[Left ventricular hypertrophy in hemodialysis patient: Prevalence, electrocardiographic, echocardiographic study and associated risk factors]

BACKGROUND

Left ventricular hypertrophy is the most prevalent cardiac abnormality in hemodialysis patients. The diagnosis of this abnormality is possible by electrocardiogram and/or echocardiography. Our study aimed to assess the prevalence of left ventricular hypertrophy in hemodialysis patients and the accuracy of different electrocardiographic criteria.

METHODS

This was a cross-sectional retrospective study including 60 hemodialysis patients between 2017 and 2018. A left ventricular mass index higher than 115g/m² and 95g/m² respectively in men and women defines echocardiographic left ventricular hypertrophy. We assessed left ventricular hypertrophy prevalence, sensitivity, specificity, and area under the receiver-operating characteristics (ROC) curve of fourteen different electrocardiographic criteria for identification of left ventricular hypertrophy.

RESULTS

This was a cohort of 60 patients composed of 27 men and 33 women with a mean age 52.6±15,8years. Hypertension was the most common cardiovascular risk factor (82 %). The prevalence of left ventricular hypertrophy at echography was 65 %. Prevalence of left ventricular hypertrophy at electrocardiographic varied across the different criteria ranging from 5 % (R wave in DI) to 32 % (Perugia score). The highest left ventricular hypertrophy prevalence at electrocardiographic was found with the five following criteria: Perugia score (32 %), Peguero-Lo Presti index (28 %), Sokolow-Lyon index, Cornell index, Framingham-adjusted Cornell voltage (17 %). Sensitivity was ranged from 5 % (R in DI, Gubner-Ungerleider index, and product) to 41 % (Perugia score). The specificity of most criteria was ≥90 % except for the Perugia score (85 %). The sensitivity, specificity, postitive and negative productive values and left ventricular hypertrophy prevalence using the five most accurate criteria combined were respectively 48, 90, 70.28, 77.85 and 33 %. Hypertension, duration of HD, arteriovenous fistula, interdialytic weight gain, systolic blood pressure, hemoglobin <9g/dL and hyperparathyroidism were significantly associated with left ventricular hypertrophy.

CONCLUSION

The prevalence of left ventricular hypertrophy detected by echocardiography was high. All electrocardiographic criteria had a low sensibility and a high specificity in the diagnostic of echocardiographic left ventricular hypertrophy. To improve the accuracy of electrocardiographic criteria, it is necessary to combine several electrocardiographic criteria and not often focused on a single classic electrocardiographic index.

Pharmacotherapy for hypertension-induced left ventricular hypertrophy

BACKGROUND

Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension-induced LVH.

OBJECTIVES

To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension-induced LVH.

SEARCH METHODS

Cochrane Hypertension's Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with at least 12 months' follow-up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension-induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all-cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence.

MAIN RESULTS

We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow-up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention-to-treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add-on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low-certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low-certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low-certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low-certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low-certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions.

AUTHORS' CONCLUSIONS

We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low-certainty evidence requires that caution be used when interpreting the findings. High-quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension-induced LVH are warranted.

Electrocardiographic left ventricular hypertrophy criteria and ambulatory blood pressure monitoring parameters in adults

BACKGROUND

To examine the relationship between ambulatory blood pressure monitoring parameters (ABPM) and electrocardiographic criteria for left-ventricular hypertrophy (LVH) in adults.

METHODS

This study analyzed 1,544 subjects from the EVIDENT study (mean age = 55 ± 14 years; 61% women). A standard electrocardiograph (ECG) and 10 criteria were used to detect LVH. Office and ABPM were performed, and we analyzed 24-hour systolic blood pressure (SBP) and diastolic blood pressure (DBP), percentage of time awake with SBP ≥135 mm Hg, percentage of time asleep with SBP ≥120 mm Hg, and central aortic blood pressure.

RESULTS

LVH according to some electrocardiographic criteria was found in 11.30% of the patients (16.60% of men and 7.70% of women). The patients with LVH were older; had higher values for office, 24-hour and, central aortic blood pressure; were more likely to be men; and had a higher prevalence of obesity, diabetes, and antihypertensive or lipid-lowering drug use. In the logistic regression analysis, the association between the parameters of ABPM and LVH, after adjusting for age, sex, body mass index, and heart rate, remained statistically significant.

CONCLUSIONS

Twenty-four hour blood pressure, the percentage of time with elevated awake and asleep SBPs, and the central systolic blood pressure are related to the presence of LVH as determined by ECG in adults. These results indicate the potential importance of the monitoring and control of different 24-hour parameters of blood pressure in addition to the standard clinic blood pressure with respect to the development of LVH.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01325064.

Relationship between electrocardiographic left ventricular hypertrophy criteria and vascular structure and function parameters in hypertensive patients

The objective of this study was to determine the electrocardiographic left ventricular hypertrophy (LVH) criterion that best correlated with vascular structure and function parameters in hypertensive patients. A cross-sectional study involving 347 hypertensive patients was performed. The mean age of the subjects was 54.9±11.8 years, and 61% were male. Electrocardiography was used to detect LVH based on the evaluation of 10 criteria, and we defined the voltage-duration product (VDP) complex criterion. The vascular structure was evaluated according to carotid intima-media thickness (C-IMT), and vascular function was evaluated according to pulse wave velocity (PWV), the ambulatory arterial stiffness index (AASI), the home arterial stiffness index, and the peripheral (PAIx) and central (CAIx) augmentation indices. LVH according to at least some electrocardiographic criteria was recorded in 29.10% of the patients (34.10% of females; 25.90% of males). The vascular structure and function parameters showed higher values in the hypertensive patients with LVH. The criterion most closely correlated with C-IMT was Lewis-VDP (r=0.257); with PWV and AASI, the criterion was the Framingham-adjusted Cornell voltage (r=0.228 and r=0.195, respectively); and with CAIx and PAIx, the criterion was Novacode (r=0.226 and r=0.277, respectively). In the multivariate analysis, the association of the vascular structure and function parameters, the VDP complex (multiple linear regression) and the presence of LVH (logistic regression) disappeared after adjusting for age, sex and antihypertensive drugs. The relationship between the electrocardiographic criteria used to detect LVH in hypertensive patients and the vascular structure and function parameters were fundamentally conditioned by age and antihypertensive drug treatment.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Hypertension and anesthesia: consensus statement of the Catalan Associations of Anesthesiology and Hypertension]

The prevalence of hypertension is high in the surgical population. Differing practices and the absence of consensus among physicians involved in caring for hypertensive patients has made it one of the most frequent reasons for cancelling scheduled surgery. The aim of this consensus statement is to outline a practical approach to managing the hypertensive surgical patient. Hypertension is associated with increased risk of perioperative complications, particularly those related to systemic effects and notable fluctuations in blood pressure during surgery. Preoperative assessment should center on a search for signs and symptoms of target organ damage. The anesthesiologist should seek to reduce perioperative fluctuations in arterial pressure, particularly guarding against sustained hypotension. After surgery, antihypertensive medication should be resumed as soon as possible.

[Interobserver agreement on electrocardiographic diagnosis of left ventricular hypertrophy in hypertensive patients in Andalusia. PREHVIA study]

OBJECTIVE

To assess the agreement between Primary Care (PC) doctors and a cardiology specialist in diagnosing left ventricular hypertrophy in the electrocardiograph (LVH-ECG) in hypertensive patients.

DESIGN

Cross-sectional, multicentre study.

SETTING

Andalusian Primary Care Centres.

PARTICIPANTS

A total of 120 PC doctors who using a random sample selected patients of 35 years or more with AHT of at least 6 months of progression. PRIMARY VARIABLES: Demographic data, risk factors and cardiovascular diseases were recorded. The LVH-ECG was evaluated by applying Cornell voltage criteria, Cornell and Sokolow-Lyon product. The PC researchers read the ECG first and the cardiologist made a second reading blind.

RESULTS

A total of 570 patients (mean +/- SD of age, 65 +/- 11 years; 54.5% females); the LVH-ECG prevalence was 13.7% (95% CI, 10.8-16.6; 12.6% by Cornell and 1.6% by Sokolow-Lyon). The agreement in the diagnosis between the PC doctors and the cardiologist was 0.378 (95% CI, 0.272-0.486; disagreements in 15.5% of cases). The PC doctors slightly underestimated the LVH-ECG prevalence by Cornell and slightly overestimated it by the Sokolow-Lyon criteria. The agreement was also low for all of them (kappa = 0.367; 95% CI, 0.252-0.482, for Cornell, and kappa = 0.274; 95% CI: 0.093-0.454 for Sokolow-Lyon).

CONCLUSIONS

The agreement between the diagnosis by the PC doctors and the cardiologist was low. The implications of this study suggest the need to improve the reading of ECG among PC doctors. The use of computerised systems could be a good option.