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Bacharova L, Chevalier P, Gorenek B, Jons C, Li Y, Locati ET, Maanja M, Pérez‐Riera AR, Platonov PG, Ribeiro ALP, Schocken D, Soliman EZ, Svehlikova J, Tereshchenko LG, Ugander M, Varma N, Elena Z, Ikeda T. ISE/ISHNE expert consensus statement on the ECG diagnosis of left ventricular hypertrophy: The change of the paradigm. Ann Noninvasive Electrocardiol 2024; 29:e13097. [PMID: 37997698 PMCID: PMC10770819 DOI: 10.1111/anec.13097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria. The classical paradigm postulates that the increased left ventricular mass generates a stronger electrical field, increasing the leftward and posterior QRS forces, reflected in the augmented QRS amplitude. However, the low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm. The theoretical background for voltage measured at the body surface is defined by the solid angle theorem, which relates the measured voltage to spatial and non-spatial determinants. The spatial determinants are represented by the extent of the activation front and the distance of the recording electrodes. The non-spatial determinants comprise electrical characteristics of the myocardium, which are comparatively neglected in the interpretation of the QRS patterns. Various clinical conditions are associated with LVH. These conditions produce considerable diversity of electrical properties alterations thereby modifying the resultant QRS patterns. The spectrum of QRS patterns observed in LVH patients is quite broad, including also left axis deviation, left anterior fascicular block, incomplete and complete left bundle branch blocks, Q waves, and fragmented QRS. Importantly, the QRS complex can be within normal limits. The new paradigm stresses the electrophysiological background in interpreting QRS changes, i.e., the effect of the non-spatial determinants. This postulates that the role of ECG is not to estimate LV size in LVH, but to understand and decode the underlying electrical processes, which are crucial in relation to cardiovascular risk assessment.
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Affiliation(s)
| | - Philippe Chevalier
- Neuromyogene InstituteClaude Bernard UniversityVilleurbanneFrance
- Service de RythmologieHospices Civils de LyonLyonFrance
| | - Bulent Gorenek
- Eskisehir Osmangazi University Cardiology DepartmentEskisehirTurkey
| | - Christian Jons
- Department of CardiologyRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Yi‐Gang Li
- Department of Cardiology, Xinhua HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Emanuela T. Locati
- Department of Arrhythmology and ElectrophysiologyIRCCS Policlinico San DonatoMilanoItaly
| | - Maren Maanja
- Department of Clinical PhysiologyKarolinska University Hospital, and Karolinska InstitutetStockholmSweden
| | | | - Pyotr G. Platonov
- Department of Cardiology, Clinical SciencesLund UniversityLundSweden
| | - Antonio Luiz Pinho Ribeiro
- Internal Medicine, Faculdade de Medicina da Universidade Federal de Minas GeraisBelo HorizonteBrazil
- Telehealth Center, Hospital das Clínicas da Universidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Douglas Schocken
- Division of Cardiology, Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Elsayed Z. Soliman
- Section on Cardiovascular Medicine, Department of Medicine, Epidemiological Cardiology Research CenterWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Jana Svehlikova
- Institute of Measurement Sciences, Slovak Academy of SciencesBratislavaSlovak Republic
| | - Larisa G. Tereshchenko
- Department of Quantitative Health SciencesLerner Research Institute, Cleveland ClinicClevelandOhioUSA
| | - Martin Ugander
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Clinical PhysiologyKarolinska InstituteStockholmSweden
| | - Niraj Varma
- Cardiac Pacing & ElectrophysiologyHeart and Vascular Institute, Cleveland ClinicClevelandOhioUSA
| | - Zaklyazminskaya Elena
- Medical Genetics LaboratoryPetrovsky National Research Centre of SurgeryMoscowRussia
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Bacharova L, Chevalier P, Gorenek B, Jons C, Li YG, Locati ET, Maanja M, Pérez-Riera AR, Platonov PG, Ribeiro ALP, Schocken D, Soliman EZ, Svehlikova J, Tereshchenko LG, Ugander M, Varma N, Zaklyazminskaya E, Ikeda T. ISE/ISHNE Expert Consensus Statement on ECG Diagnosis of Left Ventricular Hypertrophy: The Change of the Paradigm. The joint paper of the International Society of Electrocardiology and the International Society for Holter Monitoring and Noninvasive Electrocardiology. J Electrocardiol 2023; 81:85-93. [PMID: 37647776 DOI: 10.1016/j.jelectrocard.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/01/2023]
Abstract
The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria, i.e. the increased QRS complex amplitude in defined leads. The classical ECG diagnostic paradigm postulates that the increased left ventricular mass generates a stronger electrical field, increasing the leftward and posterior QRS forces. These increased forces are reflected in the augmented QRS amplitude in the corresponding leads. However, the clinical observations document increased QRS amplitude only in the minority of patients with LVH. The low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm.
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Affiliation(s)
- Ljuba Bacharova
- International Laser Center CVTI, Ilkovicova 3, 841 04 Bratislava, Slovak Republic.
| | - Philippe Chevalier
- Neuromyogene Institute, Claude Bernard University, Lyon 1, Villeurbanne, France; Service de Rythmologie, Hospices Civils de Lyon, Lyon, France.
| | - Bulent Gorenek
- Eskisehir Osmangazi University, Cardiology Department, Eskisehir, Turkiye.
| | - Christian Jons
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, 200092 Shanghai, PR China.
| | - Emanuela T Locati
- Department of Arrhythmology and Electrophysiology, IRCCS Policlinico San Donato, Piazza E. Malan 2, 20097 San Donato Milanese, Milano, Italy.
| | - Maren Maanja
- Department of Clinical Physiology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
| | | | - Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden.
| | - Antonio Luiz P Ribeiro
- Internal Medicine, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Telehealth Center, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Douglas Schocken
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Section on Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Jana Svehlikova
- Institute of Measurement Sciences, Slovak Academy of Sciences, Bratislava, Slovak Republic.
| | - Larisa G Tereshchenko
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave JJN3-01, Cleveland, OH 44195, USA.
| | - Martin Ugander
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Clinical Physiology, Karolinska Institute, Stockholm, Stockholm, Sweden
| | - Niraj Varma
- Cardiac Pacing & Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave J2-2, Cleveland, OH 44195, USA.
| | - Elena Zaklyazminskaya
- Medical Genetics Laboratory, Petrovsky National Research Centre of Surgery, Moscow 119991, Russia
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Bacharova L, Estes HE, Schocken DD, Ugander M, Soliman EZ, Hill JA, Bang LE, Schlegel TT. The 4th Report of the Working Group on ECG diagnosis of Left Ventricular Hypertrophy. J Electrocardiol 2016; 50:11-15. [PMID: 27890283 DOI: 10.1016/j.jelectrocard.2016.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Indexed: 12/18/2022]
Abstract
The 4th Report provides a brief review of publications focused on the electrocardiographic diagnosis of left ventricular hypertrophy published during the period of 2010 to 2016 by the members of the Working Group on ECG diagnosis of Left Ventricular Hypertrophy. The Working Group recommended that ECG research and clinical attention be redirected from the estimation of LVM to the identification of electrical remodeling, to better understanding the sequence of events connecting electrical remodeling to outcomes. The need for a re-definition of terms and for a new paradigm is also stressed.
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Affiliation(s)
- Ljuba Bacharova
- International Laser Center, Bratislava, Slovak Republic; Institute of Pathophysiology, Medical School, Comenius University, Bratislava, Slovak Republic.
| | - Harvey E Estes
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA
| | | | - Martin Ugander
- Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center (EPICARE), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joseph A Hill
- Department of Internal Medicine, Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lia E Bang
- Copenhagen University Hospital, Rigshospitalet, The Heart Center, Department of Cardiology, Denmark
| | - Todd T Schlegel
- Department of Clinical Physiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden; Nicollier-Schlegel SARL, Trélex, Switzerland
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