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.     

Comparison of the efficiency between electrocardiogram and echocardiogram for left ventricular hypertrophy evaluation in patients with hypertension: Insight from the Korean Hypertension Cohort Study

In patients with hypertension, left ventricular hypertrophy (LVH) represents a risk factor for cardiovascular disease and asymptomatic organ damage. Currently, electrocardiography (ECG) and two‐dimensional echocardiography (Echo) are the most widely used methods for LVH evaluation. This study aimed to compare the long‐term outcomes of LVH, as evaluated by ECG and Echo, in patients with hypertension. Patients diagnosed with hypertension as a primary disease between 2006 and 2011 were enrolled in the Korean Hypertension Cohort study. The study finally included 1743 patients who underwent both ECG and Echo. The primary endpoint was defined as the composite of major adverse cardiovascular events (MACEs) or death. Overall, LVH was identified in 747 patients. The patients were categorized into four groups according to the detection of LVH by ECG or Echo: No LVH (n = 996), LVH diagnosed by ECG alone (n = 181), LVH diagnosed by Echo alone (n = 415), LVH diagnosed by both ECG and Echo (n = 151). After adjusting for variables, the incidence of MACEs or death was significantly greater in patients with LVH diagnosed by ECG alone (hazards ratio [HR]: 1.69; 95% confidence interval [CI]: 1.22–2.35; P = .001), LVH diagnosed by Echo alone (HR: 1.54; 95% CI: 1.16–2.05; P = .002), and LVH diagnosed by both ECG and Echo (HR: 1.87; 95% CI: 1.18–2.94; P = .002) than in those with no LVH. Both ECG and Echo are efficient diagnostic tools for LVH and useful for long‐term risk stratification. Additional Echo evaluation for LVH is helpful for predicting long‐term outcomes only in patients without LVH diagnosis by ECG.     

Prognostic value of left ventricular volume response during dobutamine stress echocardiography

AIMS: An abnormal left ventricular volume response during dobutamineechocardiography identified patients with severe coronary arterydisease. The aim of the study was to assess the prognostic valueof left ventricular volume changes during dobutamine stressechocardiography in 136 patients. MEHTODS AND RESULTS: Endpoints were defined as spontaneous cardiac events at follow-up.Left ventricular end-diastolic and end-systolic volume changes(abnormal response: >10% and >20> decrease, respectively)were compared with other clinical and stress test variables.During 18±7 months of follow-up, 31 cardiac events occurred:12 hard events (cardiac death [n=6 myocardial infarction [n=6])and 19 soft events (unstable angina [n=16] congestive heartfailure [n=3] End-diastolic volume response (P=0·006),diabetes (P=0·008), inducible wall motion abnormalities(P=0·024), end-systolic volume response (P=0·039)and inducible angina (P=0·038) were related to a greaterlikelihood of cardiac events. The Cox regression analysis revealedend-diastolic volume response (odds ratio: 3·0; CI 1·44–6·32)and diabetes (odds ratio: 2·7; CI 1·28–5·69)to be independent predictors of spontaneous cardiac events.Diabetes (odds ratio: 4·0; CI 1·26–12·80)and >40% baseline ejection fraction (odds ratio: 2·21;CI 1·14–4·29) were independent predictorsof hard events. CONCLUSIONS: An abnormal end-diastolic volume response during dobutaminestress echocardiography identifies patients with an unfavourableoutcome; they should be considered for more accurate prognosticstratification.     

A quantitative relationship of electrocardiographic criteria of left ventricular hypertrophy with echocardiographic left ventricular mass: a multivariate approach

The purpose of this study was to evaluate the sensitivity of various electrocardiographic (EKG) criteria of left ventricular hypertrophy (LVH) in relation to echocardiographic left ventricular mass (LVME) and to assess the relative strength of various EKG variables used in the diagnosis of LVH by multivariate analysis. An attempt was also made to determine if a new combination of precordial and T-wave voltage could improve the sensitivity of EKG. In 89 patients, M-mode echocardiograms and standard EKGs were studied. Correlation of Romhilt-Estes point-score system with LVME was r = 0.621, sensitivity and specificity was 57 and 81%, respectively. Other voltage criteria had lower sensitivity. Various combinations of precordial and T-wave voltage were not superior. The quantitative relationship of individual EKG variable, QRS duration, S V1-3, R V4-6, strain T wave, left atrial abnormality, intrinsicoid deflection and axis, with LVM was, r = 0.661, 0.595, 0.429, 0.42, 0.347, and 0.225, respectively. By multivariate analysis, QRS duration, S V1-3, T-wave and R V4-6 voltage had F-value (relative strength) of 27.95, 27.15, 22.02, and 4.03, respectively, other variables were statistically insignificant. In conclusion, the most important EKG variables predictive of LVH are QRS duration, S V1-3, strain T-wave and lateral voltage in decreasing value. Rescoring these variables in accordance to their correlation to LVM may improve EKG sensitivity for the diagnosis of LVH.     

Prognostic significance of body mass index‐adjusted criteria for left ventricular hypertrophy

Electrocardiographic left ventricular hypertrophy (ECG‐LVH) is associated with both cardiovascular and all‐cause mortality. Obesity attenuates the sensitivity of several ECG‐LVH criteria, so body mass index (BMI) adjusted criteria have been developed. However, the prognostic significance of BMI‐adjusted ECG‐LVH criteria is not known. This analysis included 7812 participants (59.8 ± 13.4 years, 53% women, 50% non‐Hispanic‐whites) from the Third National Health and Nutrition Examination Survey. The Cornell criteria (R in aVL + S in V3 ≥ 2800 µV in men or ≥2200 µV in women) and Sokolow‐Lyon criteria (S in V1 + R in V5 or R in V6 ≥ 3500 µV) criteria were used for LVH. To account for the effects of obesity, the BMI‐adjusted Cornell criteria (product of R in aVL + S in V3 and BMI > 60 400 µV kg m⁻²) and the BMI‐adjusted Sokolow‐Lyon criteria (add 400 µV if overweight, add 800 µV if obese) were used. Compared to traditional ECG‐LVH criteria, more participants met criteria for ECG‐LVH with BMI‐adjusted Cornell voltage (9.9% vs 2.9%) and BMI‐adjusted Sokolow‐Lyon (13.1% vs 6.4%) criteria. In multivariable‐adjusted Cox proportional hazards models, the BMI‐adjusted Sokolow‐Lyon criteria performed no better than traditional criteria (HR 1.18, 95% CI 1.06‐1.32 for all‐cause, HR 1.38, 95% CI 1.17‐1.62 for cardiovascular mortality) and the BMI‐adjusted Cornell voltage criteria attenuated the association with all‐cause (HR 1.16, 95% CI 1.03‐1.32) and cardiovascular mortality (HR 1.34, 95% CI 1.13‐1.60). Despite potential improvements in the detection of LVH using BMI‐adjusted ECG‐LVH criteria, adjusting for BMI may result in the loss of prognostic information.     

False positive ST segment elevation during dobutamine stress echocardiography due to left ventricular hypertrophy

The significance of ST segment elevation in dobutamine stress echocardiography (DSE) remains controversial. In patients with prior Q wave myocardial infarction (MI), it may reflect myocardial ischemia, contractile reserve in the infarct-related area, or dyskinesia of the infarcted areas of myocardium. In the nonpost-MI population, it has been attributed to vasospasm or strongly associated with coronary artery disease and ischemia. We hypothesized that ST segment elevation in the absence of inducible ischemia or prior MI is related to the presence of left ventricular hypertrophy (LVH). During DSE, dobutamine was infused from 5 microg/kg/min up to a maximum of 50 microg/kg/min. Echocardiographic images were obtained at baseline, low dose, peak dose, and recovery. Ischemia was defined as either the development of a new wall-motion abnormality or worsening wall motion at peak dose. We reviewed 682 consecutive DSE tests and found ST elevation in 42 patients (incidence = 6.1%). After excluding two patients for > 10% uninterpretable echocardiographic segments, the study population consisted of 40 patients. In 25 patients with ST elevation and without echocardiographic evidence for dobutamine-induced ischemia, 21 (84%) patients had LVH (P = 0.001). In 15 patients with inducible ischemia, only 4 (27%) patients had LVH. No other significant differences were found except that prior MI was more common in the inducible ischemia group. In the subgroup of 18 patients without prior MI, no inducible ischemia was found in 15 (83%). LVH was present in 14 (93%) of these 15 patients (P < 0.005), and all 14 had a normal baseline left ventricular ejection fraction. None of the three patients in the nonpost-MI subgroup with inducible ischemia had LVH. The 22 patients with prior MI had no significant association with LVH (P = 0.39). We conclude that ST segment elevation during DSE can occur without echocardiographic evidence for ischemia and is associated with LVH in the nonpost-MI population. This ST elevation may be related to transient electrocardiographic repolarization changes in the hypertrophied ventricle in the presence of altered loading conditions and/or altered catecholamine influences rather than true ischemia.     

高血压左室肥厚及构型与室性心律失常的关系

为探讨高血压左室肥厚(LVH)及不同构型与室性心律失常的关系,对320例有或无左室肥厚(LVH)高血压患者进行超声心动图、24h动态心电图检测.结果表明:LVH为105例,检出率为32.8%.复杂性室性心律失常的发生率在有无LVH组间有显著性差异(P<0.05),LVH程度与复杂性室性心律失常级别有密切的关系(r=0.57,p<0.05),LVH不同构型之间复杂性室性心律失常的发生率存在显著差异(p<0.05),不对称性LVH发生率较高.因此,对于肥厚程度较重、不对称LVH的高血压患者要给予高度重视.     

老年高血压病患者左心室肥厚危险因素分析

目的　旨在探讨老年高血压病患者伴发左心室肥厚的危险因素。方法　15 5例老年男性高血压病患者分为高血压伴左心室肥厚组(45例)和高血压无左心室肥厚组(110例) ,比较两组患者2 4h血压监测各项指标、纤维蛋白原及血脂等浓度,用多元逐步回归分析,探讨左心室肥厚的可能影响因素。结果　两组患者之间年龄、体重指数、体表面积差异无显著性意义;但高血压病程、2 4h平均脉压、平均收缩压及纤维蛋白原差异有显著性意义;2 4h平均脉压升高可能为左心室肥厚的独立危险因素。结论　高血压伴发左心室肥厚是长期血压控制不良、代谢紊乱等多因素作用的结果,其中,脉压增大者更易出现左心室肥厚。     

超声心动图检查高血压左室肥厚与心电图QT离散度测定的对比研究

目的探讨左心室肥厚和左心功能损伤与QT离散度(QTd)之间的关系。方法对79例高血压病患者进行二维超声及多谱勒心脏检查,同时进行体表心电图QTd测定。结果左心室室壁最大厚度及总厚度积分[1]与QTd呈正相关,QTd与左室内径缩短分数之间无相关性。67.5%的患者存在1项或多项多谱勒左室舒张功能异常指标,QTd与左室舒张功能异常程度密切相关。结论高血压左室肥厚和左室功能损伤表现出有QTd增大,说明高血压左室肥厚超声心动图特征与心电图QTd增大产生机制是一致的。     

Transient left ventricular "hypertrophy" in a woman with meningoencephalitis

We report the echocardiographic findings in a 27-year-old woman with viral meningoencephalitis and a positive test for cardiac troponin. Initially, the basal parts of the left ventricle were severely hypokinetic, whereas contraction in the mid-ventricle and apex was normal. A second echocardiogram obtained 19 days after the development of pulmonary edema showed a generalized, severe myocardial thickening, the left ventricular ejection fraction being normal. Three months after the initial examination the "hypertrophy" had disappeared. The serial echocardiograms along with a positive cardiac troponin led to the diagnosis of myocarditis, which can very rarely present with the echocardiographic picture of severe left ventricular thickening.     

ACE inhibitors and regression of left ventricular hypertrophy.

Left ventricular hypertrophy (LVH) is a common condition and a powerful independent risk factor for coronary heart disease, congestive heart failure, and other cardiac morbidity. It is associated with the male sex and advancing age. Its most common cause is hypertension, and many antihypertensive agents induce regression of LVH. Angiotensin-converting enzyme (ACE) inhibitors have been shown to reverse LVH by a mechanism as yet unknown. Reduction in afterload and other hemodynamic abnormalities by reduction of blood pressure is clearly a factor, but ACE inhibitors also block adrenergic action and other sympathetic nervous system influences, and the reduction in angiotensin II produces many effects. By inhibiting this potent vasoconstrictor and suppressing its degradation of the powerful vasodilator bradykinin, and by promoting sodium and water excretion, ACE inhibitors contribute to the restoration of normal ventricular function. Angiotensin II promotes protein synthesis in myocardial myocytes, and blocking this action may arrest the hypertrophic process. To determine the effect of angiotensin II on LVH and normalization of LV function, a study is now underway evaluating the effects of lisinopril, a new lysine analog of enalapril, and a diuretic agent in the treatment of hypertension LVH.     

老年高血压左心室肥厚患者左心室重构和冠状动脉病变分析

目的老年高血压左心室肥厚(left ventricular hypertrophy,LVH)患者左心室重构和冠状动脉病变发生及严重程度分析。方法选择高血压患者553例,根据年龄以及是否合并LVH,分为非老年非LVH组(A组,1 41例),非老年LVH组(B组,86例),老年非LVH组(C组,196例),老年LVH组(D组,130例),比较各组危险因素伴发情况、生化指标、冠心病发生、冠状动脉病变严重程度及心脏超声结果。结果与A组比较,其余3组的冠状动脉造影阳性率明显升高;B组和D组高血压3级比例、冠状动脉3支病变率明显升高(P<0.05,P<0.01);C组和D组的二尖瓣舒张早期血流峰值速度和舒张晚期血流峰值速度的比值明显降低;B组和D组的左心房内径、左心室舒张末内径、左心室收缩末内径、左心室重量指数明显增加,LVEF明显降低(P<0.01)。C组心脏超声指标较D组变化明显,差异有统计学意义(P<0.01)。结论老年高血压LVH患者高血压病程长,高血压程度严重,冠状动脉狭窄发生率高且病变程度更严重,心脏收缩与舒张功能显著降低。     

伊贝沙坦对高血压左室肥厚患者的左室结构的影响

目的 研究伊贝沙坦对高血压左室肥厚（LVH）患者的左室结构的影响。方法 60例原发性高血压左室肥厚患者随机分为2组：治疗组每天口服伊贝沙坦150mg，对照组每天口服氨氯地平5mg。平均12个月，观察用药后血压、左室结构的变化。结果 用药后2组收缩压（SBP）和舒张压（DBP）均显著降低（P〈0．01）；室间隔厚度（IVST）及左室后壁厚度（LYPWT）均变薄（P〈0．01），左室重量指数（LYMI）明显减少（P〈0．01），对照组各项指标无明显变化（P〈0．05）。结论 对原发性高血压左室肥厚的患者，长期应用伊贝沙坦具有良好降压效果，同时还可逆转LVH，改善患者预后。     

Evaluation of the electrocardiographic criteria for left ventricular hypertrophy with use of three-dimensional echocardiography

BACKGROUND: Left ventricular hypertrophy (LVH) is a common condition that carries an increased risk of cardiovascular events. Use of ECG in detection of LVH is limited because of the reported low sensitivity. Conventional echocardiographic techniques used as the standard for estimating left ventricular (LV) mass have limitations related to the position of the image plane and shape of the ventricle. Three-dimensional echocardiography is free of these limitations and therefore is more accurate. We hypothesized that accuracy of ECG criteria for LVH would improve when LV mass was assessed by three-dimensional echocardiography. RESULTS: For most of the criteria, sensitivity, specificity and accuracy improved when LV mass was assessed by three-dimensional echocardiography. Two-dimensional echocardiography significantly overestimated LV mass as compared with the three-dimensional method. CONCLUSIONS: Sensitivity, specificity, and accuracy of the ECG criteria improved when LV mass was estimated by three-dimensional echocardiography. This improvement may be attributed at least in part to superior accuracy of three-dimensional measurements.     

Predictors of left ventricular hypertrophy in patients with essential hypertension

The purpose of this study was to assess clinical variables which might be predictive of echocardiographic left ventricular hypertrophy in mildly hypertensive patients. Eighteen patients (mean age 51) were studied following four weeks of hydrochlorothiazide monotherapy. Variables assessed included age, duration of hypertension, body surface area, serum cholesterol, alcohol consumption, smoking, maximum systolic and mean blood pressures, and variability of blood pressure determined from hourly measurements taken 12 hours after hydrochlorothiazide dosing. Using stepwise multiple linear regression (with left ventricular mass index analyzed as a continuous variable), the variability of blood pressure was predictive of an elevated left ventricular mass index (p less than 0.0003, r2 = 0.61). The duration of hypertension added significantly to the variability in predicting an elevated left ventricular mass index (p less than 0.004, multiple r = 0.74). In conclusion, echocardiographic left ventricular hypertrophy was significantly related to the variability of blood pressure recorded hourly for 12 h after subjects received 50 mg of hydrochlorothiazide.     

老年原发性高血压患者血压晨峰与左心室肥厚的关系

目的探讨老年原发性高血压患者血压晨峰与左心室肥厚的关系。方法选择老年原发性高血压患者80例,根据24 h动态血压监测分为2组:血压晨峰值≥55 mm Hg(1 mm Hg=0.133 kPa)为晨峰组,血压晨峰值<55mm Hg为非晨峰组,每组40例,均常规行超声心动图检查,计算左心室重量指数(LVMI)。结果晨峰组24h、昼间、夜间收缩压及血压晨峰均明显高于非晨峰组(P<0.05),晨峰组LVMI明显高于非晨峰组;左心室肥厚比例明显高于非晨峰组(P<0.05)。结论老年原发性高血压患者血压晨峰与左心室肥厚密切相关。     

Secondary harmonic imaging overestimates left ventricular mass compared to fundamental echocardiography.

AIMS: The significance of left ventricular hypertrophy in hypertension is well documented, being an independent risk factor for cardiovascular morbidity and mortality. Normal values for left ventricular mass and partition values for left ventricular hypertrophy come from measurements obtained by fundamental echocardiography. Secondary harmonic imaging improves definition of cardiac borders. We hypothesise that this overestimates left ventricular mass compared to fundamental imaging. METHODS AND RESULTS: Thirty patients had four parasternal long-axis M-modes performed, two using 1.7 mHz output frequency, receiving at two octaves higher and two using fixed frequency of 2.5 mHz (fundamental imaging). Absolute left ventricular mass and left ventricular mass index were calculated for each modality. Intra-observer variability was <7%. Range on fundamental imaging was 54-264 g/m2 compared to 80-293 g/m2 on secondary harmonic imaging. Mean left ventricular mass index for the group was 118 g/m2 (fundamental imaging) vs 147 g/m2, P<0.001. Twenty-nine of 30 patients had higher left ventricular mass index on secondary harmonic imaging compared to fundamental imaging. Left ventricular mass index was an average of 26% higher on secondary harmonic imaging, range (-7 to 65%) corresponding to average absolute left ventricular mass difference of 55 g. Eleven of 30 patients had left ventricular hypertrophy on fundamental imaging and 17/30 on secondary harmonic imaging. CONCLUSION: Secondary harmonic imaging overestimates left ventricular mass index compared to fundamental imaging. Normal left ventricular mass index range is based on equations using fundamental imaging measurements. Management decisions and prognostic implications made on the basis of raised left ventricular mass index using secondary harmonic imaging should be done so with caution.     

Influence of serum potassium on the electrocardiographic pattern of left ventricular hypertrophy in primary hyperaldosteronism.

Only a few studies deal with electrocardiographic (ECG) signs of left ventricular hypertrophy (LVH) in patients with primary hyperaldosteronism, although it may be presumed that many factors such as arterial hypertension, hypokalemia, increased blood volume, and decreased activity of the renin-angiotensin system can modify LVH pattern in this entity. For that reason, we evaluated ECG signs of LVH in 55 patients with primary hyperaldosteronism hospitalized in our department from 1971 to 1990. These data were compared with age, serum potassium level, plasma renin activity (PRA) and-in 14 patients-with left ventricular mass, measured echocardiographically. We found inverse correlation between serum potassium concentration and the Sokolow-Lyon index: SV1 + RV5/6 (r = -0.47, p < 0.001). Among 24 patients with only abnormal QRS voltage, without ST-T changes suggestive of LVH, 19 (79.2%) had hypokalemia. In multivariate analysis, potassium concentration was the single independent predictor of an abnormal QRS voltage: -0.743, p = 0.01 vs. 0.153 (age), -0.337 (PRA) and 0.454 (LV mass). Our observations suggest that hypokalemia is an important factor influencing an amplitude of QRS complexes and may be responsible for false-positive LVH diagnosis.