Sensitivity of electrocardiographic criteria for left ventricular hypertrophy according to type of cardiac disease

Hypersensitive C-reactive protein as a potential indicator for predicting left ventricular hypertrophy in elderly community-dwelling patients with hypertension

BACKGROUND

The aim of this study was to investigate the relationship between Hypersensitive C-reactive protein (hs-CRP) and left ventricular hypertrophy (LVH) in elderly community-dwelling patients with hypertension.

METHODS

A cross-sectional study was conducted, involving the recruitment of 365 elderly hypertensive residents ≥ 65 years of age from five communities. The participants were divided into two groups: an LVH group (n = 134) and a non-LVH group (n = 231), based on the left ventricular mass index (LVMI) determined by echocardiography. Spearman correlation analysis was used to assess the relationship between hs-CRP and LVH. Univariate and Multivariate analysis was performed to detect variables associated with LVH. The diagnostic value of hs-CRP for LVH was expressed as the area under the receiver operating characteristic (ROC) curve.

RESULTS

The incidence of LVH in elderly hypertension patients in the community was 36.7%. The hs-CRP levels were significantly higher in subjects with LVH compared to those without LVH (1.9 [0.8, 2.9] vs. 0.7 [0.4, 1.4], P = 0.002). Spearman correlation analysis demonstrated a positive correlation between hs-CRP and LVMI (r = 0.246, P < 0.001), as well as with IVST (r = 0.225, P < 0.001) and LVPWT (r = 0.172, P = 0.001). Among elderly hypertensive residents in the community, the cut-off value of hs-CRP for diagnosing LVH was 1.25 mg/L (sensitivity: 57.5%; specificity: 78.4%), and the area under the ROC curve for hs-CRP to predict LVH was 0.710 (95%CI: 0.654-0.766; P < 0.001). In the final model, hs-CRP ≥ 1.25 mg/L (OR = 3.569; 95%CI, 2.153-5.916; P<0.001) emerged as an independent risk factor for LVH. This association remained significant even after adjusting for various confounding factors (adjusted OR = 3.964; 95%CI, 2.323-6.765; P < 0.001).

CONCLUSIONS

This community-based cohort of elderly hypertensive individuals demonstrates a strong association between hs-CRP levels and the presence of LVH. The hs-CRP ≥ 1.25 mg/L may serve as an independent predictor for LVH in hypertensive subjects and exhibit good diagnostic efficacy for LVH.

The role of left ventricular hypertrophy measured by echocardiography in screening patients with ischaemia with non-obstructive coronary arteries: a cross-sectional study

Many patients with ischaemia with non-obstructive coronary arteries (INOCA) have a poor prognosis. This study aims to explore the diagnostic value of left ventricular hypertrophy (LVH)-related ultrasound parameters in INOCA patients. The study group consisted of 258 patients with INOCA in this retrospective cross-sectional study, and these patients were free of obstructive coronary artery disease, previous revascularization, atrial fibrillation, ejection fraction < 50%, major distortions of left ventricular geometry, suspected non-ischaemic causes. Control individuals were matched 1:1 with study group according to age, sex, cardiovascular risk factors, and time of hospital stay. According to left ventricular mass index (LVMI) and relative wall thickness, left ventricular geometry was composed of concentric hypertrophy, eccentric hypertrophy, concentric remodeling and normal geometry. LVH-related parameters, left ventricular geometry, demographic characteristics, laboratory parameters and other echocardiographic indicators were compared between the two groups. Subgroup analysis was performed based on sex. LVMI in the study group was higher than that in the control group (86.86 ± 18.83 g/m2 vs 82.25 ± 14.29 g/m2, P = 0.008). The ratio of LVH was higher in the study group (20.16% vs 10.85%, P = 0.006). After subgroup analysis based on sex, LVMI differences (85.77 ± 18.30 g/m2 vs 81.59 ± 14.64 g/m2, P = 0.014) and the ratio of LVH differences (25.00% vs 14.77%, P = 0.027) still existed in females between the two groups. There was no difference in the constituent ratio of left ventricular geometry between the two groups (P = 0.157). Sex-based subgroup analysis showed no difference in the constituent ratio of left ventricular geometry between the two groups in females (P = 0.242). The degree of LVH in the study group was higher than that in the control group, suggesting that LVH may play an important role in the occurrence and development of INOCA. Moreover, LVH-related ultrasound parameters may be of higher diagnostic value for female INOCA patients than for male INOCA patients.

Demonstration of subclinical left ventricular electrical and mechanical dysfunction in overweight subjects by frontal QRS-T angle and 3D-speckle tracking echocardiography

BACKGROUND

Overweightness is a considerable step in the process leading to obesity. There are no sufficient studies on the effect of cardiomyopathy defined in obese patients about overweight subjects. We thought that it may be useful to examine the myocardial involvement in overweight individuals electro-mechanically with more sensitive techniques before the development of obesity cardiomyopathy.

AIM

The aim of the present study was to demonstrate whether or not there are subclinical left ventricular (LV) electrical and mechanical dysfunctions in overweight patients using frontal QRS-T (fQRS-T) angle (electrically) and 3D-speckle tracking echocardiography (mechanically).

METHODS

A total of 80 overweight patients and 80 age- and sex-matched normal weight individuals were enrolled into the study. 3D-STE examinations of the patients were performed. Electrocardiographic recordings were obtained for fQRS-T angle assessment.

RESULTS

The LV-GLS and LV-GCS were significantly depressed in the overweight group than in the normal weight group (-14.5 ± 3.4 vs. -21.7 ± 3.6, p < .001; -15.2 ± 4.6 vs. -24.3 ± 4.8, p < .001, respectively). The fQRS-T angle was found to be increased in the overweight group (142.5 ± 39.2 vs. 114.7 ± 43.5, p = < .001). Statistically significant positive linear correlations were observed between BMI with LV-GLS, LV-GCS, and fQRS-T angle. LV-GLS and LV-GCS were found to be disrupted linearly as BMI increased (r = .718 for BMI and LV-GLS, r = .653 for BMI and LV-GCS). As BMI increased, it was found that the fQRS-T angle increased (r = .692 for BMI and fQRS-T angle).

CONCLUSION

Our results support that, overweight individuals, despite their being apparently healthy, may have subclinical LV myocardial mechanical and electrical dysfunction.

A meta-analysis of the diagnostic value of microRNA for hypertensive left ventricular hypertrophy

In this study, the diagnostic value of microRNAs (miRNAs) for hypertension (HTN) with left ventricular hypertrophy (LVH) were evaluated by meta-analysis. A correlation study of the diagnostic value of miRNAs in HTN with LVH was conducted using a computer search of the China Knowledge Network (CNKI), Wanfang, VIP, China Biomedical Literature Database (CBM), PubMed, Web of Science, and Embase. Studies from the time of database creation to May 2022 were evaluated. The quality assessment of diagnostic accuracy studies-2 (QUADAS-2) tool in RevMan 5.3 was used to evaluate the quality of the literature, and Meta-Disc 1.4 and Stata 16.0, were used to calculate the combined sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic advantage ratio (DOR), and their 95% confidence intervals. Subject working characteristic curves were plotted and the area under the curve (AUC) was calculated using Stata 16.0. Seven publications and 8 studies were included. miRNA diagnoses of HTN with LVH had SEN_combined = 0.84, SPE_combined = 0.80, PLR_combined = 4.2, NLR_combined = 0.20, DOR_combined = 21, and AUC_combined = 0.89. Subgroup analysis showed that the sensitivity of plasma miRNA for the diagnosis of HTN with LVH was 0.85, which was higher than that of serum which was 0.83. The specificity of serum miRNA for the diagnosis of HTN with LVH was 0.82, which was higher than that of plasma which was 0.78, and the diagnostic accuracy of miRNA in serum DOR was 23, which was higher than that of plasma DOR which was 20. In the diagnosis of HTN with LVH, miRNA has high sensitivity and specificity and is a better biological marker.

The effect of Systolic and diastolic blood pressure on Tp-e interval in patients divided according to World Health Organization classification for body mass index

Background: Tp-e interval, Tp-e/QT ratio and Tp-e/QTc ratio are electrocardiographic markers and indices of ventricular arrhythmogenic events. We aimed to investigate ventricular repolarization in normal weight, overweight, obese and morbidly obese individuals by using ECG parameters including the above markers.Methods: A total of 310 obese patients with various cardiac complaints, who were admitted to our outpatient clinic between May 2020 and January 2021, were prospectively included in the study. Using the World Health Organization (WHO) body mass index (BMI) classification, patients were divided into four groups: normal weight (18.5-24.9 kg/m², n = 48), overweight (25-29.9 kg/m², n = 98), obese (30-39.9 kg/m², n = 119), and morbidly obese (>40 kg/m², n = 45).Results: The morbidly obese and normal groups were younger in age than the other two groups. The Tp-e interval values for Groups I-IV were 72.1 ± 6.9, 73.1 ± 6.2, 75.7 ± 7.3 and 81.1 ± 6.9, respectively, and significantly different (P < .001). We found that age, BMI, systolic blood pressure (BP) and diastolic BP were independent predictors of a prolonged Tp-e interval.Conclusions: The principal finding of our study was the gradual increase in Tp-e interval, Tp-e/QT ratio and Tp-e/QTc ratio starting from the overweight stage and these parameters gradually increase in obese and morbidly obese patients. Additionally, systolic and diastolic blood pressure predicted Tp-e interval, Tp-e/QT ratio and Tp-e/QTc ratio.

Sensibilidade e especificidade do exame eletrocardiográfico na detecção de sobrecargas atriais e/ou ventriculares em gatos da raça Persa com cardiomiopatia hipertrófica

Resumo: A cardiomiopatia hipertrófica (CMH) é a principal cardiopatia dos felinos e é caracterizada por hipertrofia miocárdica concêntrica, sem dilatação ventricular. O ecocardiograma é o melhor meio diagnóstico não invasivo para a diferenciação das cardiomiopatias e é considerado padrão ouro para a detecção de hipertrofia ventricular presente na CMH. Alterações eletrocardiográficas também são comuns em animais com CMH e o eletrocardiograma (ECG) é um teste de triagem para detecção de hipertrofia ventricular em humanos, sendo um exame rápido e facilmente disponível. Em gatos, poucos estudos foram realizados quanto à sensibilidade e especificidade do ECG na detecção de hipertrofia ventricular. Com a intenção de avaliar o uso do ECG como ferramenta de triagem para diagnóstico de CMH em felinos, gatos da raça Persa (n=82) foram avaliados por meio de exames ecocardiográfico e eletrocardiográfico. Animais com bloqueios e/ou distúrbios de condução foram excluídos da análise estatística (n=22). Posteriormente, os animais incluídos foram classificados em: normais (n=38), suspeitos (n=6) e acometidos pela CMH (n=16). Observaram-se diferenças estatísticas na amplitude da onda P em DII e na amplitude de onda R em DII, CV6LL e CV6LU, com valores maiores nos animais com CMH; e nos valores ecocardiográficos de velocidade e gradiente de pressão do fluxo aórtico, diâmetro do átrio esquerdo (AE) e relação AE/Ao, com valores maiores nos gatos com CMH. Dentre os animais com alterações eletrocardiográficas sugestivas de sobrecarga atrial esquerda (n=7), apenas dois realmente apresentavam aumento do AE no ecocardiograma; e dentre os animais com aumento atrial esquerdo ao ecocardiograma (n=7), apenas dois apresentavam alterações eletrocardiográficas sugestivas de sobrecarga do AE (sensibilidade de 40,40% e especificidade de 90,90%). Dentre os gatos com alterações eletrocardiográficas sugestivas de sobrecarga ventricular esquerda (n=6), cinco realmente apresentavam hipertrofia ventricular ao ecocardiograma; e dentre os animais com CMH ao ecocardiograma (n=16), apenas cinco apresentaram alterações eletrocardiográficas sugestivas de sobrecarga do VE (sensibilidade de 31,25% e especificidade de 97,72%). Observou-se correlação positiva entre espessura diastólica do septo interventricular e/ou da parede livre do ventrículo esquerdo e a amplitude da onda R em derivações DII e CV6LU. O eletrocardiograma é um exame rápido e de fácil execução, apresenta boa especificidade na detecção de hipertrofia ventricular em felinos, porém, possui baixa sensibilidade, com grande número de falsos negativos. Desta forma, o ECG auxilia no diagnóstico, mas não substitui o ecocardiograma na confirmação da hipertrofia ventricular.

Validity of the surface electrocardiogram criteria for right ventricular hypertrophy: the MESA-RV Study (Multi-Ethnic Study of Atherosclerosis-Right Ventricle)

OBJECTIVES

The study aimed to assess the diagnostic properties of electrocardiographic (ECG) criteria for right ventricular hypertrophy (RVH) measured by cardiac magnetic resonance imaging (cMRI) in adults without clinical cardiovascular disease.

BACKGROUND

Current ECG criteria for RVH were based on cadaveric dissection in small studies.

METHODS

MESA (Multi-Ethnic Study of Atherosclerosis) performed cMRIs with complete right ventricle (RV) interpretation on 4,062 participants without clinical cardiovascular disease. Endocardial margins of the RV were manually contoured on diastolic and systolic images. The ECG screening criteria for RVH from the 2009 American Heart Association Recommendations for Standardization and Interpretation of the ECG were examined in participants with and without left ventricular (LV) hypertrophy or reduced ejection fraction. RVH was defined using sex-specific normative equations based on age, height, and weight.

RESULTS

The study sample with normal LV morphology and function (n = 3,719) was age 61.3 ± 10.0 years, 53.5% female, 39.6% Caucasian, 25.5% African American, 21.9% Hispanic, and 13.0% Asian. The mean body mass index was 27.9 ± 5.0 kg/m(2). A total of 6% had RVH, which was generally mild. Traditional ECG criteria were specific (many >95%) but had low sensitivity for RVH by cMRI. The positive predictive values were not sufficiently high as to be clinically useful (maximum 12%). The results did not differ based on age, sex, race, or smoking status, or with the inclusion of participants with abnormal LV mass or function. Classification and regression tree analysis revealed that no combination of ECG variables was better than the criteria used singly.

CONCLUSIONS

The recommended ECG screening criteria for RVH are not sufficiently sensitive or specific for screening for mild RVH in adults without clinical cardiovascular disease.

Electrocardiographic criteria for ST-elevation myocardial infarction in patients with left ventricular hypertrophy

Patients with electrocardiographic (ECG) left ventricular hypertrophy (LVH) have repolarization abnormalities of the ST segment that may be confused with an ischemic current of injury. We analyzed the ACTIVATE-SF database, a registry of consecutive emergency department ST-segment elevation (STE) myocardial infarction diagnoses from 2 medical centers. Univariate analysis was performed to identify ECG variables associated with presence of an angiographic culprit lesion. Recursive partitioning was then applied to identify a clinical decision-making rule that maximizes sensitivity and specificity for presence of an angiographic culprit lesion. Seventy-nine patients with ECG LVH underwent emergency cardiac catheterization for primary angioplasty. Patients with a culprit lesion had greater magnitude of STE (3.0 ± 1.8 vs 1.9 ± 1.0 mm, p = 0.005), more leads with STE (3.1 ± 1.6 vs 2.0 ± 1.8 leads, p = 0.002), and a greater ratio of STE to R-S-wave magnitude (median 25% vs 9.2%, p = 0.003). Univariate application of ECG criteria had limited sensitivity and a high false-positive rate for identifying patients with an angiographic culprit lesion. In patients with anterior territory STE, using a ratio of ST segment to R-S-wave magnitude ≥25% as a diagnostic criteria for STE myocardial infarction significantly improved specificity for an angiographic culprit lesion without decreasing sensitivity (c-statistic 0.82), with a net reclassification improvement of 37%. In conclusion, application of an ST segment to R-S-wave magnitude ≥25% rule may augment current criteria for determining which patients with ECG LVH should undergo primary angioplasty.

Is left ventricular hypertrophy regression important? Does the tool used to detect it matter?

Left ventricular hypertrophy (LVH) has been demonstrated to define an adverse cardiovascular prognosis. However, due to poor noninvasive tools in which to accurately define LVH, the clinical manifestations dictate an inexact manner in which to either initiate therapy or to gauge the success of LVH regression. Herein, the authors define the current state of imaging modalities available to interrogate LVH and its regression, but concentrating chiefly on the "gold standard" of cardiovascular magnetic resonance imaging (CMR). The authors review the data demonstrating the importance of LVH regression. Additionally, they highlight the strengths and weaknesses of CMR via several pinnacle studies that demonstrate the ease, efficiency, and accuracy of this new noninvasive reproducible and available tool to relatively inexpensively delineate LVH. Finally, upon pharmacologic administration of an antihypertensive regimen, the authors, for the first time, define a goal of left ventricular mass reduction (in grams) for echocardiography and CMR based in part on Framingham data aiming at improving cardiovascular risk.

Electrocardiographic diagnosis of left ventricular hypertrophy: the effect of left ventricular wall thickness, size, and mass on the specific criteria for left ventricular hypertrophy

BACKGROUND

The purpose of our study was to determine the relative importance and effect of an increased left ventricle wall thickness, left ventricular diastolic diameter, and left ventricular mass (LVM) on the performance of the 4 major electrocardiogram (ECG) criteria of left ventricular hypertrophy (LVH) and to determine how these findings could be incorporated into the routine ECG interpretation of LVH.

METHODS

The ECG criteria of LVH that we chose to examine were voltage, repolarization abnormalities, left atrial abnormality, and ventricular conduction time. We analyzed data from 608 consecutive patients with left ventricular wall thickness of >13 mm on the echocardiogram and with a concurrent ECG. We arbitrarily divided patients into 3 groups (groups I-III) according to the calculated LVM. Group I had an LVM of <400 g; group II had an LVM from 400 to 600 g, and group III had an LVM of >600 g. We evaluated the effect of increasing LVM, wall thickness, and ventricular diameter on the performance of the 4 ECG criteria at different severity of thickness, diameter, and mass.

RESULTS

An increase in the echocardiogram-derived LVM had significant effect on all 4 ECG criteria. As LVM progressively increased from groups I to III, the frequency of voltage criteria for LVH increased from 52% to 83%; left atrial abnormality rose from 46% to 68%; ST-T wave changes increases from 55% to 95%, and QRS prolongation significantly increased from 42% to 70%.

CONCLUSION

Increased wall thickness and ventricular diameter failed to correlate with the overall ECG score or significantly influence the frequency of any of the 4 ECG criteria for LVH in patients when LVM was held relatively constant. We also demonstrated that an increasing number of criteria on the ECG are associated with a greater mean LVM.

Distance correction in the electrocardiographic estimation of left ventricular mass

Assessment of the left ventricular mass (LVM) from electrocardiograms may be improved by the addition of clinical variables into a multivariate equation. As the heart-thorax distance may affect the results, its relationships with electrocardiographic and clinical data have been evaluated in a group of 220 subjects (53 +/- 15 years, 126 female, 175 without demonstrated heart disease) who were assessed for echocardiographic LVM and heart-thorax distance. Sokolow, Cornell, and total QRS voltage indexes were obtained. Multiple regression equations with LVM as the dependent variable were fit, with an ECG index, body mass index (BMI), age, and gender as the independent predictors. Each of the 3 ECG indexes, BMI, age, and sex was shown to be independent predictors of LVM, with the ECG and BMI contributing with most of the explanatory power. When added to the model, the distance from the interventricular septum to the precordium (septal-LVD) was not a predictor of LVM, but when BMI was withdrawn, septal-LVD became an independent predictor of LVM (P < .001). This was not observed when septal-LVD was substituted for any other clinical or ECG variable, thus suggesting that septal-LVD accounts for information contained in BMI but not in the remaining variables. In addition, the distance from the center of LV to the precordium (mid-LVD) achieved significance as an independent LVM predictor, although the coefficient of multiple determination (R) practically did not change. Almost identical results are obtained when LVM is indexed for body surface area. Body mass index supplies virtually all the information contained in the heart-thorax distance.

Microalbuminuria in hypertensive patients with electrocardiographic left ventricular hypertrophy: the LIFE study

OBJECTIVES

Left ventricular hypertrophy and albuminuria have both been shown to predict increased cardiovascular morbidity and mortality. However, the relationship between these markers of cardiac and renal glomerular damage has not been evaluated in a large hypertensive population with target organ damage. The present study was undertaken to determine whether albuminuria is associated with persistent electrocardiographic (ECG) left ventricular hypertrophy, independent of established risk factors for cardiac hypertrophy, in a large hypertensive population with left ventricular hypertrophy who were free of overt renal failure.

METHODS

Patients with stage II-III hypertension were enrolled in the study if they had left ventricular hypertrophy on a screening ECG by Cornell voltage-duration product and/or Sokolow-Lyon voltage criteria, and clinic blood pressures between 160 and 200/95-115 mmHg and plasma creatinine < 160 mmol/l. A second ECG and morning spot urine were obtained after 14 days of placebo treatment. Renal glomerular permeability was evaluated by urine albumin/creatinine (UACR, mg/mmol). Microalbuminuria was present if UACR > 3.5 mg/mmol and macroalbuminuria if UACR > 35 mg/mmol.

RESULTS

The mean age of the 8029 patients was 66 years, 54% were women. Microalbuminuria was found in 23% and macroalbuminuria in 4% of patients. Microalbuminuria was more prevalent in patients of African American (35%), Hispanic (37%) and Asian (36%) ethnicity, heavy smokers (32%), diabetics (36%) and in patients with ECG left ventricular hypertrophy by both ECG-criteria (29%). Urine albumin/creatinine was positively related to Sokolow-Lyon voltage criteria and Cornell voltage-duration product criteria. In multiple regression analysis, higher UACR was independently associated with older age, diabetes, higher blood pressure, serum creatinine, smoking and left ventricular hypertrophy. Patients smoking > 20 cigarettes/day had a 1.6-fold higher prevalence of microalbuminuria and a 3.7-fold higher prevalence of macroalbuminuria than never-smokers. ECG left ventricular hypertrophy by Cornell voltage-duration product or Sokolow-Lyon criteria was associated with a 1.6-fold increased prevalence of microalbuminuria and a 2.6-fold increase risk of macroalbuminuria compared to no left ventricular hypertrophy on the second ECG.

CONCLUSIONS

In patients with moderately severe hypertension, left ventricular hypertrophy on two consecutive ECGs is associated with increased prevalences of micro- and macroalbuminuria compared to patients without persistent ECG left ventricular hypertrophy. High albumin excretion was related to left ventricular hypertrophy independent of age, blood pressure, diabetes, race, serum creatinine or smoking, suggesting parallel cardiac damage and albuminuria.

Time-voltage QRS area of the 12-lead electrocardiogram: detection of left ventricular hypertrophy

Identification of left ventricular hypertrophy (LVH) using 12-lead ECG criteria based primarily on QRS amplitudes has been limited by poor sensitivity at acceptable levels of specificity. Because the product of QRS voltage and duration, as an approximation of the time-voltage area of the QRS complex, can improve accuracy of the 12-lead ECG for LVH, we examined the diagnostic value of true time-voltage area measurements of QRS complexes from the standard 12-lead ECG. Standard 12-lead ECGs and echocardiograms were obtained in 175 control subjects without LVH and in 74 patients with regurgitant valvular heart disease and LVH defined by echocardiographic criteria (indexed LV mass >110 g/m2 in women and >125 g/m2 in men). Standard voltage criteria, voltage-duration products (voltage multiplied by QRS duration), and true time-voltage areas of the QRS were calculated for Sokolow-Lyon criteria (SV1 +RV(5/6)) and the 12-lead sum of voltage criteria. Test sensitivities were compared using gender-specific partitions with matched specificity of 98% in the 175 subjects without LVH. Measurement of the time-voltage area significantly improved sensitivity for both criteria. The 76% sensitivity of the 12-lead sum area and 65% sensitivity of Sokolow-Lyon area were significantly greater than the 54% sensitivity of the approximation of QRS area provided by each voltage-duration product (P<.001 and P=.021) and than the 46% and 43% sensitivities of the respective simple voltage criteria (each P<.001). Comparison of receiver operating characteristic curves confirmed the superior overall performance of time-voltage area criteria compared with both voltage-duration products and simple voltage criteria. These results suggest that use of time-voltage areas can dramatically improve identification of LVH by 12-lead ECG. Further study of this approach is needed to identify optimal criteria for LVH based on the time-voltage area measurements from the 12-lead ECG.

[Comparison of the sensitivity and specificity of the electrocardiography criteria for left ventricular hypertrophy according to the methods of Romhilt-Estes, Sokolow-Lyon, Cornell and Rodríguez Padial]

INTRODUCTION AND OBJECTIVES

Because left ventricular mass is associated with an increase in the risk of morbidity and mortality of cardiovascular diseases in the general population having the electrocardiogram as an accessible and inexpensive method for the diagnosis of left ventricular hypertrophy, we decided to calculate the sensitivity and specificity of 5 electrocardiographic criteria for the diagnosis of left ventricular hypertrophy and to compare the results of the original authors to ours.

PATIENTS AND METHODS

135 patients were evaluated; 46 patients were excluded by the following criteria: chronic obstructive pulmonary disease, complete left or right bundle branch block, cardiovascular ischemic disease or Wolf-Parkinson-White Syndrome. 89 patients remained and had an electrocardiogram performed applying the following criteria: Romhilt-Estes Point-Score system. Sokolow-Lyon (SV1 + RV5 or V6 > 3.5 mV) and (RaVL > 1.1 mV), Cornell and Rodríguez Padial. Left ventricular hypertrophy was defined by the Penn Convention Criteria.

RESULTS

In our study we obtained the following results: a) Romhilt-Estes had a sensitivity of 12% and a specificity of 87%; b) Sokolow-Lyon (SV1 + RV5 or V6) had a sensitivity of 22% and a specificity of 79%; c) Sokolow-Lyon (RaVL) has a sensitivity of 18% and a specificity of 92%; d) Cornel had a sensitivity of 31% and a specificity of 87%, and e) Rodríguez Padial had a sensitivity of 82% and a specificity of 8%. There are similarities between our results and the authors's original ones. However, there are significant statistical differences between them (p < or = 0.01).

CONCLUSION

Our conclusion is that these criteria have a low diagnostic value in the isolated interpretation of patients with left ventricular hypertrophy, and we need to integrate them with the whole medical history and physical examination.

Body surface mapping criteria for diagnosis of left ventricular hypertrophy associated with complete right bundle branch block

The standard electrocardiographic (ECG) criteria for left ventricular hypertrophy are unreliable in patients with complete right bundle branch block. This study was undertaken to formulate criteria for diagnosing these patients by using body surface mapping. The echocardiographic left ventricular mass was calculated by the Penn method from M-mode measurements. Of 56 patients, 27 were defined as having left ventricular hypertrophy with a left ventricular mass of 215 g or more. Isopotential and isointegral maps of the QRS complex were observed. The QRS isointegral maps were separated into two parts at the end of the downstroke of the initial R wave of vector spatial magnitude. The body surface mapping criteria with the highest sensitivity were EPmax (maximum of early part of the QRS) 45 microV.s or greater (sensitivity 93%, specificity 90%), EPmax/d (EPmax averaged by EP duration) 0.8 mV or greater (sensitivity 93%, specificity 97%), and Max (initial maximum) 2.2 mV or greater (sensitivity 89%, specificity 90%). These results suggest that body surface mapping is a useful technique in diagnosing patients with left ventricular hypertrophy and right bundle branch block.

Time-voltage area of the QRS for the identification of left ventricular hypertrophy

Standard electrocardiographic criteria have exhibited poor sensitivity for left ventricular hypertrophy at acceptable levels of specificity and perform less well in women than men, even when sex-specific criteria are used. The time-voltage integral of the horizontal plane vector QRS complex can improve identification of hypertrophy in men, but performance of this approach in women and the effect of sex-specific criteria on accuracy have not been examined. To evaluate the accuracy of the time-voltage integral of the QRS complex for the identification of left ventricular hypertrophy in women and to examine the effect of sex-and non-sex-specific criteria on test performance, we obtained standard 12-lead and orthogonal-lead signal-averaged electrocardiograms and echocardiograms in 175 control subjects without hypertrophy (43 women and 132 men) and 75 patients with hypertrophy (26 women and 49 men) defined by echocardiographic criteria (indexed left ventricular mass > 110 g/m2 in women and > 125 g/m2 in men). Voltage of the QRS complex was integrated over the total QRS duration in leads X and Z for calculation of the time-voltage integral of the horizontal plane vector complex. With the use of a partition of 99.2 microV.s with a specificity of 98% in the entire normal group, sensitivity of the horizontal plane vector integral was significantly lower in women than men (31% versus 71%, P < .001). In contrast, use of sex-specific partitions of 75.4 microV.s in women and 99.2 microV.s in men with matched 98% specificity significantly improved sensitivity in women to 81% (P < .001), with no change in sensitivity in men (71%). Comparison of receiver operating characteristic curves with the use of sex-specific criteria demonstrated no significant difference in overall performance of the horizontal plane vector integral between men and women. The 81% and 71% sensitivities of the sex-specific horizontal plane vector integral were significantly greater than the 27% to 58% sensitivities of sex-specific 12-lead electrocardiographic criteria in this population. Thus, sex-specific criteria significantly improve performance of the time-voltage integral of the QRS for the identification of left ventricular hypertrophy in women, with no loss of accuracy in men. Use of the time-voltage integral can improve the accuracy of the electrocardiogram for the identification of left ventricular hypertrophy in both women and men.

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

OBJECTIVES

This study was conducted to validate the hypothesis that the product of QRS voltage and duration, as an approximation of the time-voltage area of the QRS complex, can improve the electrocardiographic (ECG) detection of echocardiographically determined left ventricular hypertrophy and to further assess the relative contribution of QRS duration to the ECG detection of hypertrophy.

BACKGROUND

The ECG identification of left ventricular hypertrophy has been limited by the poor sensitivity of standard voltage criteria alone. However, increases in left ventricular mass can be more accurately related to increases in the time-voltage area of the QRS complex than to changes in QRS voltage or duration alone.

METHODS

Standard 12-lead ECGs and echocardiograms were obtained for 389 patients, including 116 patients with left ventricular hypertrophy. Simple voltage-duration products were calculated by multiplying Cornell voltage by QRS duration (Cornell product) and the 12-lead sum of voltage by QRS duration (12-lead product).

RESULTS

In a stepwise logistic regression model that also included Cornell voltage, Sokolow-Lyon voltage, age and gender, QRS duration remained a highly significant predictor of the presence of left ventricular hypertrophy (chi-square 26.9, p < 0.0001). At a matched specificity of 96%, each voltage-duration product significantly improved sensitivity for the detection of left ventricular hypertrophy compared with simple voltage criteria alone (Cornell product 37% vs. Cornell voltage 28%, p < 0.02, and 12-lead product 50% vs. 12-lead voltage 43%, p < 0.005). Sensitivities of both the Cornell product and the 12-lead product were significantly greater than the 27% sensitivity of QRS duration alone (p < 0.01 vs. p < 0.001), the 20% sensitivity of a Romhilt-Estes point score > 4 (p < 0.001) and the 33% sensitivity of the best-fit logistic regression model in this cohort (p < 0.05 vs. p < 0.001).

CONCLUSIONS

QRS duration is an independent ECG predictor of the presence of left ventricular hypertrophy, and the simple product of either Cornell voltage or 12-lead voltage and QRS duration significantly improves identification of left ventricular hypertrophy relative to other ECG criteria that use QRS duration and voltages in linear combinations.

Electrocardiographic diagnosis of left ventricular hypertrophy in the presence of right bundle branch block in cases with essential hypertension

Right bundle branch block was diagnosed in electrocardiograms of 37 of 1085 patients with essential hypertension. Echocardiographically left ventricular hypertrophy was diagnosed in 14 of these 37 patients. Eighteen electrocardiographic (ECG) criteria, which were previously recommended, were determined in these 37 patients. The sensitivities of five criteria were found to be better than 50%. These are SV1 > or = 2 mm; RV6 > RV5; S III + (R+S) maximum precordial lead > or = 30 mm; P/PR > or = 1.6; R aVL > or = 11 mm. However, their specificities ranged from 56.5% to 95.6%. When the combination of RV6 > RV5 and S III + (R+S) maximum precordial lead > or = 30 mm was used, sensitivity was 57.1 and specificity was 100%. It is concluded that the presence of right bundle branch block these ECG criteria can be used for the diagnosis of left ventricular hypertrophy.

Electrocardiographic diagnosis of left ventricular hypertrophy by the time-voltage integral of the QRS complex

OBJECTIVES

This study was conducted to test the hypothesis that the time-voltage integral of the QRS complex can improve the electrocardiographic (ECG) identification of left ventricular hypertrophy.

BACKGROUND

Standard ECG criteria have exhibited poor sensitivity for left ventricular hypertrophy at acceptable levels of specificity. However, left ventricular mass may be more closely related to the time-voltage integral of the summed left ventricular dipole than to QRS duration or voltages used in standard ECG criteria.

METHODS

Standard 12-lead ECGs, orthogonal lead signal-averaged ECGs and echocardiograms were obtained in 62 male control subjects without left ventricular hypertrophy and 51 men with left ventricular hypertrophy defined by echocardiographic criteria (indexed left ventricular mass > 125 g/m2). Voltage of the QRS complex was integrated over the total QRS duration in leads X, Y and Z to calculate the time-voltage integral of each orthogonal lead, of the maximal spatial vector complex and of the horizontal, frontal and sagittal plane vector complexes.

RESULTS

At matched specificity of 99%, the 73% (37 of 51) sensitivity of the time-voltage integral of the vector QRS complex in the horizontal plane was significantly greater than the 10% sensitivity of the Romhilt-Estes point score, the 16% sensitivity of QRS duration alone, the 22% sensitivity of Cornell voltage, the 33% sensitivity of the 12-lead sum of QRS voltage and the 37% sensitivity of Sokolow-Lyon voltage (each p < 0.001). Sensitivity of the horizontal plane time-voltage integral was also greater than the 10% to 51% sensitivity of the time-voltage integral calculated in the individual X, Y or Z leads (p < 0.01 to < 0.001), the 18% and 35% sensitivity of the time-voltage integrals of the frontal and sagittal plane vectors (p < 0.001) and the 49% sensitivity of the time-voltage integral of the maximal spatial vector complex calculated from all three orthogonal leads (p < 0.001). Comparison of receiver operating characteristic curves confirmed that the superior performance of the horizontal plane time-voltage integral relative to standard and other signal-averaged criteria was independent of partition value selection.

CONCLUSIONS

These findings suggest that use of the time-voltage integral of the QRS complex, a method that can be readily implemented on commercially available computerized ECG systems, can improve the accuracy of ECG methods for the identification of left ventricular hypertrophy.

Electrocardiographic detection of left ventricular hypertrophy by the simple QRS voltage-duration product

OBJECTIVES

The object of this study was to assess the hypothesis that the product of QRS voltage and duration, as an approximation of the time-voltage integral of the QRS complex, can improve the electrocardiographic (ECG) identification of left ventricular hypertrophy.

BACKGROUND

Electrocardiographic identification of left ventricular hypertrophy has been limited by the poor sensitivity of standard voltage criteria. However, increases in left ventricular mass can be more closely related to increases in the time-voltage integral of the summed left ventricular dipole than to changes in voltage or QRS duration alone.

METHODS

Antemortem ECGs were compared with left ventricular mass at autopsy in 220 patients. There were 95 patients with left ventricular hypertrophy, defined by left ventricular mass index > 118 g/m2 in men and > 104 g/m2 in women. The voltage-duration product was calculated as the product of QRS duration and Cornell voltage (Cornell product) and the 12-lead sum of QRS voltage (12-lead product).

RESULTS

At partitions with a matched specificity of 95%, each voltage-duration product significantly improved sensitivity for the detection of left ventricular hypertrophy when compared with simple voltage criteria alone (Cornell product 51% [48 of 95] vs. Cornell voltage 36% [34 of 95], p < 0.005 and 12-lead product 45% [43 of 95] vs. 12-lead voltage 31% [30 of 95], p < 0.001). Sensitivity of both the Cornell product and 12-lead product was significantly greater than that found for QRS duration alone (28%, 27 of 95, p < 0.005) and the Romhilt-Estes point score (27%, 26 of 95, p < 0.005), and compared favorably with the sensitivity of the complex Cornell multivariate score (44%, 42 of 95, p = NS). Comparison of receiver operating characteristic curves demonstrated that improved performance of the voltage-duration products for the detection of left ventricular hypertrophy was independent of test partition selection. In addition, test performance of the voltage-duration products was not significantly affected by the presence or absence of a bundle branch block.

CONCLUSIONS

These data suggest that the simple product of either Cornell or 12-lead voltage and QRS duration can identify left ventricular hypertrophy more accurately than can voltage or QRS duration criteria alone and may approach or exceed the performance of more complex multiple regression analyses.

High-frequency analysis of the signal-averaged ECG. Correlation with left ventricular mass in rabbits

Standard electrocardiographic (ECG) criteria have exhibited poor correlation with left ventricular mass and poor sensitivity for left ventricular hypertrophy at acceptable levels of specificity. To assess the ability of the high-frequency filtered signal-averaged ECG to improve ECG correlation with left ventricular mass, signal-averaged orthogonal lead recordings in 29 normal rabbits and seven rabbits with left ventricular hypertrophy due to chronic aortic regurgitation were compared with left ventricular mass corrected for body weight. Voltage of the vector QRS complex was integrated over the total duration of the QRS after separate filtering with standard frequency (0-100 Hz) low-pass and high-frequency (44 Hz) high-pass filters. Measurement of individual X, Y, and Z lead R and S wave voltage was performed on averaged, standard frequency filtered complexes, and the maximal spatial vector magnitude was determined from the standard frequency filtered vectors. Voltage of the 44 Hz high-pass filtered vector QRS complex integrated over the total duration of the QRS (high-frequency vector integral) correlated closely with indexed left ventricular mass (r = 0.84, p less than 0.0001), significantly better than the correlation of standard frequency vector integral or maximal spatial vector magnitude voltages (r = 0.35 and r = 0.61, each p less than 0.01 vs high-frequency vector integral) and the correlation of orthogonal lead X R wave or lead Y S wave voltages (r = 0.55 and r = 0.37, respectively, each p less than 0.01 vs high-frequency vector integral).(ABSTRACT TRUNCATED AT 250 WORDS)

Electrocardiographic correlates with left ventricular morphology in idiopathic dilated cardiomyopathy

The purpose of the present study was to verify whether the electrocardiographic pattern of patients with idiopathic dilated cardiomyopathy (IDC) might be useful in predicting measurements of left ventricular (LV) morphology. A total of 12 electrocardiographic criteria for LV enlargement were evaluated in 67 patients with IDC, aged 14 to 68 years (mean 48), and were correlated to LV wall thickness, volume and mass, as assessed at angiography (all patients) and echocardiography (50 patients). Linear regression analysis showed weak correlations between multiple electrocardiographic criteria and LV wall thickness, volume and mass. Multiple logistic regression analysis showed that total 12-lead QRS amplitude, voltage criteria of Sokolow and Lyon, overshoot and U-wave inversion were the variables significantly related to LV wall thickness, as assessed by angiography (r = 0.55, p less than 0.005) and echocardiography (r = 0.43, p less than 0.025). The sum of T/R-wave ratios, the RV6/RV5 ratio and the Romhilt-Estes score were predictors of LV end-diastolic volume, as determined by angiography (r = 0.83, p less than 0.001) and echocardiography (r = 0.77, p less than 0.005). Total 12-lead QRS amplitude and the sum of T/R-wave ratios were the only independent predictors of LV mass, either angiographically (r = 0.81, p less than 0.001) or echocardiographically measured (r = 0.71, p less than 0.025). It is concluded that a single electrocardiographic criterion for prediction of LV morphology in patients with IDC is barely effective. Multiple electrocardiographic criteria should be utilized to better predict LV mass and distinguish reliably between LV wall thickening and dilatation.

T-wave changes in patients with hemodynamic evidence of systolic or diastolic overload of the left ventricle: a retrospective study on 168 patients with isolated chronic aortic valve disease

The effect of systolic and diastolic overload of the left ventricle on the T wave was studied in 86 patients with pure aortic stenosis and in 82 patients with pure aortic insufficiency documented by hemodynamic investigation. All patients had hemodynamically significant, chronic isolated aortic valve disease with electrocardiographic evidence of left ventricular hypertrophy (Sokolow index greater than or equal to 45 mm). All had undergone selective coronary angiography. Flattened or negative T waves were present in 44 patients with aortic stenosis (51%) and in 66 (80%) with aortic incompetence. Inversion of the T wave in left ventricular leads was unrelated to the presence of ventricular conduction disturbances or to coronary artery disease or to low cardiac index. It was significantly related to older age (P = 0.0001) and, in patients with aortic incompetence, to the end-diastolic volume (P = 0.04). Digitalis intake was a nonsignificant (P = 0.10) independent variable. These findings suggest that patients with aortic stenosis cannot be distinguished from patients with aortic incompetence by the electrocardiogram and that the theory of Cabrera and Monroy is not valid in this set of patients.

QRS voltage measurements in autopsied men free of cardiopulmonary disease: a basis for evaluating total QRS voltage as an index of left ventricular hypertrophy

Use of total 12-lead QRS electrocardiographic voltage as a criterion for left ventricular (LV) hypertrophy has been of recent interest. Although upper and lower limits of QRS voltage for individual electrocardiographic leads have been reported in clinically healthy men and women, the upper limit of total 12-lead QRS voltage has not been established in adults free of cardiopulmonary disease by clinical and necropsy criteria. Therefore, the total QRS voltage from all 12 electrocardiographic leads was determined in 30 autopsied men known to be free of cardiopulmonary disease by clinical assessment and by a special cardiac examination using postmortem coronary angiography and chamber partition determination of LV weight. Gross heart weight, LV weight and total QRS voltage are reported. Comparisons were made between disease-free patients and previously reported patients with aortic valve stenosis, aortic regurgitation and cardiac amyloidosis with respect to total QRS voltage and gross heart weight. Total QRS voltage and gross heart weight were significantly greater in patients with severe aortic stenosis (mean 245 mm) and severe aortic regurgitation (mean 274 mm) than in our patients (mean 127 mm). Total QRS voltage was significantly less, whereas gross heart weight was significantly greater in patients with cardiac amyloidosis (mean 101 mm) than in our normal subjects (mean 127 mm). These data provide a basis for evaluating the total 12-lead QRS voltage as a criterion for LV hypertrophy.

Performance of primary and derived M-mode echocardiographic measurements for detection of left ventricular hypertrophy in necropsied subjects and in patients with systemic hypertension, mitral regurgitation and dilated cardiomyopathy

To determine which M-mode echocardiographic (echo) measurement best detects left ventricular (LV) hypertrophy, the sensitivity and specificity of upper normal limits of echo LV anatomic measurements (previously shown to have 97% specificity in living normal subjects) were tested in 60 necropsied patients with anatomic hypertrophy and in 28 necropsied patients with normal left ventricles. The prevalence of hypertrophy by each echo criterion was determined in 165 living patients with systemic hypertension, mitral regurgitation or dilated cardiomyopathy. The best separation between patients with normal vs increased necropsy LV mass was obtained using sex-specific echo LV mass index criteria (overall accuracy = 73 of 88 patients, 83%). Lower overall accuracies for separation of patients with and without hypertrophy were observed for echo cross-sectional area (59 of 88 patients, 67%; p less than 0.05 vs LV mass index) and indexes of LV wall thickness (39 to 51%, p less than 0.001). Among 113 living patients with moderate or severe hypertension, mitral regurgitation or dilated cardiomyopathy, LV mass index was increased in 73%, cross-sectional area index in 58% (p less than 0.02 vs LV mass index), and posterior wall thickness, septal thickness and relative wall thickness in only 11 to 32% (all p less than 0.001 vs LV mass index). Thus, an M-mode echo LV mass index of more than 134 g/m2 in men and more than 110 g/m2 in women detects concentric and eccentric LV hypertrophy accurately by comparison with necropsy and clinical reference standards; cross-sectional area is slightly less useful; and other M-mode echo criteria of LV hypertrophy perform too poorly to be clinically applicable.

Echocardiographic abnormalities and disease severity in Fabry's disease

Fabry's disease is an X-linked recessive genetic deficiency of the enzyme alpha-galactosidase A, which leads to the pathologic deposition of neutral glycosphingolipids in lysosomes of the vascular endothelium of the heart, brain and kidney. The disease is progressive in hemizygous male patients, with increasing involvement of the major organs leading to death. Because cardiac involvement is a constant feature, echocardiograms were performed on 35 patients with Fabry's disease, 23 hemizygotes (aged 28.6 +/- 14 years) and 12 heterozygotes (aged 31.6 +/- 6 years), to determine whether cardiac involvement could be detected noninvasively. The results demonstrated that hemizygous male patients had a greater aortic root diameter, thicker interventricular septum and greater ventricular mass than did heterozygous female patients. Left ventricular mass per square meter of body surface area correlated well with clinical disease severity (r = 0.68, p less than 0.05), suggesting progressive glycosphingolipid deposition. Older heterozygotes (greater than 25 years old) had more severe evidence of cardiac disease than did younger male patients. Although mitral valve prolapse was identified in 12 (54%) of 23 male hemizygotes and in 7 (58%) of 12 female heterozygotes its presence did not correlate with clinical disease severity or other echocardiographic variables. Therefore, echocardiographic evidence of Fabry's disease appears to correlate with age-related disease severity and may be a useful noninvasive marker to follow disease progression and possible regression when appropriate therapy becomes available.