SL index was lower. During follow-up (median 4.3 yrs), 503 cerebro and cardiovascular events occurred. One standard deviation (1-SD) increment in uncorrected and in BMI-corrected SL index and CV was associated with an increased risk of events (HR 1.12, 95% CI 1.02-1.22 and HR 1.16, 95% CI 1.06-1.26 and HR 1.12, 95% CI 1.03-1.23 and HR 1.17, 95% CI 1.07-1.27, respectively for SL and CV). In obese subjects, 1-SD increment in uncorrected CV and in BMI-corrected CV was not associated to a significant risk of events (HR 1.05, 95% CI 0.910-1.22 and HR 1.08, 95% CI 0.95-1.23 respectively). Uncorrected SL index showed a significant association with events, which was marginally stronger with BMI-corrected SL voltage (HR 1.18, 95% CI 1.02-1.37 and HR 1.17, 95% CI 1.04-1.33 respectively, Akaike information criterion change from 3220 to 3218).

CONCLUSIONS

BMI correction of ECG LVH voltage criteria does not significantly improve the prediction of cerebro and cardiovascular events in obese patients in a large cohort at low cardiovascular risk.

Value of electrocardiographic left ventricular hypertrophy as a predictor of poor blood pressure control: Evidence from the China stroke primary prevention trial

Recent studies have shown that hypertension is poorly controlled in many populations worldwide. Electrocardiographic left ventricular hypertrophy is a common manifestation of preclinical cardiovascular disease that strongly predicts cardiovascular disease morbidity and mortality. However, little information is available regarding the role of left ventricular hypertrophy in blood pressure (BP) control. We aimed to assess the relationship between electrocardiographic left ventricular hypertrophy and BP control in the China Stroke Primary Prevention Trial. The study population included 17,312 hypertensive patients who were selected from a group of 20,702 adults who had participated in the China Stroke Primary Prevention Trial and had undergone electrocardiography at baseline visit. Multivariate analysis identified left ventricular hypertrophy as a predictor of unsatisfactory BP control. The results revealed that 8.1% of hypertensive adults exhibit left ventricular hypertrophy and that the disease is more prevalent in males (12.8%) than in females. Multivariate regression analysis showed that the electrocardiographic left ventricular hypertrophy group had a significantly higher rate of unsatisfactory BP control [odds ratio (OR) 1.42, 95% confidence interval (95% CI) 1.26-1.61, P < .001) than the nonleft ventricular hypertrophy group.Notable differences in BP control were also observed among males (OR 1.37, 95% CI 1.17-1.60, P < .001) and females (OR 1.45, 95% CI 1.18-1.77, P < .001) and especially among patients with comorbid diabetes (OR 2.32, 95% CI 1.31-4.12, P = .004). In conclusion, the results of this study indicate that electrocardiographic left ventricular hypertrophy appears to be an independent predictive factor for poor BP control, especially in females and patients with comorbid diabetes.

Long-Term Effects of an Intensive Lifestyle Intervention on Electrocardiographic Criteria for Left Ventricular Hypertrophy: The Look AHEAD Trial

BACKGROUND

Left ventricular hypertrophy assessed by electrocardiography (ECG-LVH) is a marker of subclinical cardiac damage and a strong predictor of cardiovascular disease (CVD) events. The prevalence of ECG-LVH is increased in obesity and type 2 diabetes; however, there are no data on the long-term effects of weight loss on ECG-LVH. The purpose of this study was to determine whether an intensive lifestyle intervention (ILI) reduces ECG-LVH in overweight and obese adults with type 2 diabetes.

METHODS

Data from 4,790 Look AHEAD participants (mean age: 58.8 ± 6.8 years, 63.2% White) who were randomized to a 10-year ILI (n = 2,406) or diabetes support and education (DSE, n = 2,384) were included. ECG-LVH defined by Cornell voltage criteria was assessed every 2 years. Longitudinal logistic regression analysis with generalized estimation equations and linear mixed models were used to compare the prevalence of ECG-LVH and changes in absolute Cornell voltage over time between intervention groups, with tests of interactions by sex, race/ethnicity, and baseline CVD status.

RESULTS

The prevalence of ECG-LVH at baseline was 5.2% in the DSE group and 5.0% in the ILI group (P = 0.74). Over a median 9.5 years of follow-up, prevalent ECG-LVH increased similarly in both groups (odds ratio: 1.02, 95% confidence interval: 0.83-1.25; group × time interaction, P = 0.49). Increases in Cornell voltage during follow-up were also similar between intervention groups (group × time interaction, P = 0.57). Intervention effects were generally similar between subgroups of interest.

CONCLUSIONS

The Look AHEAD long-term lifestyle intervention does not significantly lower ECG-LVH in overweight and obese adults with type 2 diabetes.

CLINICAL TRIALS REGISTRATION

Trial Number NCT00017953 (ClinicalTrials.gov).

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.

Accuracy of ECG indices for diagnosis of left ventricular hypertrophy in people >65 years: results from the ActiFE study

BACKGROUND

The detection of left ventricular hypertrophy (LVH) is still a common objective of electrocardiography (ECG) in clinical practice.

AIMS

The aim of our study was to evaluate the accuracy of LVH ECG indices in people older than 65 recruited from a population-based cohort (ActiFE-Ulm study).

METHODS

In 432 subjects (mean age 76.2 ± 5.5 years, 51% male), left ventricular mass was echocardiographically determined (Devereux formula) and indexed (LVMI) to body surface area. Several LVH ECG indices (Lewis voltage, Gubner-Ungerleider voltage, Sokolow-Lyon voltage/product, Cornell voltage/product) were calculated with the help of resting ECG data and compared with the echocardiographic assessment.

RESULTS

Despite echocardiographic signs of LVH [LVMI > 115 (♂) or >95 g/m² (♀)] in 47.5% of all subjects, diagnostic performance of all ECG indices was generally low. Magnitude of all LVH-indices was mainly predicted by frontal QRS axis in multivariate linear regression analysis. In comparison with the literature data from younger subjects, average frontal QRS axis turned counterclockwise.

DISCUSSION AND CONCLUSIONS

Most probably, age-related counterclockwise turn of frontal QRS axis is mainly explanatory for the decreased magnitude of LVH ECG indices and consecutive worse diagnostic performance of these indices in the elderly. ECG indices for detection of LVH have insufficient predictive values in geriatric subjects and should therefore not be used clinically for this purpose. Nevertheless, due to its established relevancy in cardiac risk stratification in this age group, usage of some established ECG indices might keep its significance even in the age of modern cardiac imaging.

Models for improved diagnosis of left ventricular hypertrophy based on conventional electrocardiographic criteria

BACKGROUND

Electrocardiogram (ECG) is commonly used clinically due to convenience, but its accuracy is insufficient for left ventricular hypertrophy (LVH) diagnosis. In this study, we attempted to improve diagnostic accuracy of LVH by establishing models with ECG parameters.

METHODS

Eighty hundred and twenty eight patients were recruited in the present study which were divided into groups according to gender, age and body mass index (BMI). The sensitivity, specificity, Youden index, positive predictive value, negative predictive value and accuracy were calculated using ultrasonic cardiogram criteria of LVH as the gold standard. Area under the curve was also calculated to assess the diagnostic accuracy of 22 conventional ECG criteria in different groups. Stepwise discriminant analyses were performed to establish models of ECG for LVH.

RESULTS

The diagnostic accuracy of ECG11 (S V₂ + R V_5,6) and ECG12 (S V_1,2 + R V_5,6) was significantly higher than the other 20 criteria, while ECG15 (R V₅/R V₆) was lowest. The ECG12 sensitivity for males was 52.5%, for <60 years old was 44.2%, and for BMI <25 kg/m² was 46.2%,higher than for females (27.5%), for ≧60 years old (35.7%), and for BMI ≧25 kg/m²(27.6%), respectively. The difference between genders was the most obvious. Based on these observations, the following models for males and females were established:[Formula: see text]and[Formula: see text]respectively. The sensitivities of the two new models were 71.4% and 75.8%, significantly higher than the22 conventional ECG criteria.

CONCLUSION

Two models developed based on gender can be considered for use to investigate the preliminary assessment of the probability of LVH.

Carotid Atherosclerosis and Electrocardiographic Left Ventricular Hypertrophy in the General Population: The Namwon Study

This study aimed to investigate the relationship between carotid atherosclerosis and left ventricular hypertrophy on electrocardiogram (ECG-LVH) on adults living in the community. A total of 9,266 adults who participated in the Namwon Study were included in this analysis. Carotid atherosclerosis, including intima-media thickness (IMT) and plaques, were assessed using high-resolution B-mode ultrasound. ECG-LVH was determined using the Sokolow-Lyon voltage (SokV) and Cornell voltage (CorV) criteria. The prevalence of ECG-LVH was 12.7% using the SokV criteria and 9.7% using the CorV criteria. After full adjustment, compared to the lowest quartile of common carotid artery IMT (CCA-IMT), the odds ratios and 95% confidence intervals for ECG-LVH of the carotid IMT quartiles 2, 3, and 4 increased linearly as follows: 1.54 (1.24-1.90), 1.62 (1.31-2.02), and 1.91 (1.54-2.38), respectively, for the SokV criteria (p<0.001); and 1.33 (1.05-1.68), 1.41 (1.11-1.78), and 1.48 (1.16-1.88), respectively, for the CorV criteria (p=0.003). Positive associations between the carotid bulb IMT (CB-IMT) quartiles and the ECG-LVH were also observed, although the magnitudes of association between CB-IMT and ECG-LVH were slightly lower than those of CCA-IMT. However, no significant association between carotid plaques and ECG-LVH as defined by the SokV or CorV criteria was found. The present study demonstrated that increased carotid IMT, but not carotid plaques, is significantly associated with LVH defined by various ECG criteria in a large population.

Effectiveness of Chlorthalidone Plus Amiloride for the Prevention of Hypertension: The PREVER-Prevention Randomized Clinical Trial

BACKGROUND

Prehypertension is associated with higher cardiovascular risk, target organ damage, and incidence of hypertension. The Prevention of Hypertension in Patients with PreHypertension (PREVER-Prevention) trial aimed to evaluate the efficacy and safety of a low-dose diuretic for the prevention of hypertension and end-organ damage.

METHODS AND RESULTS

This randomized, parallel, double-blind, placebo-controlled trial was conducted in 21 Brazilian academic medical centers. Participants with prehypertension who were aged 30 to 70 years and who did not reach optimal blood pressure after 3 months of lifestyle intervention were randomized to a chlorthalidone/amiloride combination pill or placebo and were evaluated every 3 months during 18 months of treatment. The primary outcome was incidence of hypertension. Development or worsening of microalbuminuria, new-onset diabetes mellitus, and reduction of left ventricular mass were secondary outcomes. Participant characteristics were evenly distributed by trial arms. The incidence of hypertension was significantly lower in 372 study participants allocated to diuretics compared with 358 allocated to placebo (hazard ratio 0.56, 95% CI 0.38-0.82), resulting in a cumulative incidence of 11.7% in the diuretic arm versus 19.5% in the placebo arm (P=0.004). Adverse events; levels of blood glucose, glycosylated hemoglobin, creatinine, and microalbuminuria; and incidence of diabetes mellitus were no different between the 2 arms. Left ventricular mass assessed through Sokolow-Lyon voltage and voltage-duration product decreased to a greater extent in participants allocated to diuretic therapy compared with placebo (P=0.02).

CONCLUSIONS

A combination of low-dose chlorthalidone and amiloride effectively reduces the risk of incident hypertension and beneficially affects left ventricular mass in patients with prehypertension.

CLINICAL TRIAL REGISTRATION

URL: http://www.ClinicalTrials.gov, www.ensaiosclinicos.gov. Unique identifiers: NCT00970931, RBR-74rr6s.

Do Combined Electrocardiographic and Echocardiographic Markers of Left Ventricular Hypertrophy Improve Cardiovascular Risk Estimation?

The authors estimated the risk of cardiovascular mortality associated with echocardiographic (ECHO) left ventricular hypertrophy (LVH) and subtypes of this phenotype in patients with and without electrocardiographic (ECG) LVH. A total of 1691 representatives of the general population were included in the analysis. During a follow-up of 211 months, 89 cardiovascular deaths were recorded. Compared with individuals with neither ECHO LVH nor ECG LVH, fully adjusted risk of cardiovascular mortality increased (hazard ratio [HR], 3.36; 95% confidence interval [CI], 1.51-7.47; P=.003) in patients with both ECHO-LVH and ECG-LVH, whereas the risk entailed by ECHO-LVH alone was of borderline statistical significance (P=.04). Combined concentric nondilated LVH and ECG-LVH, but not concentric nondilated LVH alone, predicted cardiovascular death (HR, 3.79; 95% CI, 1.25-11.38; P=.01). Similar findings were observed for eccentric nondilated LVH (HR, 3.37; 95% CI, 1.05-10.78; P=.04.). The present analysis underlines the value of combining ECG and ECHO in the assessment of cardiovascular prognosis related to abnormal left ventricular geometric patterns.

Does QRS Voltage Correction by Body Mass Index Improve the Accuracy of Electrocardiography in Detecting Left Ventricular Hypertrophy and Predicting Cardiovascular Events in a General Population?

The authors assessed the value of body mass index (BMI) correction of two electrocardiographic criteria in improving detection of left ventricular hypertrophy (LVH) and prediction of cardiovascular and all-cause mortality in the Italian study Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) population. At entry, 1549 patients underwent diagnostic tests, 24-hour ambulatory blood pressure (BP) monitoring, standard electrocardiography, and echocardiography. The BMI-corrected Cornell voltage and Sokolow-Lyon voltage criteria provided better results for detection of echocardiographic LVH as compared with unadjusted electrocardiographic parameters. Cornell voltage index, but not Sokolow-Lyon index, was associated with an increased risk of cardiovascular events (and all-cause mortality). The adjusted risk of cardiovascular events related to one-standard deviation increment of BMI-corrected Cornell voltage was similar to that conferred by the uncorrected criterion in the total population, but outperformed in obese participants. These findings show that correction for BMI may improve the diagnostic accuracy of Cornell voltage index in detecting LVH and prediction of cardiovascular mortality in obese individuals.

Performance of Sokolow-Lyon index in detection of echocardiographically diagnosed left ventricular hypertrophy in a normal Eastern German population - results of the CARLA study

BACKGROUND

Arterial hypertension is a common disease with high prevalence in the general population. Left ventricular hypertrophy (LVH) is an independent risk factor in arterial hypertension. Electrocardiographic indices like the Sokolow-Lyon index (SLI) are recommended as diagnostic screening methods for LVH. We assessed the diagnostic performance of the SLI in a cohort of a large general population.

METHODS

We used electrocardiographic and echocardiographic data from the prospective, population-based cohort study CARdio-vascular Disease, Living and Ageing in Halle (CARLA). Linear and logistic regression models were used to assess the association of SLI with LVH. To assess the impact of the body-mass-index (BMI), we performed interaction analyses.

RESULTS

AUC of SLI to predict LVH was 55.3 %, sensitivity of the SLI was 5 %, specificity 97 %. We found a significant association of SLI after covariate-adjustment with echocardiographically detected LVH (increase of left-ventricular mass index, LVMI 7.0 g/m(2) per 1 mV increase of SLI, p < 0.0001). However, this association was mainly caused by an association of SLI with the left-ventricular internal diameter (LVIDd, increase of 0.06 cm/m(2) per 1 mV increase of SLI, p < 0.0001). In obese (BMI > 30 kg/m(2)) we found the strongest association with an increase of 9.2 g/m(2) per 1 mV.

CONCLUSIONS

Although statistically significant, relations of SLI and echocardiographic parameters of LVH were weak and mainly driven by the increase in LVIDd, implicating a more eccentric type of LVH in the collective. The relations were strongest when obese subjects were taken into account. Our data do not favour the SLI as a diagnostic screening test to identify patients at risk for LVH, especially in non-obese subjects without eccentric LVH.