Electrocardiographic diagnosis of hypertrophy of the left ventricular myocardium in patients with arterial hypertension and overweight

AIM: To study efficacy of different ECG criteria of hypertrophy of left ventricular myocardium (LVH) in hypertensive patients with reference to overweight and obesity. MATERIAL AND METHODS: The authors analyse data on 100 patients (42 males and 58 females) aged 19-79 with diagnosis of arterial hypertension stage I-II. ECG was conducted in 12 leads. LVH by ECG was determined according to the following criteria: Sokolov-Lyon (S-L): Sv1+Rv5(v6) > 35 mm; Cornell voltage (Crn V): R avL +Sv3 > 28 mm (> 20 mm for females; Cornell product (Crn P): (RavL+Sv3)xQRSduration > 2440 mm x ms (for females RavL+Sv3 amplitudes + 0.6 mm). To verify L VH by echoCG, the authors used threshold values of left ventricular myocardium mass index (LVMMI) 125 g/m(2) for males and 110 g/m(2) for females. LVMMI was calculated by two methods: LVMM to body surface area (BSA) 2) LVMM to BSA of an ideal figure of a relevant height. Depending on the BMI all the patients were divided into 3 groups: with normal weight (BMI under 25 kg/m2), with overweight (BMI between 25 and 30 kg/m(2)), with obesity (BMI over 30 kg/m(2)). RESULTS: Sensitivity of the criterion Crn-P was the highest. The S-L criterion had the least sensitivity (under 10%) in groups with overweight by more than 25 kg/m(2). In these groups sensitivity of all ECG criteria of L VH depends on some factors: on indexation of LVH by body size, gender and overweight. S-L criterion sensitivity is higher in subgroups of males irrespective of overweight and obesity. CONCLUSION: Informative value of LVH ECG criteria depends on the method of LVMM indexation by body size, overweight and gender of the patients.     

Left ventricular hypertrophy detection from simple clinical measures combined with electrocardiographic criteria in a group of African ancestry

Background

Whether routine clinical parameters associated with left ventricular mass (LVM) enhance the performance of electrocardiographic (ECG) criteria for LV hypertrophy (LVH) detection and hence modify overall cardiovascular risk stratification is unknown.

Methods

An approach to echocardiographic LVH detection was identified from ECG criteria and clinical variables [age, body mass index (BMI), systolic blood pressure (SBP) and estimated glomerular filtration rate] associated with LVM in 621 participants of African ancestry. Performance (area under the receiver operating curve) and classification accuracy for LVH detection and the impact on cardiovascular risk stratification were determined.

Results

Compared to Cornell criteria alone, the combined use of Cornell criteria and clinical variables increased the performance (p < 0.001) and sensitivity (p < 0.05 to p < 0.0001) for LVH detection. The use of Cornell product together with additional clinical parameters as compared to Cornell product criteria alone increased the proportion of participants with pre-, grade I or grade II hypertension risk stratified as having a high added cardiovascular risk (56.3–67.9 %, p < 0.05).

Conclusions

In individuals of African ancestry, a combination of Cornell product criteria and age, BMI and SBP improves classification accuracy of Cornell criteria for LVH and increases those identified as having a high added as compared to lower cardiovascular risk scores.     

Detection of left ventricular hypertrophy by the R-wave voltage in lead aVL: population-based study

Background

According to hypertension guidelines, the recommended electrocardiographic (ECG) diagnostic criteria for left ventricular hypertrophy (LVH) are the Sokolow–Lyon and Cornel voltage criteria, both with general acceptance by primary care physicians. However, it was recently reported that the R-wave voltage in lead aVL (RaVL) was as good as other more complicated and time-consuming ECG criteria to detect LVH in hypertensive patients. Therefore, our aim was to investigate if the ability of the RaVL to identify echocardiographic left ventricular hypertrophy (ECHO-LVH) could be translated to the general population, a more realistic assessment of its utility in a nonreferral setting.

Methods

682 participants (43.5 % males), aged between 27 and 72 years from the urban population of Vitoria, ES, Brazil, were enrolled. We investigated the association of ECHO-LVH (LV mass >51 g/Ht^2.7) with several ECG voltage measurements: Sokolow–Lyon and Cornel criteria, S-wave voltage in lead V3 (SV3) and RaVL.

Results

The RaVL showed the best positive correlation with LV mass indexed to Ht^2.7, superior to both Cornell and Sokolow–Lyon criteria and was not influenced by gender. Analysis of the ROC curves showed that the RaVL depicted a significant superior performance in relation to all the other measurements in the ability to detect ECHO-LVH. SV3 was not correlated with LV mass. Thus, it seems that most of Cornell’s performance depends on its simplified version, that is, RaVL.

Conclusion

We have shown that the simple and single assessment of RaVL presented a greater diagnostic ability in detecting ECHO-LVH in the general population, signaling its value mainly as a screening tool.     

Sokolow指数与Cornell指数在诊断左心室肥厚中的作用

目的计算Cornell指数与Sokolow指数的敏感度与特异度,比较和评估Cornell指数与Sokolow指数在左室肥厚(LVH)心电图诊断中的作用。方法选择住院病人78例,做超声心动图检查,计算舒张晚期相对室壁厚度,正常值0.33±0.06,分为阳性组(左室肥厚)34例及阴性组(无左室肥厚)44例。两组病人做心电图测量,根据公式Ravl﹢Sv3和Rv5﹢Sv1得出Cornell指数和Sokolow指数电压值,统计LVH阳性例数,计算两指数敏感度与特异度并进行比较。结果 Cornell指数敏感度为23.53%,特异度为93.18%;Sokolow指数敏感度为29.41%,特异度为77.27%;两指数的敏感度比较差异无统计学意义(P>0.05),特异度比较差异有统计学意义(P<0.05)。结论 Cornell指数较Sokolow指数诊断LVH的特异度高,敏感度无差异,故Cornell指数对临床应用ECG诊断LVH有重要指导意义。     

Cardiovascular magnetic resonance in the diagnosis of acute heart transplant rejection: a review

Background

Left ventricular hypertrophy (LVH) is a hallmark of chronic pressure or volume overload of the left ventricle and is associated with risk of cardiovascular morbidity and mortality. The purpose was to evaluate different electrocardiographic criteria for LVH as determined by cardiovascular magnetic resonance (CMR). Additionally, the effects of concentric and eccentric LVH on depolarization and repolarization were assessed.

Methods

120 patients with aortic valve disease and 30 healthy volunteers were analysed. As ECG criteria for LVH, we assessed the Sokolow-Lyon voltage/product, Gubner-Ungerleider voltage, Cornell voltage/product, Perugia-score and Romhilt-Estes score.

Results

All ECG criteria demonstrated a significant correlation with LV mass and chamber size. The highest predictive values were achieved by the Romhilt-Estes score 4 points with a sensitivity of 86% and specificity of 81%. There was no difference in all ECG criteria between concentric and eccentric LVH. However, the intrinsicoid deflection (V6 37 ± 1.0 ms vs. 43 ± 1.6 ms, p < 0.05) was shorter in concentric LVH than in eccentric LVH and amplitudes of ST-segment (V5 -0.06 ± 0.01 vs. -0.02 ± 0.01) and T-wave (V5 -0.03 ± 0.04 vs. 0.18 ± 0.05) in the anterolateral leads (p < 0.05) were deeper.

Conclusion

By calibration with CMR, a wide range of predictive values was found for the various ECG criteria for LVH with the most favourable results for the Romhilt-Estes score. As electrocardiographic correlate for concentric LVH as compared with eccentric LVH, a shorter intrinsicoid deflection and a significant ST-segment and T-wave depression in the anterolateral leads was noted.     

Electrocardiographic diagnosis of left ventricular hypertrophy in aortic valve disease: evaluation of ECG criteria by cardiovascular magnetic resonance

Background

Left ventricular hypertrophy (LVH) is a hallmark of chronic pressure or volume overload of the left ventricle and is associated with risk of cardiovascular morbidity and mortality. The purpose was to evaluate different electrocardiographic criteria for LVH as determined by cardiovascular magnetic resonance (CMR). Additionally, the effects of concentric and eccentric LVH on depolarization and repolarization were assessed.

Methods

120 patients with aortic valve disease and 30 healthy volunteers were analysed. As ECG criteria for LVH, we assessed the Sokolow-Lyon voltage/product, Gubner-Ungerleider voltage, Cornell voltage/product, Perugia-score and Romhilt-Estes score.

Results

All ECG criteria demonstrated a significant correlation with LV mass and chamber size. The highest predictive values were achieved by the Romhilt-Estes score 4 points with a sensitivity of 86% and specificity of 81%. There was no difference in all ECG criteria between concentric and eccentric LVH. However, the intrinsicoid deflection (V6 37 ± 1.0 ms vs. 43 ± 1.6 ms, p < 0.05) was shorter in concentric LVH than in eccentric LVH and amplitudes of ST-segment (V5 -0.06 ± 0.01 vs. -0.02 ± 0.01) and T-wave (V5 -0.03 ± 0.04 vs. 0.18 ± 0.05) in the anterolateral leads (p < 0.05) were deeper.

Conclusion

By calibration with CMR, a wide range of predictive values was found for the various ECG criteria for LVH with the most favourable results for the Romhilt-Estes score. As electrocardiographic correlate for concentric LVH as compared with eccentric LVH, a shorter intrinsicoid deflection and a significant ST-segment and T-wave depression in the anterolateral leads was noted.     

Evaluation of various electrocardiographic criteria for left ventricular hypertrophy in patients with stable angina pectoris: influence of using modified limb electrodes

Background: Left ventricular hypertrophy (LVH) in coronary heart disease is associated with poor prognosis. Electrocardiography (ECG) criteria for LVH, when using ECG with modified limb electrode positions, has not been validated in patients with angina pectoris. Methods: Echocardiography and resting ECGs with modified limb electrode positions, i.e. with the limb leads placed on the abdomen instead of the extremities, were registered from 468 patients (295 men) with stable angina pectoris. To evaluate the influence of using modified limb electrode positions, ECGs with standard and modified limb electrode positions were compared in a control group consisting of 50 other patients. Results: The ECG criteria for LVH according to the Perugia score, the Minnesota code and Romhilt & Estes reached the highest sensitivity values, 27–31% in men and 24–38% in women, while the sensitivities of different Cornell criteria were as low as 6–10% in men and 19–29% in women. In the control group, the R‐ and S‐wave amplitudes of the precordial leads were only slightly changed, as expected, whereas those of the limb leads changed considerably. Based on these results, we corrected aVL in the main study, which increased the sensitivity of the Cornell voltage criteria from 15 to 30%, while the specificity was maintained at 95%. Conclusions: ECGs registered with modified limb electrode positions can be used to detect LVH with traditional ECG criteria, but changes in the limb leads are considerable and influence the sensitivities.     

Electrocardiographic (ECG) criteria for determining left ventricular mass in young healthy men; data from the LARGE Heart study

Background

Doubts remain over the use of the ECG in identifying those with increased left ventricular (LV) mass. This is especially so in young individuals, despite their high prevalence of ECG criteria for LV hypertrophy. We performed a study using cardiovascular magnetic resonance (CMR), which provides an in vivo non-invasive gold standard method of measuring LV mass, allowing accurate assessment of electrocardiography as a tool for defining LV hypertrophy in the young.

Methods and results

Standard 12-lead ECGs were obtained from 101 Caucasian male army recruits aged (mean ± SEM) 19.7 ± 0.2 years. LV mass was measured using CMR. LV mass indexed to body surface area demonstrated no significant correlation with the Cornell Amplitude criteria or Cornell Product for LV hypertrophy. Moderate correlations were seen with the Sokolow-Lyon Amplitude (0.28) and Sokolow-Lyon Product (0.284). Defining LV hypertrophy as a body surface area indexed left ventricular mass of 93 g/m², calculated sensitivities [and specificities] were as follows; 38.7% [74.3%] for the Sokolow-Lyon criteria, 43.4% [61.4%] for the Sokolow-Lyon Product, 19.4% [91.4%] for Cornell Amplitude, and 22.6% [85.7%] for Cornell Product. These values are substantially less than those reported for older age groups.

Conclusion

ECG criteria for LV hypertrophy may have little value in determining LV mass or the presence of LV hypertrophy in young fit males.     

Variants of heart remodeling in essential hypertension: prevalence and determinants

AIM: To study myocardial remodeling (MR) in hypertensive patients with normal and excessive body mass, to analyse MR features depending on clinical and hemodynamic parameters. MATERIAL AND METHODS: Structural-functional conditions of the myocardium were studied with echocardiography, and determination of left ventricular remodeling (LVR) type was made in 734 untreated hypertensive patients aged 19-76 years. RESULTS: Patients with essential hypertension (EH) stage I had mostly excentric left ventricular hypertrophy (LVH). The number of patients with concentric LVH increases with age, disease severity. This type of LVH occurs more frequently in males than in females. In females, LVH severity depends, primarily, on the degree of obesity. If EH combines with obesity, structural alterations of the myocardium are more prominent than in isolated pathology. In android obesity, LVH is more frequent. CONCLUSION: In EH, structural alterations of the heart and a LVR variant are determined, besides arterial pressure, by such factors as age and gender, duration of EH, obesity, its degree and kind.     

Evaluation of left ventricular mass measured by 3D echocardiography using magnetic resonance imaging as gold standard

OBJECTIVE: Increased left ventricular mass (LVM) and presence of left ventricular hypertrophy (LVH) are predictors of cardiovascular morbidity and mortality, but can be reversed with proper treatment of the underlying cause. Therefore accurate as well as reproducible methods for diagnosis and follow-up are needed. We evaluated different modalities by which to measure LVM in patients with no known LVH using magnetic resonance imaging (MRI) as the gold standard: ECG using the formulae proposed by Sokolow-Lyon and Cornell, 2D echocardiography and 3D echocardiography. METHODS: 34 subjects were included in the study; 17 had a history of myocardial infarction, 7 had pulmonary hypertension and 10 were healthy. All patients and controls had a standard 12-lead ECG, a transthoracic 2D and 3D echocardiographic study and a cardiac MRI. RESULTS: ECG estimates of LVM correlated poorly with LVM by MRI (r = 0.18, NS and 0.16, NS for Sokolow-Lyon and Cornell, respectively), whereas a moderate correlation between 2D and 3D echocardiography and MRI was observed (r = 0.63, p<0.001 and r = 0.74, p<0.001, respectively). All methods were reproducible with no significant bias. CONCLUSION: LVM measured by 3D echocardiography is highly accurate compared to LVM measured by MRI. LVM calculated from 2D echocardiography also proved useful, whereas estimates of LVM by ECG are inaccurate in a non-hypertrophic population.     

Hypertensive concentric left ventricular hypertrophy: when is ventricular ectopic activity increased?

The Framingham Study has indicated that patients with left ventricular hypertrophy (LVH) have a greater risk of cardiovascular complications and sudden death than subjects with a normal heart. We have previously demonstrated that ventricular ectopy was more prevalent and complex in hypertensive patients with LVH by electrocardiographic (ECG) criteria than in those without ECG evidence of LVH. The present study was designed to detect and quantify ventricular dysrhythmias in hypertensive patients with early concentric LVH by echocardiography but without LVH by ECG criteria. Continuous ambulatory ECG tracings were recorded for 24 hours in 94 patients with essential hypertension: 37 without LVH, 26 with concentric LVH by echocardiographic but not ECG criteria, and 31 with LVH on both echocardiography and ECG. Patients with LVH by ECG criteria had significantly more premature ventricular contractions (P less than .001) and more complex (higher Lown's class) ventricular ectopy (P less than .001) than hypertensives without LVH or with LVH only by echocardiographic criteria. Prevalence and complexity of ventricular ectopic activity, however, was not affected by mild to moderate concentric cardiac hypertrophy detected echocardiographically. We conclude that unlike LVH shown by ECG, early hypertensive concentric LVH detected echocardiographically is not associated with increased electrical irritability of the myocardium.     

Outpatient diagnostics of the initial stage of essential hypertension

The informative value of functional diagnostic methods in the revealing of the initial stage of essential hypertension (EH) in patients with high risk of cardiovascular complications (CVC) and type 2 diabetes mellitus (DM2) was studied. The subjects of the study were 186 men considering themselves practically healthy, with high risk of CVC according to SCORE scale. Mean age of the subjects was 47.9 +/- 0.87 years; persons with various metabolic disorders prevailed. The patients were divided into two groups according to body mass index (BMI): group 1 patients (n = 142) had a BMI of > or = 25 kg/m2 (29.16 +/- 0.49); group 2 (n = 46) patients had a BMI of < 25 kg/m2 (22.95 +/- 0.37). The patients underwent clinical and laboratory examination including the measurement of biochemical parameters of lipid, carbohydrate, and purine metabolism. ECG, EchoCG, and 24-hour blood pressure monitoring (BPM) were performed. Office BP levels, 24-hour BMP data, and signs of left ventricular hypertrophy (LVH) according to ECG and EchoCG were evaluated. The study found that in persons with excessive body weight stable 24-hour arterial hypertension with both systolic and diastolic BP increased prevailed, while in subjects with normal body weight systolic arterial hypertension prevailed. The use of milder LVH criteria (left ventricular myocardial mass index > 116 g/m2) increased the number of persons with stage 2 EH. The prevalence of the initial stage of EH according to 24-hour BPM (87.4%) is 2.8 times higher than that according to office BP measurement (31.3%).     

Use of vectorcardiography in determination of the left ventricular muscle mass

Summary. Many studies have investigated different ECG and vectorcardiographic (VCG): criteria for diagnosis of left ventricular hypertrophy (LVH). In some investigations VCG was more sensitive than ECG in this respect. This study was performed to elucidate whether it is possible also to determine the degree of LVH using VCG. Eighty cardiovascularly healthy subjects aged 15–39 were investigated with ECG, VCG (Frank system) and echocardiography. The echocardiographic left ventricular (LV) mass has been shown by others to correlate closely to the anatomical and the angiographically determined LV mass and was used as reference standard. Thirty-eight of the subjects were endurance sportsmen and had a LV mass above standard reference limits. The measured ECG variables were R-amplitude in aVL, I, V5, V6, S-amplitude in VI and SV1 + RV5/V6 and the VCG variables were QRS spatial area and circumference and left maximal spatial vector. The sensitivity and specificity of single criteria tested were similar for ECG and VCG in the quantitative determination of LVH. The correlations between ECG-amplitudes and the magnitude of the LV mass were weak. The correlations were higher with the VCG-variables, QRS spatial circumference being superior to the others, but not good enough to permit an estimation of the LV mass in individual subjects. In conclusion, normal VCG variables were highly specific for a normal LV mass but in individuals with LVH, VCG was not useful for the estimation of the LV mass.     

高血压左室肥厚心电图新标准临床评价

目的评估2009年欧洲高血压指南再评述推荐的心电图诊断左室肥厚(LVH)新标准(Sokolow-Lyon和Cornell product)(2009 ESC),并比较目前沿用的8种心电图诊断左室肥厚标准之间差异。方法以超声心动图检查结果计算的左室质量指数(LVMI)作为左室肥厚诊断标准,运用不同心电图诊断左室肥厚标准,评价高血压病患者352例,计算并比较各种心电图标准诊断左室肥厚的敏感度、特异度。结果 352例高血压患者超声心动图诊断左室肥厚58例,占高血压患者16.48%。左室肥厚心电图诊断标准的特异度(由高到低):Perugia score(68.97%)、Left ventricularstrain(53.45%)、Framingham criteria(51.72%)、Sokolow-Lyon index(41.38%)、2009 ESC(27.59%)、Romhilt-Estesscore(25.86%)、Cornell product(18.97%)、Cornell voltage index(18.97%)、Gubner(5.17%);左室肥厚心电图诊断标准的特异度(由高到低):Gubner(99.70%)、Cornell product(94.90%)、Romhilt-Estes score(94.56%)、Cornell voltage index(93.54%)、2009 ESC(93.54%)、Sokolow-Lyon index(88.44%)、Left ventricular strain(84.01%)、Perugia score(75.51%)、Framingham criteria(75.51%)。结论现行诊断左室肥厚的心电图指标中,Perugia score特异度最高,是因其综合了Cornell voltage、Left ventricular strain、Romhilt-Estes score3种标准,但其特异度受影响。Framingham criteria标准汇集了多导联的电压指标,增加了诊断的特异度。2009欧洲高血压指南再评述LVH诊断标准较原Sokolow-Lyon index特异度降低,较原Cornell product特异度有所提高,特异度保持在较高水平。     

Electrocardiographic left ventricular hypertrophy Cornell product is a feasible predictor of cardiac prognosis in patients with chronic heart failure

Background

Left ventricular hypertrophy (LVH) is an independent risk factor for cardiovascular disease and is associated with heart failure development. The Cornell product is an easily measured electrocardiographic parameter for assessing LVH. However, it is undetermined whether the Cornell product can predict the cardiac prognosis of chronic heart failure (CHF) patients.

Methods and results

We performed standard 12-lead electrocardiography and calculated the Cornell product in 432 consecutive CHF patients. LV geometry was assessed as normal, concentric remodeling, concentric or eccentric hypertrophy. The Cornell product was significantly higher in patients with eccentric hypertrophy, and increased with advancing New York Heart Association functional class. During a median follow-up of 660 days, there were 121 cardiac events including 36 cardiac deaths and 85 re-hospitalizations for worsening heart failure. Multivariate Cox proportional hazard analysis showed that the Cornell product was an independent predictor of cardiac events in CHF patients. Patients in the highest quartile of Cornell product had a higher prevalence of LV eccentric hypertrophy (22, 29, 33 and 67 % for quartiles one through four). Kaplan–Meier analysis demonstrated that the highest quartile of Cornell product was associated with the greatest risk among CHF patients.

Conclusion

The Cornell product is associated with LV eccentric hypertrophy and can be used to predict future cardiac events in CHF patients.     

Preventing left ventricular hypertrophy by ACE inhibition in hypertensive patients with type 2 diabetes: a prespecified analysis of the Bergamo Nephrologic Diabetes Complications Trial (BENEDICT)

OBJECTIVE—In patients with type 2 diabetes, left ventricular hypertrophy (LVH) predicts cardiovascular events, and the prevention of LVH is cardioprotective. We sought to compare the effect of ACE versus non-ACE inhibitor therapy on incident electrocardiographic (ECG) evidence of LVH (ECG-LVH).RESEARCH DESIGN AND METHODS—This prespecified study compared the incidence of ECG-LVH by Sokolow-Lyon and Cornell voltage criteria in 816 hypertensive type 2 diabetic patients of the Bergamo Nephrologic Diabetes Complications Trial (BENEDICT), who had no ECG-LVH at baseline and were randomly assigned to at least 3 years of blinded ACE inhibition with trandolapril (2 mg/day) or to non-ACE inhibitor therapy. Treatment was titrated to systolic/diastolic blood pressure <130/80 mmHg. ECG readings were centralized and blinded to treatment.RESULTS—Baseline characteristics of the two groups were similar. Over a median (interquartile range) follow-up of 36 (24–48) months, 13 of the 423 patients (3.1%) receiving trandolapril compared with 31 of the 376 patients (8.2%) receiving non-ACE inhibitor therapy developed ECG-LVH (hazard ratio [HR] 0.34 [95% CI 0.18–0.65], P = 0.0012 unadjusted, and 0.35 [0.18–0.68], P = 0.0018 adjusted for predefined baseline covariates). The HR was significant even after adjustment for follow-up blood pressure and blood pressure reduction versus baseline. Compared with baseline, both Sokolow-Lyon and Cornell voltages significantly decreased with trandolapril but did not change with non-ACE inhibitor therapy.CONCLUSIONS—ACE inhibition has a specific protective effect against the development of ECG-LVH that is additional to its blood pressure–lowering effect. Because ECG-LVH is a strong cardiovascular risk factor in people with hypertension and diabetes, early ACE inhibition may be cardioprotective in this population.Left ventricular hypertrophy (LVH), a cardinal manifestation of preclinical cardiovascular disease, strongly predicts myocardial infarction, stroke, and cardiovascular death in patients with hypertension (1) or coronary artery disease (2), as well as in the general population (3). In the Framingham Study, electrocardiographic (ECG) evidence of LVH (ECG-LVH) was associated with a twofold increase in mortality over that resulting from hypertension alone (4).Studies have consistently shown that antihypertensive therapy may effectively limit the incidence of ECG-LVH, regardless of the treatments used to reduce blood pressure (5). However, the Heart Outcomes Prevention Education (HOPE) (6) and the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) trials (7) showed that, in patients with ECG-LVH at inclusion, the ACE inhibitor ramipril and the angiotensin receptor blocker (ARB) losartan, respectively, regressed LVH more effectively than drugs that do not directly interfere with the renin-angiotensin-aldosterone system (RAAS). The finding in both trials that this benefit was significant even after adjustments for the small differences in blood pressure between the two treatment groups provided consistent evidence that RAAS inhibitor therapy has a specific cardioprotective effect that exceeds expectations based on changes in blood pressure alone. However, the HOPE trial (6) was not powered to assess the treatment effect on new-onset LVH in the subgroup with no ECG-LVH at baseline, and the LIFE trial (7) included only patients with LVH. Thus, whether RAAS inhibitor therapy may also prevent new-onset LVH in subjects with normal left ventricular mass to start with is unknown. To formally explore this issue, we compared the effect of ACE versus non-ACE inhibitor therapy on incident ECG-LVH in patients from the Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) (8–11) who had no ECG-LVH at inclusion.     

高血压左室肥厚患者T波峰-末间期的改变

目的:探讨高血压左室肥厚(LVH)患者T波峰-末间期(TpTe间期)的改变及其临床意义.方法:随机抽取原发性高血压(EH)患者313例,依据超声心动图(UCG)测定的左室重量指数(LVMI)分为LVH组和非LVH (NLVH)组.比较LVH组和NLVH组TpTe间期、TpTec、QT间期、QTc、QRS时限、LVMI、LVD、IVS、LVPW的改变及EH左室不同构型TpTe间期改变的特点.结果:(1) LVH组较NLVH组TpTe间期、TpTec、QTc、QRS时限延长(P＜ 0.05 ～ 0.01),LVMI、LVD、IVS、LVPW增大(P＜0.01),QT间期延长,但差别不显著(P＞ 0.05);(2) TpTe间期值在不同左室构型间的改变为:离心型肥厚＞向心性肥厚＞向心性重构＞正常组,后两组差别不显著(P＞0.05).结论:TpTe间期可作为检测EH患者左心室肥厚靶器官损害及预测心脏事件的新指标.     

Quantitative diagnosis of apical cardiomyopathy using contrast echocardiography.

BACKGROUND: The echocardiographic diagnosis of apical hypertrophic cardiomyopathy (ACM) has been limited by the frequent inability to visualize the apical endocardium. We hypothesized that the use of contrast agents in patients with suspected ACM, but nondiagnostic echocardiographic studies, would allow quantitative diagnosis. METHODS: Contrast enhancement was performed in 26 patients with nondiagnostic transthoracic echocardiograms (TTEs) for the diagnosis of ACM; 6 patients with suspected ACM based on unexplained symmetric precordial T-wave inversions and increased apical tracer uptake on single-photon emission computed tomography (SPECT) scans, 10 patients with normal electrocardiogram (ECG) readings and no history of hypertension (healthy group), and 10 patients with hypertension and ECG criteria for left ventricular hypertrophy (LVH group). Images were obtained with Optison (Mallinckrodt Medical; IV, 1.0 mL) using harmonic imaging and low mechanical index. Posterior (PW) and septal wall (SW) thicknesses were measured at end-diastole in the parasternal long-axis view. Apical wall thickness (A) was measured from the contrast-enhanced apical endocardium to the visceral epicardial surface in the apical 4-chamber view. A/PW and A/SW ratios were calculated for each group. Asymmetric apical hypertrophy was defined as an A/PW ratio greater than 1.5. RESULTS: Contrast-enhanced apical thickness was greater than 2.0 cm in all patients in the suspected ACM group but less than 1.2 cm in all patients in the LVH and healthy groups. In all 6 patients in the suspected ACM group, A/PW and A/SW ratios were greater than 1.5. No patient in the healthy or LVH groups had thickness ratios greater than 0.85. CONCLUSION: Contrast echocardiography allows quantitative diagnosis of ACM in patients with suggestive ECG and SPECT but nondiagnostic TTEs. This study suggests that contrast echocardiography should be performed before using more expensive or invasive diagnostic testing for this condition.     

Informative value of orthogonal electrocardiogram in the diagnosis of the left ventricular hypertrophy

AIM: To estimate the informative value of orthogonal ECG parameters for the diagnosis of left ventricular hypertrophy (LVH). MATERIALS AND METHODS: The study comprised 142 apparently healthy individuals and 125 patients with arterial hypertension (AH) and LVH (left ventricular mass index more than 125 g/m2 for males and more than 110 g/m2 for females). Characteristic curves (ROC curves) were used to describe and compare the informative value of vectorcardiographic, demapping criteria for L VH with the informavalue of the Sokolov-Lyons criterion, the Cornelian index, and the Cornelian product. RESULTS: The informative indices of orthogonal ECG were Rx + Sz and IADIM: the area under the ROC curve was 0.89 +/- 0.02 and 0.88 +/- 0.02, respectively, which was significantly higher than with the Sokolov-Lyons criterion (0.64 +/- 0.04; p < 0.05) and similar to the Cornelian product (0.84 +/- 0.03). Of great informative value is the angle phi (area under the ROC curve was 0.88 +/- 0.04) in males and the area of QRS loop in the horizontal plane (area under the ROC curve was 0.89 +/- 0.03) in females. With 96% specificity, the male sensitivity of IADIM was 80%, Rx + Sz--73%, which was significantly higher than that of the Cornelian index (56%; p < 0.05) and the Sokolov-Lyons criterion (27%; p < 0.05). With 96% specificity, the female sensitivity of IADIM was 73%, Rx + Sz--84%, SQRSxz--70%, which was significantly higher than that of the Cornelian index (49%; p < 0.05), the Cornelian product (55%; p < 0.05), and the Sokolov-Lyons criterion (30%; p < 0.05). CONCLUSION: The threshold values of the most informative indices of orthogonal ECG are presented, which could provide the optimum sensitivity-specificity ratios. These values allow cardiac lesions to be detected in hypertensive patients with normal 12-lead ECG.     

Are 12-lead ECG findings associated with the risk of cardiovascular events after ischemic stroke in young adults?

Introduction: Ischemic stroke (IS) in a young patient is a disaster and recurrent cardiovascular events could add further impairment. Identifying patients with high risk of such events is therefore important. The prognostic relevance of ECG for this population is unknown.

Materials and methods: A total of 690 IS patients aged 15–49 years were included. A 12-lead ECG was obtained 1–14 d after the onset of stroke. We adjusted for demographic factors, comorbidities, and stroke characteristics, Cox regression models were used to identify independent ECG parameters associated with long-term risks of (1) any cardiovascular event, (2) cardiac events, and (3) recurrent stroke.

Results: Median follow-up time was 8.8 years. About 26.4% of patients experienced a cardiovascular event, 14.5% had cardiac events, and 14.6% recurrent strokes. ECG parameters associated with recurrent cardiovascular events were bundle branch blocks, P-terminal force, left ventricular hypertrophy, and a broader QRS complex. Furthermore, more leftward P-wave axis, prolonged QTc, and P-wave duration?>120?ms were associated with increased risks of cardiac events. No ECG parameters were independently associated with recurrent stroke.

Conclusion: A 12-lead ECG can be used for risk prediction of cardiovascular events but not for recurrent stroke in young IS patients.

• KEY MESSAGES

• ECG is an easy, inexpensive, and useful tool for identifying young ischemic stroke patients with a high risk for recurrent cardiovascular events and it has a statistically significant association with these events even after adjusting for confounding factors.

• Bundle branch blocks, P-terminal force, broader QRS complex, LVH according to Cornell voltage duration criteria, more leftward P-wave axis, prolonged QTc, and P-wave duration >120?ms are predictors for future cardiovascular or cardiac events in these patients.

• No ECG parameters were independently associated with recurrent stroke.