Regression of electrocardiographic left ventricular hypertrophy or strain is associated with lower incidence of cardiovascular morbidity and mortality in hypertensive patients independent of blood pressure reduction – A LIFE review

Cornell product criteria, Sokolow–Lyon voltage criteria and electrocardiographic (ECG) strain (secondary ST-T abnormalities) are markers for left ventricular hypertrophy (LVH) and adverse prognosis in population studies. However, the relationship of regression of ECG LVH and strain during antihypertensive therapy to cardiovascular (CV) risk was unclear before the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) study. We reviewed findings on ECG LVH regression and strain over time in 9193 hypertensive patients with ECG LVH at baseline enrolled in the LIFE study.The composite endpoint of CV death, nonfatal MI, or stroke occurred in 1096 patients during 4.8 ± 0.9 years follow-up. In Cox multivariable models adjusting for randomized treatment, known risk factors including in-treatment blood pressure, and for severity ECG LVH by Cornell product and Sokolow–Lyon voltage, baseline ECG strain was associated with a 33% higher risk of the LIFE composite endpoint (HR. 1.33, 95% CI [1.11–1.59]). Development of new ECG strain between baseline and year-1 was associated with a 2-fold increased risk of the composite endpoint (HR. 2.05, 95% CI [1.51–2.78]), whereas the risk associated with regression or persistence of ECG strain was attenuated and no longer statistically significant (both p > 0.05). After controlling for treatment with losartan or atenolol, for baseline Framingham risk score, Cornell product, and Sokolow–Lyon voltage, and for baseline and in-treatment systolic and diastolic blood pressure, 1 standard deviation (SD) lower in-treatment Cornell product was associated with a 14.5% decrease in the composite endpoint (HR. 0.86, 95% CI [0.82–0.90]). In a parallel analysis, 1 SD lower in-treatment Sokolow–Lyon voltage was associated with a 16.6% decrease in the composite endpoint (HR. 0.83, 95% CI [0.78–0.88]).The LIFE study shows that evaluation of both baseline and in-study ECG LVH defined by Cornell product criteria, Sokolow–Lyon voltage criteria or ECG strain improves prediction of CV events and that regression of ECG LVH during antihypertensive treatment is associated with better outcome, independent of blood pressure reduction.     

Neck circumference for predicting the occurrence of future cardiovascular events: A 7.6-year longitudinal study

Background & aimsThis study aimed to investigate whether neck circumference (NC) could be used to predict future cardiovascular (CV) events in a community-based Chinese cohort.Methods and resultsWe enrolled 1435 participants aged 50–80 years (men, 43.62%) from communities in Shanghai. High NC was defined as NC ≥ 38.5 cm in men and NC ≥ 34.5 cm in women. Kaplan-Meier analysis and Cox proportional hazards regression were performed to explore the association between NC and CV events. During a mean follow-up period of 7.6 years, 148 CV events (10.31%) occurred. The incidence of CV events was higher in men than in women (83 (13.26%) vs. 65 (8.03%), P = 0.002). Multivariable-adjusted Cox regression analysis showed that for every 1-SD increase in NC in the whole population, the hazard ratio (HR) of CV events was 1.45 (95% confidence interval [CI], 1.15–1.83). The dose-response association between NC and CV events was significant in men (HR, 1.37, 95% CI, 1.10–1.71) but not in women (HR, 1.19, 95% CI, 0.94–1.52). In comparison with participants showing low baseline NC, those with high baseline NC showed a significantly higher risk of CV events (HR, 1.59, 95% CI, 1.14–2.22). Further stratified by sex, the positive association remained significant in men (HR, 1.90, 95% CI, 1.21–2.98) but not in women (HR, 1.25, 95% CI, 0.75–2.07).ConclusionNC was significantly associated with the risk of future CV events in middle-aged and elderly populations in the community and was a better predictor in men.     

Electrocardiographic strain pattern and prediction of cardiovascular morbidity and mortality in hypertensive patients

The ECG strain pattern of lateral ST depression and T-wave inversion is a marker for left ventricular hypertrophy (LVH) and adverse prognosis in population studies. However, whether ECG strain is an independent predictor of cardiovascular (CV) morbidity and mortality in the setting of aggressive antihypertensive therapy is unclear. ECGs were examined at study baseline in 8854 hypertensive patients with ECG LVH who were treated in a blinded manner with atenolol- or losartan-based regimens. Strain was defined by the presence of a downsloping convex ST segment with an inverted asymmetrical T wave opposite to the QRS axis in leads V5 and/or V6 and was present in 971 patients (11.0%). The Losartan Intervention For Endpoint reduction in hypertension (LIFE) study composite end point of CV death or nonfatal myocardial infarction or stroke occurred in 1035 patients (11.7%). In Cox analyses adjusting only for treatment effect, ECG strain was a significant predictor of CV death (hazard ratio [HR] 2.26, 95% confidence interval [CI] 1.78 to 2.86), fatal/nonfatal myocardial infarction (HR 2.16, 95% CI 1.67 to 2.80), fatal/nonfatal stroke (HR 1.76, 95% CI 1.39 to 2.21), and the composite CV end point (HR 1.99, 95% CI 1.70 to 2.33). After further adjusting for standard CV risk factors, baseline blood pressure, and severity of ECG LVH, ECG strain remained a significant predictor of CV mortality (HR 1.53, 95% CI 1.18 to 2.00), myocardial infarction (HR 1.55, 95% CI 1.16 to 2.06), and the composite CV end point (HR 1.33, 95% CI 1.11 to 1.59). Thus, ECG strain is a marker of increased CV risk in hypertensive patients in the setting of aggressive blood pressure lowering, independent of baseline severity of ECG LVH.     

Do Combined Electrocardiographic and Echocardiographic Markers of Left Ventricular Hypertrophy Improve Cardiovascular Risk Estimation?

The authors estimated the risk of cardiovascular mortality associated with echocardiographic (ECHO) left ventricular hypertrophy (LVH) and subtypes of this phenotype in patients with and without electrocardiographic (ECG) LVH. A total of 1691 representatives of the general population were included in the analysis. During a follow‐up of 211 months, 89 cardiovascular deaths were recorded. Compared with individuals with neither ECHO LVH nor ECG LVH, fully adjusted risk of cardiovascular mortality increased (hazard ratio [HR], 3.36; 95% confidence interval [CI], 1.51–7.47; P=.003) in patients with both ECHO‐LVH and ECG‐LVH, whereas the risk entailed by ECHO‐LVH alone was of borderline statistical significance (P=.04). Combined concentric nondilated LVH and ECG‐LVH, but not concentric nondilated LVH alone, predicted cardiovascular death (HR, 3.79; 95% CI, 1.25–11.38; P=.01). Similar findings were observed for eccentric nondilated LVH (HR, 3.37; 95% CI, 1.05–10.78; P=.04.). The present analysis underlines the value of combining ECG and ECHO in the assessment of cardiovascular prognosis related to abnormal left ventricular geometric patterns.     

Serial evaluation of electrocardiographic left ventricular hypertrophy for prediction of risk in hypertensive patients

Background

Although the presence and severity of electrocardiographic (ECG) left ventricular hypertrophy (LVH) have been associated with an increased risk of cardiovascular (CV) morbidity and mortality, the relationship of regression of ECG LVH during antihypertensive therapy to CV risk has only recently been examined.

Methods

Electrocardiographic LVH was evaluated over time in 9193 hypertensive patients enrolled in the Losartan Intervention for Endpoint Reduction in Hypertension study. Patients were treated with losartan- or atenolol-based regimens and followed with serial ECGs at 6 months and then yearly until death or study end. Electrocardiographic LVH was measured using gender-adjusted Cornell product (RaVL + SV3 [+6 mm in women]) ? QRS duration) and Sokolow-Lyon voltage (SV1 + RV5/6).

Results

After mean (SD) follow-up of 4.8 (0.9) years, the Losartan Intervention for Endpoint Reduction in Hypertension study composite end point of CV death, nonfatal myocardial infarction, or stroke occurred in 1096 patients. In Cox regression models controlling for treatment type, baseline Framingham risk score, baseline, and in-treatment blood pressure and for severity of baseline ECG LVH by Cornell product and Sokolow-Lyon voltage, lower in-treatment ECG LVH by Cornell product and Sokolow-Lyon voltage were associated with 14% and 17% lower rates, respectively, of the composite CV end point: adjusted hazard ratios (HRs) of 0.86 (95% confidence interval [CI], 0.82-0.90; P < .001) for every 1050 mm · ms (1 SD) decrease in Cornell product and 0.83 (95% CI, 0.78-0.88; P < .001) for every 10.5 mm (1 SD) decrease in Sokolow-Lyon voltage. In parallel analyses, lower Cornell product and Sokolow- Lyon voltage were each independently associated with lower risks of CV mortality (HR, 0.78; 95% CI, 0.73-0.83; P < .001; HR, 0.80; 95% CI, 0.73-0.87; P < .001), of myocardial infarction (HR, 0.90; 95% CI, 0.82-0.98; P = .011; HR, 0.90; 95% CI, 0.81-1.00; P = .043), and of stroke (HR, 0.90; 95% CI, 0.84-0.96; P = .002; HR, 0.81; 95% CI, 0.75-0.89; P < .001). Regression of ECG LVH was also associated with significantly reduced risks of sudden cardiac death, new-onset atrial fibrillation, hospitalization for heart failure, and new-onset diabetes mellitus.

Conclusions

Regression of ECG LVH by Cornell product and/or Sokolow-Lyon voltage criteria during antihypertensive therapy is associated with lower likelihoods of CV morbidity and mortality, all-cause mortality, and new-onset diabetes, independent of blood pressure lowering and treatment modality in essential hypertension. These findings suggest that antihypertensive therapy targeted at regression or prevention of ECG LVH may improve prognosis.     

Abnormal ankle-brachial index (ABI) predicts primary and secondary cardiovascular risk and cancer mortality

BackgroundAn abnormal ankle-brachial pressure index (ABI) is a marker of the risk for increased total and cardiovascular (CV) mortality. However, it is not clear whether it is associated with an even worse prognosis in patients with previous CV events or with cancer mortality.Materials and MethodsConsecutive subjects undergoing ABI assessment for suspected peripheral artery disease or for stratification of CV risk in ten centers in the Veneto Region (northeast Italy), between 2011 and 2014 were enrolled. The ABI was expressed as normal ≥0.9 to ≤1.3, and abnormal <0.9 or >1.3. All-cause mortality and CV or cancer mortality and hospitalizations for CV disease were collected from administrative databases up to December 2018.ResultsThe study enrolled 1,177 patients. ABI was abnormal in 57.2%. Median follow-up was 61.6 months (53.4–70.1). All-cause, CV and cancer mortality were higher in patients with abnormal than normal ABI, with hazard ratios (HR) respectively 2.0 (95% CI 1.48–2.69), 1.98 (95% CI 1.24–3.17) and 1.85 (95% CI 1.09–3.15). Among subjects with abnormal ABI, the risk of overall mortality, HR 1.57 (95% CI 1.17–2.12), and CV mortality, HR 2.39 (95% CI 1.43–3.99), was higher in those with previous CV events. These latter also had a higher risk of hospitalization for myocardial infarction and stroke: HR 1.85 (95% CI 1.023.37) and 2.17 (95% CI 1.10–4.28).ConclusionsThe co-existence of abnormal ABI and a history of CV events identifies subjects at higher risk, who call for a more aggressive approach. Abnormal ABI is also a predictor of cancer mortality.     

Prognostic Value of a New Electrocardiographic Method for Diagnosis of Left Ventricular Hypertrophy in Essential Hypertension

Objectives. We tested the prognostic value of a new electrocardiographic (ECG) method (Perugia score) for diagnosis of left ventricular hypertrophy (LVH) in essential hypertension and compared it with five standard methods (Cornell voltage, Framingham criterion, Romhilt-Estes point score, left ventricular strain, Sokolow-Lyon voltage).Background. Several standard ECG methods for assessment of LVH are used in the clinical setting, but a comparative prognostic assessment is lacking.Methods. A total of 1,717 white hypertensive subjects (mean age 52 years; 51% men) were prospectively followed up for up to 10 years (mean 3.3).Results. At entry, the prevalence of LVH was 17.8% (Perugia score), 9.1% (Cornell), 3.9% (Framingham), 5.2% (Romhilt-Estes), 6.4% (strain) and 13.1% (Sokolow-Lyon). During follow-up there were 159 major cardiovascular morbid events (33 fatal). The event rate was higher in the subjects with than in those without LVH (all p < 0.001) according to all methods except the Sokolow-Lyon method. By multivariate analysis, an independent association between LVH and cardiovascular disease risk was maintained by the Perugia score (hazard ratio [HR] 2.04, 95% confidence interval [CI] 1.5 to 2.8) and the Framingham (HR 1.91, 95% CI 1.1 to 3.2), Romhilt-Estes (HR 2.63, 95% CI 1.7 to 4.1) and strain methods (HR 2.11, 95% CI 1.4 to 3.2). The Perugia score showed the highest population-attributable risk for cardiovascular events, accounting for 15.6% of all cases, whereas the Framingham, Romhilt-Estes and strain methods accounted for 3.0%, 7.4% and 6.8% of all events, respectively. LVH diagnosed by the Perugia score was also associated with an increased risk of cardiovascular mortality (HR 4.21, 95% CI 2.1 to 8.7), with a population-attributable risk of 37.0%.Conclusions. The Perugia score carried the highest population-attributable risk for cardiovascular morbidity and mortality compared with classic methods for detection of LVH. Traditional interpretation of standard electrocardiography maintains an important role for cardiovascular risk stratification in essential hypertension.     

Prognostic impact of electrocardiographic left ventricular hypertrophy following transcatheter aortic valve replacement

BackgroundLeft ventricular hypertrophy (LVH) develops with both structural and electrical remodeling in response to elevated afterload due to aortic stenosis (AS). This study evaluated the prognostic value of electrocardiographic LVH (ECG LVH) after transcatheter aortic valve replacement (TAVR).MethodsA retrospective study including 157 consecutive patients who underwent TAVR was conducted. ECG LVH was defined as Sokolow–Lyon voltage (S in V₁ + R in V_5/6) before TAVR was ≥3.5mV. We investigated the association between ECG LVH and the 1-year composite outcome comprising all-cause death and rehospitalization related to heart failure. ECG and echocardiographic measurements at 1, 6, and 12 months after TAVR were assessed.ResultsThe baseline characteristics were comparable between the ECG LVH (n = 74) and non-ECG LVH groups (n = 83). The ECG LVH was associated with a significantly greater reduction of Sokolow–Lyon voltage and LV mass index than the non-ECG LVH after TAVR. The absence of ECG LVH was an independent predictor of the 1-year composite outcome [adjusted hazard ratio (HR), 2.27; 95% confidence interval (CI), 1.01 – 5.60; p = 0.04]. Furthermore, a reduction of Sokolow–Lyon voltage from baseline to 1-month follow-up, but not a reduction of LV mass index, was associated with a lower cumulative composite outcome from 1 month to 1 year (adjusted HR, 0.36; 95% CI, 0.15 – 0.86; p = 0.02).ConclusionsECG LVH was associated with a low incidence of adverse clinical outcomes and greater reverse LV remodeling after TAVR. Preprocedural and serial LVH assessment by ECG might be useful in AS patients undergoing TAVR.     

Association of morning hypertension with chronic kidney disease progression and cardiovascular events in patients with chronic kidney disease and hypertension

Background and aimAssociations of morning hypertension with chronic kidney disease are rarely investigated in prospective studies. We aim to investigate the predictive value of uncontrolled morning hypertension (UMH) to chronic kidney disease (CKD) progression and cardiovascular (CV) events in patients with CKD and hypertension.Methods and resultsIn this prospective two-center observational study, 304 hypertensive patients with CKD were enrolled. Time to total mortality, CKD progression and CV events was recorded; Kaplan–Meier survival function estimates and Multivariable Cox proportional hazard model were used to investigate associations between UMH and outcomes. The study protocol was approved by the Institutional Review Board (http://www.thaiclinicaltrials.org; TCTR20180313004). After a follow-up for median 30 months, 23 (7.6%) patients died, 34 (11.2%) had CKD progression, and 95 (31.3%) occurred new-onset CV events, respectively. UMH was shown to be a strong predictor of CKD progression [hazard ratio (HR) 2.46, 95% confidence interval (CI) 1.22–4.94] and CV events (HR 1.69, 95% CI 1.12–2.53). When morning hypertension was analyzed as a continuous variable, morning systolic blood pressure (per 10 mmHg) was also shown to be predictive to CKD progression (HR 1.28, 95% CI 1.07–1.53, P < 0.01) and CV events (HR 1.15, 95% CI 1.03–1.28, P < 0.01).ConclusionsUMH is strongly associated with CKD progression and CV events in patients with CKD and hypertension. UMH in CKD patients deserves further attentions.     

Prognostic value of serial electrocardiographic voltage and repolarization changes in essential hypertension: the HEART Survey study

BACKGROUND: The interpretation of serial electrocardiographic (ECG) changes in hypertensive subjects is uncertain. We tested the hypothesis that serial changes in repolarization and voltage are independent determinants of outcome. METHODS: The Hypertrophy at ECG And its Regression during Treatment (HEART) Survey was a prospective observational study performed at 61 centers. We studied 711 subjects with hypertension and ECG left-ventricular hypertrophy (LVH) at entry. Tracings from 496 subjects at entry and one or more visits during follow-up were available for central reading. RESULTS: The prevalence of ECG LVH progressively decreased by 49.6% at 3 years. The crude rate of a prespecified primary composite end point of cardiovascular events was 4.17 per 100 subjects per year (95% confidence interval [CI], 3.27 to 5.33). We used Cox regression models of ECG LVH indexes as time-varying covariates at baseline and at follow-up. Time-varying LVH, defined as an absence of ST-T alterations ("strain"), was associated with a lower event rate hazard ratio (HR), 0.47; 95% CI, 0.28 to 0.78; P = .0035), whereas the LVH changes defined in terms of ECG voltages did not achieve significance (HR, 0.91; 95% CI, 0.74 to 1.13; P = .39). The crude event rate in subjects with versus without in-treatment ST-T alterations on the last available ECG before the event or before censoring was 8.38 versus 3.17 per 100 subjects per year (P < .0001). CONCLUSIONS: In this study of subjects with hypertension and ECG LVH at entry, serial changes in repolarization significantly predicted the prognosis, independent of voltage change (which was not significantly predictive in this study). The persistence or new development of ST-T alterations identifies subjects at very high risk of cardiovascular events.     

Cardiovascular risk assessment in prediabetic patients in a hypertensive population: The role of cystatin C

Background

The aim of our study was to determine whether prediabetes increases cardiovascular (CV) risk compared to the non-prediabetic patients in our hypertensive population. Once this was achieved, the objective was to identify relevant CV prognostic features among prediabetic individuals.

Prognostic implications of left ventricular hypertrophy diagnosed on electrocardiogram vs echocardiography

It is unclear whether 12‐lead ECG employing standard criteria for left ventricular hypertrophy (LVH) provides similar information with respect to long‐term cardiovascular risk as echocardiography. The authors performed a retrospective cohort study of 1376 individuals without cardiovascular disease, who underwent ECG (LVH defined using the Sokolow‐Lyon voltage combination (>35 mm) or the Cornell voltage‐duration product (>2440 mm × ms)) and echocardiography (LVH defined as LV mass index (LVMI) >95 g/m² for women and >115 g/m² for men). The prognostic ability of LVH was assessed in Cox regression models adjusted for age, sex, smoking, systolic blood pressure, total cholesterol, antihypertensive medication, and fasting glucose. The primary end point was the composite of coronary events, heart failure, stroke, or death. The main secondary end point was heart failure or cardiovascular death. Median age was 67 (range 56‐79) years, 68% were male. Eleven percent had ECG‐defined LVH, 17% had echocardiographic LVH. Over median 8.5 years, 29% experienced a primary event. Event rates were 29%/35% for persons without/with ECG‐defined LVH and 27%/39% for those without/with echocardiographic LVH. The Sokolow‐Lyon combination, Cornell product, and ECG‐defined LVH did not significantly predict the primary end point (P ≥ .05), but ECG‐defined LVH predicted heart failure or cardiovascular death (adjusted hazard ratio (HR), 1.86, 95% confidence interval (CI), 1.13‐3.08); P = .02). Conversely, LVMI was a significant, independent predictor of the primary end point (adjusted HR, 1.87, 95% CI, 1.13‐3.10; P = .01), as was echocardiographic LVH (adjusted HR, 1.27, 95% CI, 1.01‐1.61; P = .04). Echocardiographic LVH may be a better predictor of long‐term cardiovascular risk than ECG‐defined LVH in middle‐aged and older individuals.     

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.     

Improved cardiovascular risk stratification by a simple ECG index in hypertension

BACKGROUND: We determined the prognostic value of the Cornell/strain [C/S] index, a simple electrocardiographic (ECG) index for left ventricular hypertrophy (LVH) defined by the presence of either a classic strain pattern or a Cornell voltage (sum of R in aVL + S in V(3)) >2.0 mV in women or 2.4 mV in men, or both. METHODS: In a prospective, cohort study, 2190 initially untreated subjects (age 51 [+/- 12], 47% women) with essential hypertension without prior events were followed for up to 14 years (median, 5 years). RESULTS: Prevalence of LVH at entry was 16.3% by using the C/S index, which yielded 33.6% sensitivity and 91.0% specificity. Other ECG criteria for LVH including Sokolow-Lyon, Romhilt-Estes, Framingham, Cornell, and strain alone, achieved a lower sensitivity and prevalence. Over the subsequent follow-up, 244 patients experienced a first major cardiovascular event. Event rate (x 100 person-years) was 2.01 in those without and 4.44 in those with LVH by the C/S index (P <.001). After adjustment for age, sex, smoking, and other counfounders, the C/S index identified subjects at increased risk of events (relative risk 1.76; 95% confidence interval 1.32-2.33). The C/S index achieved the highest population-attributable risk (16.1%) for cardiovascular events. CONCLUSIONS: A simple ECG index that can be quickly measured from nondigital machines and without algorithms identifies LVH in a consistent proportion (16.3%) of hypertensive subjects. The LVH defined by such technique allows identification of individuals at high risk for cardiovascular events.     

Associations of Left Ventricular Hypertrophy and Geometry with Adverse Outcomes in Patients with CKD and Hypertension

Background and objectives

Left ventricular hypertrophy (LVH) and abnormal left ventricular (LV) geometry predict adverse outcomes in the general and hypertensive populations, but findings in CKD are still inconclusive.

Design, setting, participants, & measurements

We enrolled 445 patients with hypertension and CKD stages 2–5 in two academic nephrology clinics in 1999–2003 who underwent both echocardiography and ambulatory BP monitoring. LVH (LV mass >100 g/m² [women] and >131 g/m² [men]) and relative wall thickness (RWT) were used to define LV geometry: no LVH and RWT≤0.45 (normal), no LVH and RWT>0.45 (remodeling), LVH and RWT≤0.45 (eccentric), and LVH and RWT>0.45 (concentric). We evaluated the prognostic role of LVH and LV geometry on cardiovascular (CV; composite of fatal and nonfatal events) and renal outcomes (composite of ESRD and all-cause death).

Results

Age was 64.1±13.8 years old; 19% had diabetes, and 22% had CV disease. eGFR was 39.9±20.2 ml/min per 1.73 m². LVH was detected in 249 patients (56.0%); of these, 125 had concentric LVH, and 124 had eccentric pattern, whereas 71 patients had concentric remodeling. Age, women, anemia, and nocturnal hypertension were independently associated with both concentric and eccentric LVH, whereas diabetes and history of CV disease associated with eccentric LVH only, and CKD stages 4 and 5 associated with concentric LVH only. During follow-up (median, 5.9 years; range, 0.04–15.3), 188 renal deaths (112 ESRD) and 103 CV events (61 fatal) occurred. Using multivariable Cox analysis, concentric and eccentric LVH was associated with higher risk of CV outcomes (hazard ratio [HR], 2.59; 95% confidence interval [95% CI], 1.39 to 4.84 and HR, 2.79; 95% CI, 1.47 to 5.26, respectively). Similarly, greater risk of renal end point was detected in concentric (HR, 2.33; 95% CI, 1.44 to 3.80) and eccentric (HR, 2.30; 95% CI, 1.42 to 3.74) LVH. Sensitivity analysis using LVH and RWT separately showed that LVH but not RWT was associated with higher cardiorenal risk.

Conclusions

In patients with CKD, LVH is a strong predictor of the risk of poor CV and renal outcomes independent from LV geometry.     

Risk of cardiovascular events in patients with polycystic ovary syndrome

Women with polycystic ovary syndrome (PCOS) have increased prevalence of cardiovascular (CV) risk factors. However, data on the incidence of CV events are lacking in this population. Using Rochester Epidemiology Project resources, we conducted a retrospective cohort study comparing CV events in women with PCOS with those of women without PCOS in Olmsted County, Minnesota. Between 1966 and 1988, 309 women with PCOS and 343 without PCOS were identified. Mean (SD) age at PCOS diagnosis was 25.0 (5.3) years; mean age at last follow-up was 46.7 years. Mean (SD) follow-up was 23.7 (13.7) years. Women with PCOS had a higher body mass index (29.4 kg÷m2 vs 28.3 kg÷m2; p=.01). Prevalence of type 2 diabetes mellitus and hypertension and levels of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides were similar in the two groups. We observed no increase in CV events, including myocardial infarction (adjusted hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.32 to 1.72; p=.48); coronary artery bypass graft surgery (adjusted HR 1.52; 95% CI 0.42 to 5.48; p=.52); death (adjusted HR 1.03; 95% CI, 0.29 to 3.71; p=.96); death due to CV disease (adjusted HR 5.67; 95% CI 0.51 to 63.7; p=.16); or stroke (adjusted HR 1.05; 95% CI 0.28 to 3.92; p=.94). Although women with PCOS weighed more than controls, there was no increased prevalence of other CV risk factors. Furthermore, we found no increase in CV events. While prospective studies are needed to confirm these findings, women with PCOS do not appear to have adverse CV outcomes in midlife.     

Does QRS Voltage Correction by Body Mass Index Improve the Accuracy of Electrocardiography in Detecting Left Ventricular Hypertrophy and Predicting Cardiovascular Events in a General Population?

The authors assessed the value of body mass index (BMI) correction of two electrocardiographic criteria in improving detection of left ventricular hypertrophy (LVH) and prediction of cardiovascular and all‐cause mortality in the Italian study Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) population. At entry, 1549 patients underwent diagnostic tests, 24‐hour ambulatory blood pressure (BP) monitoring, standard electrocardiography, and echocardiography. The BMI‐corrected Cornell voltage and Sokolow‐Lyon voltage criteria provided better results for detection of echocardiographic LVH as compared with unadjusted electrocardiographic parameters. Cornell voltage index, but not Sokolow‐Lyon index, was associated with an increased risk of cardiovascular events (and all‐cause mortality). The adjusted risk of cardiovascular events related to one‐standard deviation increment of BMI‐corrected Cornell voltage was similar to that conferred by the uncorrected criterion in the total population, but outperformed in obese participants. These findings show that correction for BMI may improve the diagnostic accuracy of Cornell voltage index in detecting LVH and prediction of cardiovascular mortality in obese individuals.     

Does healthy obesity exist in the elderly? Findings from the Northern Shanghai Study

Background and aimsMetabolic unhealthiness and obesity are both associated with an increased risk of cardiovascular disease. We aimed to investigate the significance of metabolic unhealthiness and obesity in organ damages in a community-based elderly cohort.Methods and resultsA total of 3325 elderly participants (>65 years old) were recruited in northern Shanghai. Associations of metabolic status and obesity with organ damages were investigated. In all, 1317 (39.6%) participants were metabolically unhealthy and 481 (14.5%) were obese. Compared with metabolically healthy nonobese (MH-nonobese) individuals, metabolically healthy obese subjects had a greater left ventricular mass index (LVMI) and pulse wave velocity (PWV). Metabolically unhealthy subjects, regardless of their obesity status, had greater organ damage parameters including E/Ea, LVMI, PWV, and urine albumin-creatinine ratio (UACR) than MH-nonobese subjects (all P < 0.05). After multivariate adjustments, both metabolic unhealthiness and obesity increased the risk of left ventricular hypertrophy (LVH) (OR 1.31, 95% CI 1.10–1.57 and OR 1.63, 95% CI 1.30–2.04), diastolic dysfunction (OR 1.33, 95% CI 1.06–1.67 and OR 1.51, 95% CI 1.14–1.99), and lower extremity atherosclerosis (OR 1.44, 95% CI 1.11–1.85 and OR 2.01, 95% CI 1.49–2.70). Metabolic unhealthiness was also associated with arterial stiffness, microalbuminuria and chronic kidney disease (all P < 0.05). In a subgroup analysis, metabolic unhealthiness was associated with more organ damages in nonobese subjects, and obesity was associated with LVH and lower extremity atherosclerosis regardless of metabolic status.ConclusionBoth obesity and metabolic unhealthiness were associated with organ damages. Metabolic unhealthiness was associated with more organ damages, especially in nonobese individuals. Even healthy obesity was significantly associated with cardiac and vascular impairment.Registration number for clinical trialsNCT02368938.     

Adverse effects of left ventricular hypertrophy in the reduction of endpoints in NIDDM with the angiotensin II antagonist losartan (RENAAL) study

Aims/hypothesis We explored the impact of baseline left ventricular hypertrophy (LVH) and losartan treatment on renal and cardiovascular (CV) events in 1,513 patients from the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) trial, which studied the effects of losartan on the progression of renal disease and/or death in patients with type 2 diabetes and nephropathy.Materials and methods LVH was assessed using ECG criteria (Cornell product and/or Sokolow–Lyon voltage). The risk of renal or CV events was determined by a proportional hazards model fit with treatment allocation and presence of LVH. Covariates at baseline included age, sex, systolic BP, mean arterial pressure, pulse, proteinuria, serum creatinine, albumin and haemoglobin.Results A total of 187 subjects (12%) had LVH at baseline. Treatment with losartan resulted in a significant decrease in the Cornell product (–6.2%) and Sokolow–Lyon voltage (–6.3%). LVH was shown to be significantly associated with the primary endpoint, which was a composite of doubling of serum creatinine (DSCR), endstage renal disease (ESRD) or death (hazard ratio [HR]=1.44, p=0.011), as well as with the composite renal endpoint of DSCR/ESRD (HR=1.42, p=0.031) and CV events (HR=1.68, p=0.001). Losartan treatment of patients with LVH decreased the CV as well as renal risk to a level similar to that of patients without LVH.Conclusions/interpretation In patients with type 2 diabetes and nephropathy, LVH is associated with significantly increased risk of CV events and the progression of kidney disease. Importantly, in patients with LVH, losartan reduced the CV as well as the renal risk to a level similar to that seen in subjects without LVH.     

Racial/ethnic differences in the prognostic utility of left ventricular mass index for incident cardiovascular disease

Background

Evidence exists for racial/ethnic differences in left ventricular mass index (LVMI). How this translates to future cardiovascular disease (CVD) events is unknown.

Hypothesis

The impact of racial/ethnic differences in LVMI on incident cardiovascular outcomes could have potential implications for the optimization of risk stratification strategies.

Methods

Using the prospectively collected database of the Multi‐Ethnic Study of Atherosclerosis (MESA) involving 4 racial/ethnic groups (non‐Hispanic Whites, Chinese, Blacks, and Hispanics) free of CVD at baseline, we assessed for racial/ethnic differences in the relationship between LVMI and incident CVD using a Cox model.

Results

5004 participants (mean age, 62 ± 10 years; 48% male) were included in this study. After an average follow‐up of 10.2 years, 369 (7.4%) CVD events occurred. Significant racial/ethnic differences existed in the relationship between LVMI and incident CVD (P for interaction = 0.04). Notably, the relationship was strongest for Chinese (HR per 10‐unit increase in LVMI: 1.7, 95% CI: 1.1–2.8) and Hispanics (HR per 10‐unit increase in LVMI: 1.9, 95% CI: 1.5–2.2). Non‐Hispanic Whites demonstrated the lowest relationship (HR: 1.3, 95% CI: 1.1–1.5). LVMI values of 36.9 g/m^2.7, 31.8 g/m^2.7, 39.9 g/m^2.7, and 41.7 g/m^2.7 were identified as optimal cutpoints for defining left ventricular hypertrophy (LVH) for non‐Hispanic Whites, Chinese, Blacks, and Hispanics, respectively. In secondary analysis of LVH (vs no LVH) using these optimal cutpoints, we found a similar pattern of association as above (P for interaction = 0.04). For example, compared with those without LVH, Chinese with LVH had HR: 5.3, 95% CI: 1.6–17, whereas non‐Hispanic Whites with LVH had HR: 1.6, 95% CI: 1.2–2.1 for CVD events.

Conclusions

Among 4 races/ethnicities studied, LVMI has more prognostic utility predicting future CVD events for Chinese and Hispanics and is least significant for non‐Hispanic Whites.