Electrocardiographic measures of left ventricular hypertrophy in children across the distribution of blood pressure: the Muscatine study

We sought to test the effectiveness of the ECG as a measure of increased left ventricular wall mass in children with high blood pressure. One hundred eighty-one children, ages 9-18 years, were selected from the lowest, middle and highest quintile of systolic blood pressure from the Muscatine Study, based upon two biennial school screenings. After correction for age, sex, height, weight and skinfold thickness, children with the highest blood pressure had increased echocardiographic left ventricular wall mass (p less than 0.02). Voltage measurements of maximum R and S waves in the standard and precordial leads were measured by computer. We correlated blood pressure and echocardiographic measurements of the interventricular septum, left ventricular posterior wall and left ventricular wall mass to electrocardiographic combinations used to predict left ventricular hypertrophy in both children and adults. The electrocardiographic correlations ranged from -0.01 to + 0.17. Poor correlations were found between electrocardiographic measures and blood pressure, left ventricular wall thickness or left ventricular wall mass. Skinfold thickness and weight had negative correlations, suggesting a damping effect upon measured voltage. We conclude that the echocardiogram is a more sensitive measurement of increased left ventricular mass than the ECG in children with elevated blood pressure.     

An echocardiographic study of the interventricular septum in constrictive pericarditis.

Ten patients with constrictive pericarditis were studied echocardiographically with specific reference to inter-ventricular septal dynamics. Abnormal movement of the interventricular septum was present in 8 patients and consisted of flattening in systole and unusual posterior motion in diastole. The aetiology of this type of movement is at present unknown but may be related to restriction of normal cardiac rotational dynamics. The interventricular septum also showed diminished degree of thickening (mean 21-2%). The amplitude of excursion was generally at the upper limit of or greater than normal. Left ventricular posterior wall amplitude of excursion was normal. Flattening of left ventricular posterior wall diastolic movement was seen in 4 patients. Right ventricular end-diastolic dimension was slightly increased (1-2 to 1-7 cm/m2) in 5 of 8 patients with abnormal septal motion, but no haemodynamic evidence of diastolic volume overload was found. Posterior pericardial thickening was noted echocardiographically when posterior calcification was present. We conclude that the most common though non-specific feature of the echocardiogram in patients with constrictive pericarditis is abnormal septal motion. Flattening of left ventricular posterior wall diastolic movement, posterior pericardial thickening, and epicardial-pericardial separation may also occur.     

Impact of left ventricular hypertrophy on ventricular arrhythmias in the absence of coronary artery disease

Left ventricular hypertrophy has a grave prognosis. Ventricular arrhythmias may account for a large portion of this poor prognosis, but the contribution of coronary artery disease has not been excluded. The occurrence of ventricular arrhythmias was investigated by 24 h ambulatory electrocardiographic (ECG) monitoring in 49 hypertensive patients who had normal findings on coronary arteriography. The presence of left ventricular hypertrophy was assessed by both ECG and echocardiography. The frequency and complexity of ventricular arrhythmias were significantly related to the presence of left ventricular hypertrophy whether it was defined by wall thickness (interventricular septum or posterior wall greater than or equal to 1.2 cm) or by left ventricular mass indexed to height (left ventricular mass/height greater than or equal to 163 g/m in men and greater than or equal to 121 g/m in women). The relation between left ventricular mass or wall thickness to ventricular arrhythmia was graded and continuous; for every 1 mm increase in the thickness of interventricular septum or posterior wall there was an associated two- to threefold increase, respectively, in the occurrence and complexity of ventricular arrhythmias. In conclusion, left ventricular hypertrophy is associated with an increase in the frequency and complexity of ventricular arrhythmias in the absence of coronary artery disease, and the relation is graded and continuous.     

Eelectrocardiographic correlates of ultrasonically increased septal, left ventricular posterior wall and left ventricular internal dimensions.

The electrocardiograms (ECG) of 64 subjects who exhibited an echocardiographically demonstrable increase in thickness of the interventricular septum and left ventricular posterior wall (Group 1, 22 patients), isolated left ventricular internal dimension (Group 2,26 patients), combined wall thickness and chamber diameter (Group 3, 2 patients), and septal thickness, (Group 4, asymmetric septal hypertrophy, 14 patients) were reviewed in order to determine sensitivity of ECG criteria for the diagnosis of left ventricular hypertrophy (LVH) proposed in 1949 by Sokolow and Lyon (13), in 1968 by Romhilt and Estes (14), and in 1973 the New York Heart Association (15). Relative sensitivity of the three methods was as follows: Total group, NYHA (77%) greater than Sokolow and Lyon (67%) greater than Romhilt and Estes (58%); Group 1, NYHA (91%) greater than Sokolow and Lyon (73%) greater than Romhilt and Estes (54%); Group 2, NYHA and Sokolow and Lyon (65%) greater than Romhilt and Estes (61%); Group 4, NYHA (79%) greater than Sokolow and Lyon (64%) greater than Romhilt and Estes (57%). We conclude that 1)ECG criteria of the NYHA for the diagnosis of LVH correlate best with an increase of ultrasonically determined septal, left ventricular posterior wall or left ventricular internal dimensions when compared with voltage criteria of Sokolow and Lyon and the point score system of Romhilt and Estes; and 2) isolated increase of left ventricular internal dimension, in the absence of thickened septum or posterior left ventricular wall, frequently results in ECG criteria compatible with the diagnosis of LVH.     

Electrocardiographic correlates of ultrasonically increased septal,left ventricular posterior wall and left ventricular internal dimensions

The electrocardiograms (ECG) of 64 subjects who exhibited an echocardiographically demonstrable increase in thickness of the interventricular septum and left ventricular posterior wall (Group 1,22 patients), isolated left ventricular internal dimension (Group 2, 26 patients), combined wall thickness and chamber diameter (Group 3, 2 patients), and septal thickness, (Group 4, asymmetric septal hypertrophy, 14 patients) were reviewed in order to determine sensitivity of ECG criteria for the diagnosis of left ventricular hypertrophy (LVH) proposed in 1949 by Sokolow and Lyon (13), in 1968 by Romhilt and Estes (14), and in 1973 the New York Heart Association (15). Relative sensitivity of the three methods was as follows: Total group, NYHA (77%) > Sokolow and Lyon (67%) > Romhilt and Estes (58%); Group 1, NYHA (91%) > Sokolow and Lyon (73%) > Romhilt and Estes (54%); Group 2, NYHA and Sokolow and Lyon (65%) > Romhilt and Estes (61%); Group 4, NYHA (79%) > Sokolow and Lyon (64%) > Romhilt and Estes (57%). We conclude that (1) ECG criteria of the NYHA for the diagnosis of LVH correlate best with an increase of ultrasonically determined septal, left ventricular posterior wall or left ventricular internal dimensions when compared with voltage criteria of Sokolow and Lyon and the point score system of Romhilt and Estes; and (2) isolated increase of left ventricular internal dimension, in the absence of thickened septum or posterior left ventricular wall, frequently results in ECG criteria compatible with the diagnosis of LVH.     

The echocardiographic correlates of left ventricular hypertrophy diagnosed by electrocardiography.

Echocardiography was performed in 28 consecutive patients who manifested accepted criteria for left ventricular hypertrophy on their electrocardiograms. Four groups of patients were identified: Group 1, nineteen (68%) who had an increase in both interventricular septal and left ventricular posterior wall thickness; Group 2, three patients (11%) with isolated enlargement of the left ventricular internal dimension; Group 3, two subjects (7%) with increased septal thickness, left ventricular posterior wall thickness and left ventricular internal dimension and Group 4, four patients (14%) with normal echocardiographic measurements. It is concluded that increases in both septal and left ventricular wall thickness are the primary echocardiographic correlates of left ventricular hypertrophy as diagnosed on the electrocardiogram.     

Cardiac characteristics and postoperative courses in Cushing's syndrome.

To assess the cardiac characteristics and postoperative courses in patients with Cushing's syndrome, electrocardiography and echocardiography were performed to study 12 consecutive, unselected patients, and results were compared with those of essential hypertension and primary aldosteronism. Eleven patients had hypertension and 7 had diabetes mellitus. Before adrenalectomy, common electrocardiographic abnormalities consisted of high-voltage QRS complexes (10 patients) and negative T waves (7 patients). Echocardiograms showed left ventricular hypertrophy in 9 patients, and all the patients had evidence of asymmetric septal hypertrophy. In patients with left ventricular hypertrophy, the thickness of the interventricular septum ranged from 16 to 32 mm, whereas the ratio of the thickness of interventricular septum to that of the posterior wall ranged from 1.33 to 2.67. The interventricular septum in Cushing's syndrome was extremely thicker and asymmetric septal hypertrophy occurred more often than essential hypertension and primary aldosteronism. Nine patients could be followed up after operation. In these patients abnormal electrocardiographic findings had normalized, the thickness of interventricular septum had decreased and asymmetric septal hypertrophy had disappeared except in 1 patient. The reason why left ventricular hypertrophy in Cushing's syndrome is severe is still unknown. Because left ventricular hypertrophy is more severe and the frequency of asymmetric septal hypertrophy much greater in Cushing's syndrome than in essential and other secondary hypertension, it is thought that not only increased aortic pressure but excessive plasma cortisol may be etiologic factors in the progression of left ventricular hypertrophy in Cushing's syndrome.     

Serial changes in left ventricular configuration and function in hypertrophic cardiomyopathy

Fifteen patients, 12 males and three females, with hypertrophic cardiomyopathy (HCM) including three of obstructive type (HOCM) were investigated to observe the long-term course of HCM. Left ventriculography and bi-ventriculography were performed twice serially in all cases. We studied the correlations between the serial ECG changes, especially the negative T wave, and the left ventricular configuration, wall thickness, and left ventricular function. Serial ECG changes included: 1) negativity of the T wave which developed or increased concomitantly with increased voltages of SV1 + RV5 (A-1 group: five cases), 2) the negativity decreased or resolved with decreased voltages of SV1 + RV5 (A-2 group: four cases), and 3) insignificant changes of both T waves and SV1 + RV5 (B group: six cases). In the right oblique views at end-diastole, the configuration of the left ventricle was classified in three forms; (1) spade form (S), (2) round form (R), and (3) intermediate form (SR). The results were as follows: 1. The A-1 group showed increased thickness of the apical and anterior walls, but the thickness of the posterior wall and interventricular septal wall did not change serially. In three cases, the thickness of the interventricular septum showed mild hypertrophy at the initial and final observations. The configuration changed from the R or SR form to the S form. Diastolic dysfunction (peak dV/dt/V, peak dV/dt/EDV) was progressive, but end-diastolic volume and ejection fraction did not change. 2. The A-2 group showed the significantly decreased thickness of the apical and anterior walls. The thicknesses of the posterior wall and interventricular septal wall tended to decrease in all cases. In three cases (75%), the interventricular septal wall was markedly hypertrophied on the initial observation. The configuration changed from the S or SR form to the R form. Left ventricular diastolic function and ejection fraction decreased significantly and end-diastolic volume increased. Two cases showed clinical pictures of dilated cardiomyopathy at the final observation. 3. In the B group, there were no marked changes in wall thickness, left ventricular configuration, or systolic and diastolic functions. In conclusion, serial changes in left ventricular configuration, wall thickness, especially of the anterior and apical walls, and left ventricular function were all compatible with the serial changes of the ECG in hypertrophic cardiomyopathy.(ABSTRACT TRUNCATED AT 400 WORDS)     

ECG-gated magnetic resonance imaging of the left ventricle: visualization of anatomical characteristics and quantification of wall thickness and ventricular volume in left ventricular hypertrophy

Electrocardiography- and respiration-gated magnetic resonance imaging (MRI) was performed using a 0.15-Tesla resistive magnet system in 54 patients with left ventricular hypertrophy to define the site and extent of abnormal wall thickness and to estimate left ventricular function. Because the major cardiac axes are not orthogonal to the conventional transverse, sagittal or coronal planes, the long-axis and short-axis images of the left ventricle were obtained at the end-diastolic and end-systolic phases. The anatomic characteristics of concentric hypertrophy, asymmetric septal hypertrophy, and asymmetric apical hypertrophy were clearly demonstrated by MRI, even in patients with poor echocardiographic images. Quantitatively, left ventricular wall thicknesses obtained from MR images correlated well with those obtained from echocardiography (r = 0.95), and regression was y = 0.99x + 0.39, and so did the ratios of wall thickness of the interventricular septum to the left ventricular posterior wall (r = 0.91, y = 0.80x + 0.24). Left ventricular volumes calculated by the area-length method from MRI and those from left ventriculography also correlated well (r = 0.98, y = 1.13x + 24.5). In conclusion, using the gated long-axis and short-axis MR images of the left ventricle, the anatomical location and extent of hypertrophy and left ventricular volumes are noninvasively demonstrated.     

Hypothyroid cardiomyopathy: echocardiographic documentation of reversibility

The concept of hypothyroid heart disease remains controversial. Although hemodynamic abnormalities have been described, the presence of underlying abnormal cardiac structures has not been confirmed. The authors studied 20 hypothyroid patients using M-mode echocardiography before and after l-thyroxine therapy. Fifteen additional hypothyroid patients were studied using two-dimensional echocardiography to confirm the data of the first study. The findings were the same in both studies: during hypothyroidism, the interventricular septum is thickened, the ratio of septal thickness to left ventricular posterior wall thickening is increased, the right ventricular wall is thickened, regional wall motion of interventricular septum and right ventricular wall is decreased, and global function of the left ventricle is decreased. These findings are reversed with l-thyroxine therapy; they occur within 6 months of the development of hypothyroidism, but appear unrelated to elevated TSH levels. Whether the thickened interventricular septum and right ventricular wall represent true muscular hypertrophy requires further elucidation. Nevertheless, these data demonstrate the existence of a hypothyroid cardiomyopathy.     

Echocardiographic assessment of the left ventricle in juvenile hypertension

We studied with M-mode echocardiography the morphology and function of the left ventricle in a group of 36 juvenile hypertensives with borderline hypertension, whose cuff arm pressure exceeded 150/90 mmHg in at least three separate sessions. The results were compared with those of 23 age-matched normotensives with no evidence of any cardiovascular disease. Left ventricular hypertrophy (i.e. septum and/or posterior wall thicknesses in diastole greater than or equal to 12 mm) was present in 13 subjects of the hypertensive group (36%). Significant increase of interventricular septal thickness together with higher septum/posterior wall ratio and a higher incidence of asymmetric septal hypertrophy were the most characteristic findings in juvenile hypertensives. Of the functional parameters the only observed difference between the two groups was an elevated peak velocity of left ventricular contraction in hypertensives which tended to correlate inversely with the values of septum/posterior wall ratio. Additional comparison of electrocardiographic and echocardiographic detection of left ventricular hypertrophy in young hypertensives revealed a lower sensitivity but a satisfactory specificity of electrocardiography (31 and 87% respectively). The results indicate that besides an elevated systemic arterial pressure, other factors such as increased sympathetic or humoral activity may play a role in the incipient stage of essential hypertension and that isolated septal hypertrophy seems to be an early sign of cardiac involvement.     

肥厚性心肌病患者左心室形态学改变与QT间期离散度的关系

目的探讨体表心电图上QT间期离散度（QTd）与肥厚性心肌病（HCM）左心室形态学改变的关系。方法43例HCM患者,均经二维超声心动图确诊。根据心室肥厚的部位不同,将患者分为4组:A组（室间隔肥厚）16例、B组（室间隔肥厚及左室前壁肥厚）10例、C组（室间隔肥厚、左室前壁肥厚及左室侧壁肥厚）10例、D组（室间隔肥厚及广泛左室壁肥厚）7例。在安静状态下记录同步12导联心电图（ECG）,人工测量各导联的QT间期、QRS波时间,并计算QT及QRS离散度（QTd及QRSd）。结果超声心动图检查D组的左室后壁厚度（PWT）明显大于A、B、C组,D组的室间隔厚度（IVST）/PWT明显小于A、B、C组。A、B组的QTd明显大于C、D组,差异有显著性意义。结论QTd不仅反应了左心室复极的不均一性,也反应了左心室肥厚的形态学改变的不均性。     

Angled interventricular septum on echocardiography: Anatomic anomaly or technical artifact?

An acutely angled interventricular septum has been reported to constitute a distinct two-dimensional echocardiographic geometric pattern that may permit a false M-mode echocardiographic recording of asymmetric septal hypertrophy. In light of experience suggesting that the angle between the aortic root and interventricular septum varied with the intercostal space of the transducer, 45 subjects were prospectively studied by two-dimensional and M-mode echocardiography. Parasternal long- and short-axis views were obtained from two to four intercostal spaces in each subject. Two-dimensional echographic cursor-generated M-mode echocardiograms were obtained from the long-axis views; interventricular septal and left ventricular posterior wall thickness was measured from both the two-dimensional and M-mode echocardiograms. On two-dimensional echocardiography, the angle between the aortic root and septum became more acute as a progressively lower intercostal space was used (p less than 0.001). Although no change in septal thickness was apparent, the septal thickness significantly increased as a progressively lower intercostal space was used. On M-mode echocardiography, 21 subjects (47%) demonstrated asymmetric septal hypertrophy (septal/posterior wall thickness ratio greater than 1.3) from at least one intercostal space, but this was confirmed by the two-dimensional technique in only 4 subjects (9%). Thus, a two-dimensional echocardiographic recording of an angled interventricular septum can be produced by positioning the transducer in a low intercostal space, and caution must be used in the interpretation of asymmetric septal hypertrophy on M-mode echocardiograms. Two-dimensional echocardiography is a useful means of identifying subjects with apparent asymmetric septal hypertrophy that often may be the result of a technical artifact.     

Relation of hemodynamic load to left ventricular hypertrophy and performance in hypertension

Left ventricular hypertrophy and dysfunction in patients with hypertension are often poorly related to the level of blood pressure. To evaluate the reasons for this, 100 untreated patients (44 +/- 14 years) with essential hypertension were studied using cuff blood pressure and quantitative echocardiography to measure left ventricular mass index and end-diastolic relative wall thickness as 2 indexes of left ventricular hypertrophy. Left ventricular hypertrophy, as measured by either left ventricular mass index or end-diastolic relative wall thickness, correlated weakly with all indexes of blood pressure including systolic, diastolic, and mean blood pressure (r = 0.16 to 0.32). In contrast, end-diastolic relative wall thickness, an index which assesses the severity of concentric hypertrophy, showed a closer direct relation with total peripheral resistance (r = 0.52 p less than 0.001) and a significant inverse relation with cardiac index (r = -0.47, p less than 0.001). Left ventricular performance as assessed by fractional systolic shortening of left ventricular internal dimensions was not significantly related to left ventricular mass index, blood pressure, or peak systolic wall stress, but declined significantly with increasing mean systolic wall stress (r = -0.42, p less than 0.001) and even more with increasing end-systolic wall stress (r = -0.71, p less than 0.001). It is concluded that in patients with hypertension (1) left ventricular hypertrophy is correlated only modestly with measurements of resting blood pressure; and (2) the classic pattern of concentric left ventricular hypertrophy, as measured by relative wall thickness, is more closely related to the "typical" hypertensive abnormality of elevated peripheral resistance, suggesting that these anatomic and hemodynamic changes may be pathophysiologically interdependent. Furthermore, left ventricular performance declines when the pressure overload in hypertension is not offset by compensating hypertrophy, allowing wall stresses to increase.     

Cardiac involvement in Friedreich's heredo-ataxia

The frequency and characteristics of cardiac involvement have been evaluated in 22 patients with Friedreich's ataxia and in 10 patients with non Friedreich's ataxia (Strumpell-Lorraine 5 cases; Pierre Marie 5 cases), classified according to the severity and the lasting of neurological disease. In a high percentage (45%) of patients with Friedreich's ataxia, the results show left ventricular hypertrophy as proved echocardiographically by an increase of the interventricular septum thickness and of the posterior wall thickness. On the contrary, no patient with non Friedreich's ataxia had left ventricular hypertrophy. In the patients with Friedreich's ataxia, left ventricular hypertrophy was of concentric type in 27% of the cases and of asymmetric type in 18% of the cases; left ventricular systolic indexes were not reduced. The left ventricular end-diastolic diameter was normal in all the patients. Furthermore, in 4 patients with Friedreich's ataxia (18% of the cases) without left ventricular hypertrophy, mitral valve prolapse has been found. No correlation exists between the severity and the lasting of neurologic disease and the presence of cardiac hypertrophy. This supports the hypothesis that the cardiac abnormality is a primary expression of a genetic defect and not a secondary manifestation of spinocerebellar degeneration. It is therefore necessary to always consider a patient with Friedreich's ataxia as affected with a cardiac disease even if it is not clinically evident.     

Cardiac hypertrophy in hypertension

The time course of regression of left ventricular hypertrophy and changes in left ventricular function were followed in 52 middle-aged hypertensive patients divided into two groups: 30 treated with betablockers and 22 with methyldopa. In case of inadequate blood pressure control, diuretics and/or vasodilators were added in both groups. Blood pressure decreased significantly over a three-year follow-up period. The decrease was most pronounced during the first three months. The biggest decrease in posterior wall and interventricular septum thickness was detected by echocardiography also within the first three months. While complete regression of posterior wall hypertrophy was noted within the next three months, interventricular septum thickness decreased steadily over a period of two years. No significant change was seen in the septum in the third year of follow-up. Complete regression of hypertrophy was found in 30 (57.7%) of probands, with no change altogether observed in as few as two patients. Regression was incomplete in 20 (38.4%) obese patients with manifest hypertrophy at the start of the study. Regression of hypertrophy was not associated with left ventricular function deterioration and was observed even after vasodilator administration. There were no differences between the two groups of patients.     

Electrocardiographic detection of left ventricular hypertrophy: development and prospective validation of improved criteria

To develop improved electrocardiographic criteria of left ventricular hypertrophy, individual electrocardiographic voltage measurements were compared with echocardiographic left ventricular mass in a "learning series" of 414 subjects. The strongest independent relations with left ventricular mass were exhibited by the S wave in lead V3, the R wave in lead a VL and the T wave in lead V1 (each p less than 0.001), and by age and sex. Better electrocardiographic detection of left ventricular hypertrophy was achieved by new criteria that stratified QRS voltage and repolarization findings in sex and age subsets. For men, at all ages, left ventricular hypertrophy is suggested by QRS voltage alone when the R wave in lead aVL and the S wave in lead V3 total more than 35 mm. When this voltage exceeds 22 mm, left ventricular hypertrophy is suggested in men under age 40 years when the T wave in lead V1 is positive (greater than or equal to 0 mm), and in men 40 years or older when the T wave in lead V1 is at least 2 mm. For women, at all ages, left ventricular hypertrophy is suggested when the R wave in lead a VL and the S wave in lead V3 total more than 25 mm. When this voltage exceeds 12 mm, left ventricular hypertrophy is suggested in women under 40 when the T wave in lead V1 is positive (greater than or equal to 0 mm), and in women over 40 when the T wave in lead V1 is 2 mm or greater.(ABSTRACT TRUNCATED AT 250 WORDS)     

Systolic anterior motion of the mitral valve with and without asymmetric septal hypertrophy. Role of left ventricular posterior wall motion

Abnormal systolic anterior (SAM) motion of the mitral valve without asymmetric hypertrophy of the interventricular septum was observed in 16 patients (group 1). 5 of the 16 patients had no other evidence of heart disease and the remaining 11 had a variety of cardiac disorders. Left ventricular dimensions, septal and posterior wall thickness, left ventricular ejection fraction, the mean velocity of circumferential fiber shortening, and the mean velocity of the posterior wall and septal contraction was measured by echocardiography in all patients in group 1. These measurements were compared with similar measurements in 14 patients with idiopathic hypertrophic subaortic stenosis (group 2) and in 11 normal subjects (group 3) to evaluate the role of the left ventricular contractility with particular reference to the left ventricular posterior wall motion in production of SAM. All patients with SAM (groups 1 and 2) showed significantly higher indexes of left ventricular contractility, particularly posterior wall velocity, and normalized mean posterior wall velocity, when compared to the normal subjects. The significantly higher posterior wall and the normalized mean posterior wall velocities in all patients with SAM suggest that the exaggerated systolic anterior motion of the left ventricular posterior wall plays an important role in production of SAM in the presence or absence of asymmetric septal hypertrophy.