心电图电压标准诊断左室肥大价值的研究

目的 评价临床上最常用的几项心电图电压标准诊断左室肥大（LVH）的价值及性别差异。方法 选择1999—2003年我院体检及住院患者499例，依据超声心动图测定的左室重量指数（LVMI）分为正常组（男210饲，女83例）和左室肥大组（男126例，女80例）。计算各项电压标准诊断左室肥大的敏感性、特异性和准确率，并比较各项电压标准诊断左室肥大的性别差异。结果 各项电压标准诊断左室肥大的特异性均〉95％,在单项指标中，Rvs〉2．5my标准的敏感性和准确率分别为62．8％和85．1％，明显高于Rvs及RaVL电压标准。在复合指标中，Comell指数和Sokolow指数诊断左室肥大的敏感性和准确率明显高于R4＋Sm指标。男、女性采用相同的电压阈值，其诊断性能存在明显性别差异。结论 Cornell指数、Sokolow指数及Rv5电压标准是诊断左宣肥大较好的指标。男、女性采用不同的电压阈值标准，可望进一步改善目前心电图诊断左室肥大的性能。     

Influence of metabolic syndrome on hypertension-related target organ damage

OBJECTIVES: The aim of our study was to analyse, in a wide group of essential hypertensive patients without diabetes mellitus, the influence of metabolic syndrome (MS) (defined according to the criteria laid down in the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults) on markers of preclinical cardiac, renal and retinal damage. DESIGN: Cross-sectional study. SETTING: Outpatient hypertension clinic. SUBJECTS AND METHODS: A total of 353 young and middle-aged hypertensives, free from cardiovascular and renal diseases (and 37% of whom had MS), underwent echocardiographic examination, microalbuminuria determination and non-mydriatic retinography. RESULTS: When compared with subjects without MS, hypertensive patients with MS exhibited more elevated left ventricular (LV) mass (either normalized by body surface area or by height elevated by a power of 2.7), higher myocardial relative wall thickness, albumin excretion rate (AER) and a greater prevalence of LV hypertrophy (57.7% vs. 25.1%; P < 0.00001), of microalbuminuria (36.2% vs. 19.3%; P = 0.002) and of hypertensive retinopathy (87.7% vs. 48.4%; P < 0.00001). These results held even after correction for age, 24-h blood pressures, duration of hypertension, previous antihypertensive therapy, and gender distribution. The independent relationships between LV mass and MS, and between AER and MS, were confirmed in multivariate regression models including MS together with its individual components. CONCLUSIONS: MS may amplify hypertension-related cardiac and renal changes, over and above the potential contribution of each single component of this syndrome. As these markers of target organ damage are well-known predictors of cardiovascular events, our results may partly explain the enhanced cardiovascular risk associated with MS.     

Prognostic value of left ventricular hypertrophy in hypertensive patients: A meta‐analysis of electrocardiographic studies

Electrocardiographic left ventricular hypertrophy (LVH) has been used to predict adverse outcomes in different clinical settings. This meta‐analysis aimed to compare the prognostic value of different electrocardiographic criteria of LVH at baseline in hypertensive patients. A systematic literature search was conducted in PubMed and Embase databases until December 3, 2019. Cohort studies that reported the association of baseline electrocardiographic LVH (Sokolow‐Lyon voltage, Cornell voltage or Cornell product) with all‐cause mortality or major cardiovascular events in hypertensive patients were included. The prognostic value of LVH was expressed by the risk ratio (RR) with 95% confidence interval (CI). Nine studies involving 41 870 hypertensive patients were identified. Comparison with those with and without LVH patients indicated that the pooled RR value of all‐cause mortality was 1.30 (95% CI 1.01‐1.66) for the Sokolow‐Lyon voltage criteria, 1.33 (95% CI 1.20‐1.47) for the Cornell voltage criteria, and 1.31 (95% CI 0.97‐1.78) for the Cornell product criteria. In addition, the pooled RR of major cardiovascular events was 1.53 (95% CI 1.27‐1.86) for the Sokolow‐Lyon criteria and 1.46 (95% CI 1.22‐1.76) for the Cornell voltage criteria, respectively. This meta‐analysis suggests that different electrocardiographic criteria for detecting LVH at baseline differ in prediction of all‐cause mortality in patients with hypertension. LVH detected by the Cornell voltage and Sokolow‐Lyon criteria can independently predict the major cardiovascular events in hypertensive patients.     

Modified Cornell electrocardiographic criteria in the assessment of left ventricular hypertrophy geometry of patients with essential hypertension

To evaluate the value of modified Cornell electrocardiographic criteria in the assessment of left ventricular hypertrophy (LVH) for patients with essential hypertension. A total of 381 patients with essential hypertension diagnosed in our hospital were selected. Using the left ventricle (LV) geometric patterns classified by the American Society of Echocardiography (ASE), we examined the distribution of the modified Cornell criteria of Ravl + S_D (the deepest S wave in 12‐lead ECG) in different geometric patterns and analyzed the correlation of modified Cornell criteria with changes in the LV geometric patterns using multiple linear regression analysis. The distribution of modified Cornell criteria, Sokolow‐Lyon criteria (RV5/V6 + SV1), and Cornell criteria (Ravl + SV3) in gender‐specific hypertensive geometric patterns were significantly different (P ≤ .01 for all). The voltage of Ravl + S_D in male patients showed an increase trend in the normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH) groups, and this increase trend was significantly in the unadjusted model and the adjusted model. The voltages of Ravl + SV3 and RV5/V6 + SV1 of male patients in CR, CH and RH groups showed a gradual increase trend, but the increase trend in CR group has no statistical significance compared to that in NG group (P ≥ .05). The voltages of Ravl + S_D, RV5/V6 + SV1, and Ravl + SV3 in female patients in CR, CH and EH groups showed a trend of increase after decrease in the adjusted model. In conclusion, the modified Cornell criteria could dynamically reflect left ventricular hypertensive geometry of male patients.     

Subclinical target organ damage in subjects with different components of metabolic syndrome

Background: To assess the association of metabolic syndrome (MS) and its components with target organ damage in a follow-up study of relatively healthy bank employers.

Methods: Out of 1600 random samples of office workers in Saint Petersburg (Russia), a group of 383 participants with at least one component of MS and without cardiovascular complications was selected (mean age 46.6 ± 9.0 years, 214 females (64.6%)). Follow-up visit was performed in 331 subjects. Target organ damage (TOD) was assessed by echocardiography, carotid ultrasound, applanational tonometry, brachial–ankle index, and urine albumin excretion measurements. Anthropometry, vital signs, and biochemistry were performed according to standard protocols.

Results: Presence of MS was not associated with higher probability of TOD. Multiple linear regression revealed significant association of all markers of TOD with older age. Hypertension was a significant predictor of left ventricular hypertrophy (LVH), increased arterial stiffness, and early signs of carotid atherosclerosis in logistic regression adjusted for age and gender. During follow-up, proportion of patients with LVH significantly decreased (from 46.7% to 32.9%, р = 0.003) and prevalence of patients with IMT > 0.09 сm increased (from 24.5% to 44.1%, p < 0.001) accompanying by significant declining of office blood pressure (BP) and total cholesterol.

Conclusions: MS per se is not related to increased probability to TOD. Hypertension, female gender, and older age are main determinants of subclinical changes. After 2-years follow-up, significant LVH and renal damage regression was observed probably owing to BP reduction. Alternatively, early signs of carotid atherosclerosis increase with aging despite decreasing of the prevalence of hypercholesterolemia.     

Short‐term repeatability of the peguero‐lo presti electrocardiographic left ventricular hypertrophy criteria

BackgroundElectrocardiographic left ventricular hypertrophy (ECG‐LVH) represents preclinical cardiovascular disease and predicts cardiovascular disease morbidity and mortality. While the newly developed Peguero‐Lo Presti ECG‐LVH criteria have greater sensitivity for LVH than the Cornell voltage and Sokolow–Lyon criteria, its short‐term repeatability is unknown. Therefore, we characterized the short‐term repeatability of Peguero‐Lo Presti ECG‐LVH criteria and evaluate its agreement with Cornell voltage and Sokolow–Lyon ECG‐LVH criteria.MethodsParticipants underwent two resting, standard, 12‐lead ECGs at each of two visits one week apart (n = 63). We defined a Peguero‐Lo Presti index as a sum of the deepest S wave amplitude in any single lead and lead V₄ (i.e., S_D + SV₄) and defined Peguero‐Lo Presti LVH index as ≥ 2,300 µV among women and ≥ 2,800 µV among men. We estimated repeatability as an intraclass correlation coefficient (ICC), agreement as a prevalence‐adjusted bias‐adjusted kappa coefficient (κ), and precision using 95% confidence intervals (CIs).ResultsThe Peguero‐Lo Presti index was repeatable: ICC (95% CI) = 0.94 (0.91–0.97). Within‐visit agreement of Peguero‐Lo Presti LVH was high at the first and second visits: κ (95% CI) = 0.97 (0.91–1.00) and 1.00 (1.00–1.00). Between‐visit agreement of the first and second measurements at each visit was comparable: κ (95% CI) = 0.90 (0.80–1.00) and 0.93 (0.85–1.00). Agreement of Peguero‐Lo Presti and Cornell or Sokolow–Lyon LVH on any one of the four ECGs was slightly lower: κ (95% CI) = 0.71 (0.54–0.89).ConclusionThe Peguero‐Lo Presti index and LVH have excellent repeatability and agreement, which support their use in clinical and epidemiological studies.     

Sex‐related relationships between uric acid and target organ damage in hypertension

Heterogeneous results have been obtained in the relationship between serum uric acid (SUA) and target organ damage (TOD) in patients with hypertension. Clinic blood pressure, SUA, and cardiac, arterial (carotid and aortic), and renal TOD were assessed in 762 consecutive patients with hypertension. Hyperuricemia was defined as an SUA >7.0 in men and >6.0 mg/dL in women. Men with hyperuricemia compared with those with normal SUA showed lower estimated glomerular filtration rates and E/A ratios and a higher prevalence of carotid plaques. Women with hyperuricemia showed lower estimated glomerular filtration rates and E/A ratios and a higher intima‐media thickness. Except for pulse wave velocity, all TODs significantly correlated with SUA. However, at multivariate analysis, only estimated glomerular filtration rate was significantly determined by SUA. Our data provide evidence on the role of SUA in the development of TOD only in the case of renal alteration. It is likely that SUA may indirectly act on the other TODs through the increase in blood pressure and the decrease in glomerular filtration rate.     

Homocysteine predicts vascular target organ damage in hypertension and may serve as guidance for first‐line antihypertensive therapy

Homocysteine is an independent risk factor for cardiovascular and cerebrovascular disease and has been proposed to contribute to vascular dysfunction. We sought to determine in a real‐world clinical setting whether homocysteine levels were associated with hypertension mediated organ damage (HMOD) and could guide treatment choices in hypertension. We performed a cross‐sectional analysis of prospectively collected data in 145 hypertensive patients referred to our tertiary hypertension clinic at Royal Perth Hospital and analyzed the association of homocysteine with HMOD, renin‐angiotensin‐aldosterone system (RAAS), and RAAS blockade. The average age of participants was 56 ± 17 years, and there was a greater proportion of males than females (89 vs. 56). Regression analysis showed that homocysteine was significantly associated with PWV (β = 1.99; 95% CI 0.99‐3.0; p < .001), albumin‐creatinine ratio (lnACR: β = 1.14; 95% CI 0.47, 1.8; p < .001), 24 h urinary protein excretion (β = 0.7; 95% CI 0.48, 0.92; p < .001), and estimated glomerular filtration rate (β = −29.4; 95% CI −36.35, −22.4; p < .001), which persisted after adjusting for potential confounders such as age, sex, 24 h BP, inflammation, smoking, diabetes mellitus (DM), and dyslipidemia. A positive predictive relationship was observed between plasma homocysteine levels and PWV, with every 1.0 µmol/L increase in homocysteine associated with a 0.1 m/s increase in PWV. Homocysteine was significantly associated with elevated aldosterone concentration (β = 0.26; p < .001), and with attenuation of ACEi mediated systolic BP lowering and regression of HMOD compared to angiotensin receptor blockers in higher physiological ranges of homocysteine. Our results indicate that homocysteine is associated with hypertension mediated vascular damage and could potentially serve to guide first‐line antihypertensive therapy.     

壮族原发性高血压左心室肥厚患者不同心电图诊断指标的应用价值

目的探讨不同心电图诊断指标在壮族原发性高血压患者左心室肥厚临床诊断中的应用价值。方法选择壮族原发性高血压患者100例,以超声心动图检查所得到的左心室质量指数作为左心室肥厚诊断的参考标准,验证Cornell指数、Sokolow-Lyon指数和Romhilt-Estes积分3种心电图诊断指标的临床应用价值。结果以超声心动图诊断的左心室肥厚结果为标准,3种心电图指标均存在敏感性低,特异性高的特点;男性的诊断价值均大于女性;Romhilt-Estes积分高于Cornell指数和Sokolow-Lyon指数(P0.05)。结论 3种心电图指标可以作为诊断左心室肥厚的常规方法。     

The cumulative blood pressure load and target organ damage in patients with essential hypertension

The area under the blood pressure curve is associated with target organ damage, but accurately estimating its value is challenging. This study aimed to improve the utility of the area under the blood pressure curve to predict hypertensive target organ damage. This retrospective cohort study comprised of 634 consecutive patients with essential hypertension for >1 year. Target organ damage was defined as the presence of left ventricular hypertrophy and/or carotid artery plaques. We evaluated the associations between the cumulative blood pressure load, which was derived from ambulatory blood pressure monitoring data, and target organ damage. The predictive value of the cumulative blood pressure load for target organ damage was assessed using receiver operating characteristic curves. Left ventricular hypertrophy and carotid artery plaques were present in 392 (61.8%) and 316 (49.8%) patients, respectively. Patients with left ventricular hypertrophy and/or carotid artery plaques had higher 24‐hour blood pressure, nocturnal cumulative systolic blood pressure, and nocturnal cumulative pulse pressure load. The nocturnal cumulative systolic blood pressure load was an independent predictor of left ventricular hypertrophy (odds ratio = 1.002, 95% confidence interval: 1.001‐1.004; P = .000) and carotid artery plaques (odds ratio = 1.003, 95% confidence interval: 1.002‐1.007; P = .007). The nocturnal cumulative systolic blood pressure and cumulative pulse pressure load, relative to mean blood pressure, were superior in predicting hypertensive target organ damage. Hence, the cumulative blood pressure load is a better indicator of blood pressure consequences, and the nocturnal cumulative systolic blood pressure and cumulative pulse pressure loads could predict target organ damage.     

A meta‐analytic evaluation of the diagnostic accuracy of the electrocardiographic Peguero‐Lo Presti criterion for left ventricular hypertrophy

Although electrocardiography (ECG) is a cost‐effective and convenient tool for routine screening of left ventricular hypertrophy (LVH), its performance has been shown to be poor. The Peguero‐Lo Presti, a novel voltage criterion, was found to be potentially better than the most commonly used criteria. We conducted a systematic review and meta‐analysis of its diagnostic accuracy compared to Cornell and Sokolow‐Lyon voltage criteria. Bibliographic databases were searched to identify relevant articles. Pooled sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic (ROC) curves were performed for comparison. Ten studies reporting data from 5984 individuals were included in the meta‐analysis. Peguero‐Lo Presti had the highest pooled sensitivity (43.0%, 95% confidence interval [CI]: 30.2‐56.9) followed by Cornell (26.1%; 95% CI: 16.9‐37.9) and Sokolow Lyon (22.0%; 95% CI: 14.1‐32.7). However, Peguero‐Lo Presti had the lesser pooled specificity (90.5%; 95% CI: 86.3‐93.5) and Cornell the highest (94.9%; 95% CI: 90.3‐97.3). The pooled DOR was 6.63 (95% CI: 3.95‐11.13), 5.50 (95% CI: 3.64‐8.30), and 2.94 (95% CI: 2.20‐3.92) for Peguero‐Lo Presti, Cornell, and Sokolow‐Lyon, respectively. Peguero‐Lo Presti had the best accuracy according to summary ROC curves, with an area under the curve of 0.827 compared to 0.715 for Cornell, and 0.623 for Sokolow‐Lyon. In conclusion, according to this meta‐analysis, Peguero‐Lo Presti has a better diagnostic performance than Cornell and Sokolow‐Lyon and might be more useful in routine clinical practice as a screening tool for LVH.     

Supine blood pressure—A clinically relevant determinant of vascular target organ damage in hypertensive patients

Night‐time blood pressure (BP) is an important predictor of cardiovascular outcomes. Its assessment, however, remains challenging due to limited accessibility to ambulatory BP devices in many settings, costs, and other factors. We hypothesized that BP measured in a supine position during daytime may perform similarly to night‐time BP when modeling their association with vascular hypertension‐mediated organ damage (HMOD). Data from 165 hypertensive patients were used who as part of their routine clinic workup had a series of standardized BP measurements including seated attended office, seated and supine unattended office, and ambulatory BP monitoring. HMOD was determined by assessment of kidney function and pulse wave velocity. Correlation analysis was carried out, and univariate and multivariate models were fitted to assess the extent of shared variance between the BP modalities and their individual and shared contribution to HMOD variables. Of all standard non‐24‐hour systolic BP assessments, supine systolic BP shared the highest degree of variance with systolic night‐time BP. In univariate analysis, both systolic supine and night‐time BP were strong determinants of HMOD variables. In multivariate models, supine BP outperformed night‐time BP as the most significant determinant of HMOD. These findings indicate that supine BP may not only be a clinically useful surrogate for night‐time BP when ambulatory BP monitoring is not available, but also highlights the possibility that unattended supine BP may be more closely related to HMOD than other BP measurement modalities, a proposition that requires further investigations in prospective studies.     

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.     

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.     

Blood pressure variables and prevalent electrocardiographic left ventricular hypertrophy in sub‐Saharan African individuals with type 2 diabetes

Background: The aim of the present study was to investigate whether brachial blood pressure (BP) variables (systolic BP [SBP], diastolic BP [DBP], pulse [PP] and mean arterial pressure [MAP]) are similar determinants of prevalent electrocardiographic left ventricular hypertrophy (LVH) in sub‐Saharan Africans with type 2 diabetes (T2D). Methods: The study included 420 individuals (49% men) with T2D who were receiving chronic care in two main referral centers in the two major cities (Douala and Yaounde) of Cameroon. Logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (CI) for a standard deviation (SD) higher level of SBP (25 mmHg), DBP (13), PP (18) and MAP (20) with the risk of LVH. Discrimination was assessed and compared with c‐statistics and relative integrated discrimination improvement (RIDI; %). Results: The multivariable adjusted OR (95% CI) for prevalent LVH with each SD higher pressure variable was 1.61 (1.22–2.11) for SBP, 1.27 (0.99–1.63) for DBP, 1.62 (1.23–2.15) for PP and 1.44 (1.11–1.87) for MAP. Comparison of c‐statistics revealed no difference in the discrimination power of models with each of the BP variables (P > 0.09). However, RIDI showed enhanced discrimination in the models when other BP variables were replaced with PP. However, this enhancement was marginal for SBP. Using BP combinations modestly improved discrimination. Conclusions: The best predictors of prevalent LVH in the present study population were PP and SBP, whereas DBP was the least effective predictor. These findings have implications for cardiovascular risk stratification and monitoring of risk‐reducing therapies.     

血压正常高值者亚临床靶器官损害与危险因素相关性研究

目的探讨血压正常高值者亚临床靶器官损害与危险因素之间的相关性。方法将1 947例血压正常高值者按合并危险因素的数量分为0个危险因素组(482例)、1个危险因素组(499例)、2个危险因素组(493例)、≥3个危险因素组(473例)。所有受试者均进行危险因素调查,并进行颈动脉内膜中层厚度(IMT)、左心室重量指数(LVMI)以及尿微量白蛋白(microalbuminuria,MAU)检测。结果随着合并危险因素的增加,4组受试者的腰臀比、TC、TG、LDL-C、空腹血糖、吸烟史及家族史明显增高,HDL-C明显降低;IMT、LVMI、MAU明显增高(P<0.01);颈动脉粥样硬化、左心室肥厚、MAU异常率逐渐增加(P<0.01)。以0个危险因素组为基数,随着合并危险因素的增加,发生亚临床靶器官损害的风险比明显增加。结论随着合并危险因素数量的增加,血压正常高值者亚临床靶器官损害的危险性明显增加,危险因素之间具有联合协同作用。