ECG detection of left ventricular hypertrophy: the simpler, the better?

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.

ECG Interpretation: Clinical Relevance, Challenges, and Advances

Since its inception, the electrocardiogram (ECG) has been an essential tool in medicine. The ECG is more than a mere tracing of cardiac electrical activity; it can detect and diagnose various pathologies including arrhythmias, pericardial and myocardial disease, electrolyte disturbances, and pulmonary disease. The ECG is a simple, non-invasive, rapid, and cost-effective diagnostic tool in medicine; however, its clinical utility relies on the accuracy of its interpretation. Computer ECG analysis has become so widespread and relied upon that ECG literacy among clinicians is waning. With recent technological advances, the application of artificial intelligence-augmented ECG (AI-ECG) algorithms has demonstrated the potential to risk stratify, diagnose, and even interpret ECGs—all of which can have a tremendous impact on patient care and clinical workflow. In this review, we examine (i) the utility and importance of the ECG in clinical practice, (ii) the accuracy and limitations of current ECG interpretation methods, (iii) existing challenges in ECG education, and (iv) the potential use of AI-ECG algorithms for comprehensive ECG interpretation.

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.

The Association Between Left Ventricular Hypertrophy and the Occurrence and Prognosis of Atrial Fibrillation: A Meta-Analysis

Aims: The aim of this study was to perform a meta-analysis of studies of the association of left ventricular hypertrophy (LVH) and atrial fibrillation (AF), especially the predictive and prognostic role of LVH.

Methods and Results: We searched Medline, Embase, and the Cochrane Library from inception through 10 April 2020. A total of 16 cohorts (133,091 individuals) were included. Compared with the normal subjects, patients with LVH were more susceptible to AF (RR = 1.46, 95% CI, 1.32–1.60). In patients with AF and LVH, there was a higher risk of all-cause mortality during 3.95 years (RR = 1.60, 95% CI, 1.42–1.79), and these patients were more likely to progress to persistent or paroxysmal AF (RR = 1.45, 95% CI, 1.20–1.76) than were patients without LVH. After catheter ablation of AF, patients with LVH were more likely to recur (RR = 1.58, 95% CI, 1.27–1.95).

Conclusion: LVH is strongly associated with AF and has a negative impact on outcome in patients with AF.

Standard ECG for differential diagnosis between Anderson-Fabry disease and hypertrophic cardiomyopathy

OBJECTIVES

To evaluate the role of the ECG in the differential diagnosis between Anderson-Fabry disease (AFD) and hypertrophic cardiomyopathy (HCM).

METHODS

In this multicentre retrospective study, 111 AFD patients with left ventricular hypertrophy were compared with 111 patients with HCM, matched for sex, age and maximal wall thickness by propensity score. Independent ECG predictors of AFD were identified by multivariate analysis, and a multiparametric ECG score-based algorithm for differential diagnosis was developed.

RESULTS

Short PR interval, prolonged QRS duration, right bundle branch block (RBBB), R in augmented vector left (aVL) ≥1.1 mV and inferior ST depression independently predicted AFD diagnosis. A point-by-point ECG score was then derived with the following diagnostic performances: c-statistic 0.80 (95% CI 0.74 to 0.86) for discrimination, the Hosmel-Lemeshow χ² 6.14 (p=0.189) for calibration, sensitivity 69%, specificity 84%, positive predictive value 82% and negative predictive value 72%. After bootstrap resampling, the mean optimism was 0.025, and the internal validated c-statistic for the score was 0.78.

CONCLUSIONS

Standard ECG can help to differentiate AFD from HCM while investigating unexplained left ventricular hypertrophy. Short PR interval, prolonged QRS duration, RBBB, R in aVL ≥1.1 mV and inferior ST depression independently predicted AFD. Their systematic evaluation and the integration in a multiparametric ECG score can support AFD diagnosis.

Left Ventricular Hypertrophy and Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis

Background and Purpose

Left ventricular hypertrophy (LVH) is associated with the risk of stroke and dementia independently of other vascular risk factors, but its association with cerebral small vessel disease (CSVD) remains unknown. Here, we employed a systematic review and meta-analysis to address this gap.

Methods

Following the MOOSE guidelines (PROSPERO protocol: CRD42018110305), we systematically searched the literature for studies exploring the association between LVH or left ventricular (LV) mass, with neuroimaging markers of CSVD (lacunes, white matter hyperintensities [WMHs], cerebral microbleeds [CMBs]). We evaluated risk of bias and pooled association estimates with random-effects meta-analyses.

Results

We identified 31 studies (n=25,562) meeting our eligibility criteria. In meta-analysis, LVH was associated with lacunes and extensive WMHs in studies of the general population (odds ratio [OR]_lacunes, 1.49; 95% confidence interval [CI], 1.12 to 2.00) (OR_WMH, 1.73; 95% CI, 1.38 to 2.17) and studies in high-risk populations (OR_lacunes: 2.39; 95% CI, 1.32 to 4.32) (OR_WMH, 2.01; 95% CI, 1.45 to 2.80). The results remained stable in general population studies adjusting for hypertension and other vascular risk factors, as well as in sub-analyses by LVH assessment method (echocardiography/electrocardiogram), study design (cross-sectional/cohort), and study quality. Across LV morphology patterns, we found gradually increasing ORs for concentric remodelling, eccentric hypertrophy, and concentric hypertrophy, as compared to normal LV geometry. LVH was further associated with CMBs in high-risk population studies.

Conclusions

LVH is associated with neuroimaging markers of CSVD independently of hypertension and other vascular risk factors. Our findings suggest LVH as a novel risk factor for CSVD and highlight the link between subclinical heart and brain damage.

Evaluation of relationships between results of electrocardiography and echocardiography in 341 chimpanzees (Pan troglodytes)

OBJECTIVE

To examine potential relationships between ECG characteristics and echocardiographic measures of cardiac structure in chimpanzees (Pan troglodytes).

ANIMALS

341 chimpanzees (175 males and 166 females) from 5 sanctuaries and 2 zoological collections.

PROCEDURES

Chimpanzees were anesthetized for routine health examinations between May 2011 and July 2017 as part of the International Primate Heart Project and, during the same anesthetic events, underwent 12-lead ECG and transthoracic echocardiographic assessments. Relationships between results for ECG and those for echocardiographic measures of atrial areas, left ventricular internal diameter in diastole (LVIDd), and mean left ventricular wall thicknesses (MLVWT) were assessed with correlational analysis, then multiple linear regression analyses were used to create hierarchical models to predict cardiac structure from ECG findings.

RESULTS

Findings indicated correlations (r = -0.231 to 0.310) between results for ECG variables and echocardiographic measures. The duration and amplitude of P waves in lead II had the strongest correlations with atrial areas. The Sokolow-Lyon criteria, QRS-complex duration, and R-wave amplitude in leads V₆ and II had the strongest correlations with MLVWT, whereas the Sokolow-Lyon criteria, QRS-complex duration, and S-wave amplitude in leads V₂ and V₁ had the strongest correlations with LVIDd. However, the ECG predictive models that were generated only accounted for 17%, 7%, 11%, and 8% of the variance in the right atrial end-systolic area, left atrial end-systolic area, MLVWT, and LVIDd, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that relationships existed between ECG findings and cardiac morphology in the chimpanzees of the present study; however, further research is required to examine whether the predictive models generated can be modified to improve their clinical utility.

Diagnostic Capability and Influence Factors for a New Electrocardiogram Criterion in the Diagnosis of Left Ventricular Hypertrophy in a Chinese Population

INTRODUCTION

Based on a small sample of patients with hypertension, a few studies have reported that the newly proposed SD + SV4 criterion for left ventricular hypertrophy (LVH) is better than traditional criteria. This study aimed to verify the diagnostic capability of the SD + SV4 criterion in a Chinese population with or without hypertension and to analyze the factors affecting the diagnostic accuracy of LVH.

METHODS

A total of 248 patients with LVH or paroxysmal supraventricular tachycardia (PSVT) discharged from Fuwai Hospital from January 2010 to July 2018 were enrolled. Patients with LVH were diagnosed according to the left ventricular mass index calculated by the echocardiogram parameter as the gold standard in this study. The receiver operating curve (ROC) curve was performed to assess the diagnostic capability and cut-off values of the SD + SV4, RavL + SV3, and SV1 + RV5/RV6 criteria for LVH. Then, multivariate logistic regression analyses were performed to in-vestigate the factors affecting the accuracy of the SD + SV4 criterion.

RESULTS

There were 170 (68.5%) patients with hypertension and 110 (44.4%) with PSVT. According to echocardiography, 107 (43.1%) patients were diagnosed with LVH. The area under the curve (AUC) of the SD + SV4 criterion was the largest compared with that of the RavL + SV3 and SV1 + RV5/RV6 criteria (AUC 0.765 vs. 0.718 vs. 0.713, respectively). The sex-specific SD + SV4 criterion had the highest consistency with the gold standard (r = 0.532 ± 0.054, p < 0.01), accompanied by the highest sensitivity (70.1%) and specificity (85.8%). The cut-off values of the sex-specific SD + SV4 criterion for LVH were ≥2.65 mV (male)/2.15 mV (female). The left ventricular ejection fraction (LVEF; OR 0.920, 95% CI 0.882-0.959, p < 0.001) was significantly different between the SD + SV4 criterion and the gold standard for LVH after adjusting for hypertension, PSVT history, body surface area, interventricular septum thickness, posterior wall thickness, and left ventricular internal diameter.

CONCLUSION

The newly proposed SD + SV4 criterion provides improved sensitivity and accuracy for the diagnosis of LVH in the Chinese population. A decrease in LVEF is an independent factor affecting the diagnostic accuracy of LVH.

Conventional and new electrocardiographic criteria for hypertension-mediated cardiac organ damage: A narrative review

Hypertension-mediated organ damage (HMOD) is frequently observed in hypertensive patients at different cardiovascular (CV) risk profile. This may have both diagnostic and therapeutic implications for the choice of the most appropriate therapies. Among different markers of HMOD, the most frequent functional and structural adaptations can be observed at cardiac level, including left ventricular hypertrophy (LVH), diastolic dysfunction, aortic root dilatation, and left atrial enlargement. In particular, LVH was shown to be a strong and independent risk factor for major CV events, namely myocardial infarction, stroke, congestive heart failure, CV death. Thus, early identification of LVH is a key element for preventing CV events in hypertension. Although echocardiographic assessment of LVH represents the gold standard technique, this is not cost-effective and cannot be adopted in routine clinical practice of hypertension. On the other hand, electrocardiographic (ECG) assessment of HMOD relative to the heart is a simple, reproducible, widely available and cost-effective method to assess the presence of LVH, and could be preferred in large scale screening tests. Several new indicators have been proposed and tested in observational studies and clinical trials of hypertension, in order to improve the relatively low sensitivity of the conventional ECG criteria for LVH, despite high specificity. This article reviews the differences in the use of the main conventional and the new 12 lead ECG criteria of LVH for early assessment of asymptomatic, subclinical cardiac HMOD in a setting of clinical practice of hypertension.

Newly proposed electrocardiographic criteria for the diagnosis of left ventricular hypertrophy in a Chinese population

BACKGROUND

The electrocardiographic criteria currently available for the diagnosis of left ventricular hypertrophy (LVH) are low in sensitivity. Thus, we compared the diagnostic performance of newly proposed electrocardiographic criteria to the existing criteria in a Chinese population.

METHODS

A total of 235 consecutive hypertensive patients, hospitalized in our department between May 2017 and April 2018, were included. They were divided into two groups based on the gold standard echocardiogram: those with (n = 116) and without LVH (n = 119). The newly proposed ECG criteria were calculated by summating the amplitude of the deepest S wave (S_D ) in any single lead and the S-wave amplitude of lead V₄ (S_V4 ). The area under the curve was calculated and compared against the sex-specific Cornell limb lead and Sokolow-Lyon criteria.

RESULTS

ECG analysis of the cohort showed that the newly proposed criteria had the highest sensitivity in diagnosing LVH (male: 65.5%; female: 81%), followed by the Cornell limb lead criteria (male: 55.2%; female: 56.9%). The specificities of both sets of criteria were higher than 70%, with no significant differences between them. Receiver operator curve analysis showed an optimal cutoff of ≥2.1 mV for females (AUC: 0.832; 95% CI: 0.757-0.906) and ≥2.6 mV for males (AUC: 0.772; 95% CI: 0.687-0.856).

CONCLUSION

The newly proposed S_D  + S_V4 criteria provide an improved sensitivity for the ECG diagnosis of LVH compared to existing criteria, but its routine use will require further validation in larger populations.

ECG Voltage in Relation to Peripheral and Central Ambulatory Blood Pressure

BACKGROUND

The heart ejects in the central elastic arteries. No previous study in workers described the diurnal profile of central blood pressure (BP) or addressed the question whether electrocardiogram (ECG) indexes are more closely associated with central than peripheral BP.

METHODS

In 177 men (mean age, 29.1 years), we compared the associations of ECG indexes with brachial and central ambulatory BP, measured over 24 hours by the validated oscillometric Mobil-O-Graph 24h PWA monitor.

RESULTS

From wakefulness to sleep, as documented by diaries, systolic/diastolic BP decreased by 11.7/13.1 mm Hg peripherally and 9.3/13.6 mm Hg centrally, whereas central pulse pressure (PP) increased by 4.3 mm Hg (P < 0.0001). Over 24 hours and the awake and asleep periods, the peripheral-minus-central differences in systolic/diastolic BPs averaged 11.8/–1.6, 12.7/–1.8, and 10.3/–1.2 mm Hg, respectively (P < 0.0001). Cornell voltage and index averaged 1.18 mV and 114.8 mV·ms. Per 1-SD increment in systolic/diastolic BP, the Cornell voltages were 0.104/0.086 mV and 0.082/0.105 mV higher in relation to brachial 24-hour and asleep BP and 0.088/0.90 mV and 0.087/0.107 mV higher in relation to central BP. The corresponding estimates for the Cornell indexes were 9.6/8.6 and 8.2/10.5 mV·ms peripherally and 8.6/8.9 and 8.8/10.7 mV·ms centrally. The regression slopes (P ≥ 0.067) and correlation coefficients (P ≥ 0.088) were similar for brachial and central BP. Associations of ECG measurements with awake BP and PP were not significant.

CONCLUSIONS

Peripheral and central BPs run in parallel throughout the day and are similarly associated with the Cornell voltage and index.

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.

Understanding and treating hypertension in diabetic populations

Hypertension and diabetes frequently occurs in the same individuals in clinical practice. Moreover, the presence of hypertension does increase the risk of new-onset diabetes, as well as diabetes does promote development of hypertension. Whatever the case, the concomitant presence of these conditions confers a high risk of major cardiovascular complications and promotes the use integrated pharmacological interventions, aimed at achieving the recommended therapeutic targets. While the benefits of lowering abnormal fasting glucose levels in patients with hypertension and diabetes have been consistently demonstrated, the blood pressure (BP) targets to be achieved to get a benefit in patients with diabetes have been recently reconsidered. In the past, randomized clinical trials have, indeed, demonstrated that lowering BP levels to less than 140/90 mmHg was associated to a substantial reduction of the risk of developing macrovascular and microvascular complications in hypertensive patients with diabetes. In addition, epidemiological and clinical reports suggested that "the lower, the better" for BP in diabetes, so that levels of BP even lower than 130/80 mmHg have been recommended. Recent randomized clinical trials, however, designed to evaluate the potential benefits obtained with an intensive antihypertensive therapy, aimed at achieving a target systolic BP level below 120 mmHg as compared to those obtained with less stringent therapy, have challenged the previous recommendations from international guidelines. In fact, detailed analyses of these trials showed a paradoxically increased risk of coronary events, mostly myocardial infarction, in those patients who achieved the lowest BP levels, particularly in the high-risk subsets of hypertensive populations with diabetes. In the light of these considerations, the present article will briefly review the common pathophysiological mechanisms, the potential sites of therapeutic interactions and the currently recommended BP targets to be achieved under pharmacological treatment in hypertension and diabetes.

R Wave in aVL Lead is a Robust Index of Left Ventricular Hypertrophy: A Cardiac MRI Study

BACKGROUND

In patients free from overt cardiac disease, R wave in aVL lead (RaVL) is strongly correlated with left ventricular mass index (LVMI) assessed by transthoracic echocardiography. The aim of the present study was to extend this finding to other settings (cardiomyopathy or conduction disorders), by comparing ECG criteria of left ventricular hypertrophy (LVH) to cardiac MRI (CMR).

METHODS

In 501 patients, CMR and ECG were performed within a median-period of 5 days. CMR LVH cut-offs used were 83 g/m2 in men and 67 g/m2 in women.

RESULTS

RaVL was independently correlated with LVMI in patients with or without myocardial infarction (MI) (N = 300 and N = 201, respectively). SV3 was independently correlated with LVMI and LV enlargement only in patients without MI. In the whole cohort, RaVL had area under receiver-operating characteristic curve of 0.729 (specificity 98.3%, sensitivity 19.6%, optimal cut-off 1.1 mV). The performance of RaVL was remarkable in women, in Caucasians, and in the presence of right bundle branch block. It decreased in case of MI. Overall, it is proposed that below 0.5 mV and above 1.0 mV, RaVL is sufficient to exclude or establish LVH. Between 0.5 and 1 mV, composite indices (Cornell voltage or product) should be used. Using this algorithm allowed classifying appropriately 85% of the patients.

CONCLUSIONS

Our results showed that RaVL is a good index of LVH with a univocal threshold of 1.0 mV in various clinical conditions. SV3 may be combined to RaVL in some conditions, namely LV enlargement to increase its performance.

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.

A Novel Electrocardiographic T-Wave Measurement (Tp-Te Interval) as a Predictor of Heart Abnormalities in Hypertension: A New Opportunity for First-Line Electrocardiographic Evaluation

The aim of the study was to evaluate the role of conventional and new markers of early cardiac organ damage (OD) on 12-lead electrocardiography (ECG) in 25 outpatients with newly diagnosed untreated essential hypertension compared with 15 normotensive, otherwise healthy individuals. Each participant underwent ECG, echocardiographic, and blood pressure (BP) measurements. Conventional and new ECG indexes for cardiac OD (Tp-Te interval, ventricular activation time, and P-wave analysis) were also measured. Clinic and 24-hour ambulatory BP levels as well as left ventricular mass indexes were significantly higher in hypertensive than in normotensive patients. No significant differences were found between the two groups for ECG and echocardiographic markers of OD. Only Tp-Te interval was higher in hypertensive than in normotensive individuals (3.06 mm vs 2.24 mm; P<.0001), even after adjustment for anthropometric and clinical parameters. Preliminary results of this study demonstrated prolonged Tp-Te interval in newly diagnosed, untreated hypertensive outpatients compared with normotensive individuals.

Differential value of left ventricular mass index and wall thickness in predicting cardiovascular prognosis: data from the PAMELA population

BACKGROUND

Data on the prognostic value of echocardiographic left ventricular (LV) hypertrophy (LVH) as defined by LV wall thickness rather than LV mass estimate are scarce and not univocal. Thus, we investigated the value of LV mass index, wall thickness, and relative wall thickness (RWT) in predicting cardiovascular events in the PAMELA population.

METHODS

At entry 1,716 subjects underwent diagnostic tests, including laboratory investigations, 24-hour ambulatory blood pressure (BP) monitoring, and echocardiography. For the purpose of this analysis, all subjects were divided into quintiles of LV mass, LV mass/ body surface area (BSA), LV mass/height(2.7), interventricular septum (IVS), posterior wall (PW) thickness, IVS+PW thickness, and RWT.

RESULTS

Over a follow-up of 148 months, 139 nonfatal or fatal cardiovascular events were documented. After adjustment for age, sex, BP, fasting blood glucose, total cholesterol, and use of antihypertensive drugs, only the subjects stratified in the highest quintiles of LV mass indexed to body surface area (BSA) or height(2.7) exhibited a greater likelihood of incident cardiovascular disease (relative risk (RR) = 2.72, 95% confidence interval (CI) = 1.05-7.00, P = 0.03; RR = 4.83, 95% CI = 1.45-16.13, P = 0.01, respectively) as compared with the first quintile (reference group). The same was not true for the highest quintiles of IVS, PW thickness, IVS+PW thickness, and RWT. Similar findings were found when echocardiographic parameters were expressed as continuous variables.

CONCLUSIONS

This study indicates that LV wall thickness, different from LV mass index, does not provide a reliable estimate of cardiovascular risk associated with LVH in a general population. From these data it is recommended that echocardiographic laboratories should provide a systematic estimate of LV mass index, which is a strong, independent predictor of incident cardiovascular disease.

Prevalence and associated factors of silent brain infarcts in a Mediterranean cohort of hypertensives

Silent brain infarcts (SBIs) are detected by neuroimaging in approximately 20% of elderly patients in population-based studies. Limited evidence is available for hypertensives at low cardiovascular risk countries. Investigating Silent Strokes in Hypertensives: a Magnetic Resonance Imaging Study (ISSYS) is aimed to assess the prevalence and risk factors of SBIs in a hypertensive Mediterranean population. This is a cohort study in randomly selected hypertensives, aged 50 to 70 years old, and free of clinical stroke and dementia. On baseline, all participants underwent a brain magnetic resonance imaging to assess prevalence and location of silent infarcts, and data on vascular risk factors, comorbidities, and the presence of subclinical cardiorenal damage (left ventricular hypertrophy and microalbuminuria) were collected. Multivariate analyses were performed to determine SBIs associated factors. A total of 976 patients (49.4% men, mean age 64 years) were enrolled, and 163 SBIs were detected in 99 participants (prevalence 10.1%; 95% CI, 8.4%-12.2%), most of them (64.4%) located in the basal ganglia and subcortical white matter. After adjustment, besides age and sex, microalbuminuria and increasing total cardiovascular risk (assessed by the Framingham-calibrated for Spanish population risk function) were independently associated with SBIs. Male sex increased the odds of having SBIs in 2.5 as compared with females. Our results highlight the importance of considering both global risk assessment and sex differences in hypertension and may be useful to design future preventive interventions of stroke and dementia.

Biological, electrical and echocardiographic indices versus cardiac magnetic resonance imaging in diagnosing left ventricular hypertrophy

The aim of this study was to compare the diagnostic performance of N-terminal pro-brain natriuretic peptide (NT-proBNP), electrocardiographic (ECG) criteria and transthoracic echocardiography (TTE) versus cardiac magnetic resonance imaging in detecting left ventricular hypertrophy (LVH). The study included 42 hypertensive subjects with mean±s.d. age 48.1±12.3 years, 57.1% men, 24-h ambulatory blood pressure 144/89 mm Hg, left ventricular ejection fraction >50%, without symptoms of heart failure, and not taking any drugs that interfere with hormonal regulation. The accuracies of the methods in detecting LVH were compared at two diagnostic LVH cutoffs: low, 83 g m(-2) in men and 67 g m(-2) in women; and high, 96 g m(-2) in men and 81 g m(-2) in women. With the low and high LVH cutoffs, the areas under the receiver-operating characteristic curves and the optimal values for NT-proBNP were 0.761, 0.849, 200 and 421 pg ml(-1), respectively. An NT-proBNP level under 30 pg ml(-1) ruled out LVH with 100% sensitivity. The optimal values and literature-based values of NT-proBNP allowed a correct classification of 73-81% of the subjects. In 80-90% of the cases, the diagnostic accuracy of NT-proBNP was close to that of ECG criteria but lower than that of TTE criteria. Interestingly, combining ECG criteria and NT-proBNP level improved the diagnostic performance to be at least comparable to that of TTE: the percentages of correctly classified subjects were 73-95% vs. 67-86%, respectively. Of note, the range considers both diagnostic LVH cutoffs. The simultaneous use of ECG criteria and NT-proBNP plasma levels seemed to be powerful enough to detect LVH in most hypertensive subjects.

Investigating silent strokes in hypertensives: a magnetic resonance imaging study (ISSYS): rationale and protocol design

BACKGROUND

Silent brain infarcts are detected by neuroimaging in up to 20% of asymptomatic patients based on population studies. They are five times more frequent than stroke in general population, and increase significantly both with advancing age and hypertension. Moreover, they are independently associated with the risk of future stroke and cognitive decline.Despite these numbers and the clinical consequences of silent brain infarcts, their prevalence in Mediterranean populations is not well known and their role as predictors of future cerebrovascular and cardiovascular events in hypertensive remains to be determined.ISSYS (Investigating Silent Strokes in Hypertensives: a magnetic resonance imaging study) is an observational cross-sectional and longitudinal study aimed to: 1- determine the prevalence of silent cerebrovascular infarcts in a large cohort of 1000 hypertensives and to study their associated factors and 2-to study their relationship with the risk of future stroke and cognitive decline.

METHODS/DESIGN

Cohort study in a randomly selected sample of 1000 participants, hypertensive aged 50 to 70 years old, with no history of previous stroke or dementia.On baseline all participants will undergo a brain MRI to determine the presence of brain infarcts and other cerebrovascular lesions (brain microbleeds, white matter changes and enlarged perivascular spaces) and will be also tested to determine other than brain organ damage (heart-left ventricular hypertrophy, kidney-urine albumin to creatinine ratio, vessels-pulse wave velocity, ankle brachial index), in order to establish the contribution of other subclinical conditions to the risk of further vascular events. Several sub-studies assessing the role of 24 hour ambulatory BP monitoring and plasma or genetic biomarkers will be performed.Follow-up will last for at least 3 years, to assess the rate of further stroke/transient ischemic attack, other cardiovascular events and cognitive decline, and their predictors.

DISCUSSION

Improving the knowledge on the frequency and determinants of these lesions in our setting might help in the future to optimize treatments or establish new preventive strategies to minimize clinical and socioeconomic consequences of stroke and cognitive decline.