Morphologic significance of left atrial involvement

Left atrial involvement, defined as the terminal negativity of the P wave in Lead V₁ of 1 mm. or more in depth and a duration of 0.04 second or more, was evaluated in 270 autopsied cases with the use of a chamber dissection technique for the determination of atrial and ventricular hypertrophy. Left atrial involvement was present in the following: 35 (44.3 per cent) of 79 hearts with left atrial hypertrophy, 31 (34.8 per cent) of 89 hearts with right atrial hypertrophy, 32 (22.4 per cent) of 143 hearts without atrial hypertrophy, 52 (44.4 per cent) of 117 hearts with left ventricular hypertrophy, 17 (34.7 per cent) of 49 hearts with right ventricular hypertrophy, 9 (11.5 per cent) of 78 hearts without anatomic evidence of atrial or ventricular hypertrophy, and 3 (3.8 per cent) of 78 hearts without anatomic evidence of atrial or ventricular hypertrophy or any clinical or postmortem findings of cardiopulmonary disease. Left atrial involvement has a significant correlation with left atrial hypertrophy (p < 0.01) and left ventricular hypertrophy (p < 0.001). Left atrial involvement was frequently noted to be transient. The presence of left atrial involvement on the ECG appears to be the result of many factors including left-sided heart disease, left atrial hypertrophy, left ventricular hypertrophy, increases in left atrial volume or pressure, and possibly intra-atrial conduction delays.     

Computer interpretation of pediatric orthogonal electrocardiograms: statistical and deterministic classification methods

Statistical multivariate and conventional deterministic methods of computerized interpretation of the electrocardiogram (ECG) were compared in the analysis of 1711 pediatric orthogonal ECGs validated by nonelectrocardiographic criteria on the basis of clinical and anatomic diagnoses. Among 642 children catheterized for the evaluation of congenital heart disease, there were 140 patients with left ventricular hypertrophy, 299 with right ventricular hypertrophy, and 203 with biventricular hypertrophy. A group of 1069 obviously healthy school children was studied as a control. The overall accuracy of multigroup ECG diagnosis was 85% and 79% for the statistical and deterministic methods, respectively. The diagnostic performances of both methods expressed in terms of sensitivity and predictive value were the highest for normal children and those with right ventricular hypertrophy and lowest for children with biventricular hypertrophy. The statistical method was more sensitive in the diagnosis of left ventricular hypertrophy (74% vs 64%), right ventricular hypertrophy (86% vs 83%), and biventricular hypertrophy (62% vs 50%). Mutual agreement for a correct diagnosis by the two methods was 83% for normal children and 82% for those with right ventricular hypertrophy but only 61% for children with left ventricular hypertrophy and 39% for those with biventricular hypertrophy. In conclusion, better classification results are obtained with statistical multivariate techniques as compared with conventional deterministic analysis, but both methods of ECG interpretation are complementary and their combination in the same electrocardiographic computer program can improve diagnostic accuracy.     

Electrocardiographic patterns of patients with echocardiographically determined biventricular hypertrophy.

The numerous criteria proposed for the electrocardiographic (ECG) diagnosis of biventricular hypertrophy (BVH) suffer from inadequate correlative data. We used two-dimensional (2D) echocardiography to identify BVH and analyzed the ECG patterns in these patients. The study group had 69 such patients with BVH and the control group had 22 patients with isolated left ventricular hypertrophy (LVH) demonstrated by 2D echocardiography. The electrocardiograms were analyzed for the presence of established criteria used in the diagnosis of LVH and right ventricular hypertrophy (RVH). Of the 69 patients in the study group, 17 (25%) had ECG findings of BVH, 25 (36%) had LVH, and 14 (20%) had RVH. An S wave in V5/V6 of >7 mm was most the frequent finding in the 17 patients with BVH on the electrocardiogram. The sensitivity of ECG criteria for BVH was 24.6%, specificity was 86.4%, and positive predictive value was 85%. This study reemphasizes the difficulty of ECG diagnosis of BVH. The electrocardiogram has a low sensitivity but satisfactory specificity and positive predictive accuracy for BVH.     

Significance of site of origin of premature ventricular contractions.

One hundred and sixty-five inpatients with premature ventricular contractions (PVC's) were clinically evaluated in regard to the presence (130 patients) or absence (35 patients) of organic heart disease. PVC's were classified based on QRS morphology (bundle branch block pattern) in Lead V₁ as being either left ventricular (66 patients), right ventricular (71 patients), or of both ventricles (28 patients). The incidence of organic heart disease was significantly greater in patients with left ventricualr PVC's 60 of 66 (91 per cent) and biventricular PVC's 25 of 28 (89 per cent) than in patients with right ventricular PVC's 45 of 71 (63 per cent) (p < 0.001). Of the 130 patients with organic heart disease, 60 (46 per cent) had left ventricular PVC's, 25 (19 per cent) had biventricular PVC's, and 45 (35 per cent) had right ventricular PVC's. of the 35 patients without organic heart disease, six (17 per cent) had left ventricualr PVC's, four (9 per cent) had biventricular PVC's, and 26 (74 per cent) had right ventricular PVC's.These data suggest the following conclusions regarding inpatients with PVC's: (1) Organic heart disease is frequent in patients with right ventricular PVC's and almost universally present in patients with left ventricular and biventricular PVC's. (2) Patients without organic heart disease primarily have PVC's of right ventricular origin. The mechanism of the latter association is unknown.     

Reevaluation of electrocardiographic criteria for left, right and combined cardiac ventricular hypertrophy

Cardiac chamber weight was determined at necropsy in 323 men to develop correlative studies of electrocardiographic criteria for ventricular hypertrophy. Thirty recommended criteria for left ventricular (LV) hypertrophy, 10 for right ventricular (RV) hypertrophy, and combinations of both criteria for combined hypertrophy were evaluated. Four methods for electrocardiographic diagnosis of LV hypertrophy were derived: (1) a modification of the Romhilt-Estes point system; (2) the presence of any 1 of 3 criteria: (a) S V1 + R V5 or V6 greater than 35 mm, (b) left atrial abnormality, or (c) intrinsicoid deflection in lead V5 or V6 greater than or equal to 0.05 second; (3) a combination of any 2 criteria or of 1 criterion (above) plus at least 1 of the following 3 additional criteria: (a) left-axis deviation greater than -30 degrees, (b) QRS duration greater than 0.09 second, or (c) T-wave inversion in lead V6 of 1 mm or more; and (4) the use of a single criterion--left atrial abnormality. Sensitivity varied from 57 to 66% and specificity from 85 to 93% among these 4 methods. Myocardial infarction increased sensitivity of the foregoing methods, but the specificity was reduced. Method 2 is preferred for the electrocardiographic diagnosis of LV hypertrophy. Two methods were useful for right ventricular (RV) hypertrophy: (1) the use of any 1 of 4 criteria: (a) R/S ratio in lead V5 or V6 less than or equal to 1; (b) S V5 or V6 greater than or equal to 7 mm; (c) right-axis deviation of more than +90 degrees, or (d) P pulmonale; and (2) use of any 2 combinations of the foregoing criteria. Sensitivity ranged from 18 to 43% and specificity from 83 to 95%. Combined hypertrophy was best diagnosed using left atrial abnormality as the sole criteria of LV hypertrophy, plus any 1 of 3 criteria of RV hypertrophy: (a) R/S ratio in lead V5 or V6 less than or equal to 1, (b) S V5 or V6 greater than or equal to 7 mm, or (c) right axis deviation greater than +90 degrees.(ABSTRACT TRUNCATED AT 250 WORDS)     

Body surface mapping criteria for diagnosis of left ventricular hypertrophy associated with complete right bundle branch block

The standard electrocardiographic (ECG) criteria for left ventricular hypertrophy are unreliable in patients with complete right bundle branch block. This study was undertaken to formulate criteria for diagnosing these patients by using body surface mapping. The echocardiographic left ventricular mass was calculated by the Penn method from M-mode measurements. Of 56 patients, 27 were defined as having left ventricular hypertrophy with a left ventricular mass of 215 g or more. Isopotential and isointegral maps of the QRS complex were observed. The QRS isointegral maps were separated into two parts at the end of the downstroke of the initial R wave of vector spatial magnitude. The body surface mapping criteria with the highest sensitivity were EPmax (maximum of early part of the QRS) 45 μV·s or greater (sensitivity 93%, specificity 90%), EPmax/d (EPmax averaged by EP duration) 0.8 mV or greater (sensitivity 93%, specificity 97%), and Max (initial maximum) 2.2 mV or greater (sensitivity 89%, specificity 90%). These results suggest that body surface mapping is a useful technique in diagnosing patients with left ventricular hypertrophy and right bundle branch block.     

Limitations of the electrocardiographic diagnosis of left ventricular hypertrophy: the influence of left anterior hemiblock and right bundle branch block.

We analysed the performance of the electrocardiogram in diagnosing left ventricular hypertrophy in 70 patients with isolated left anterior hemiblock and in 75 patients with right bundle branch block, either isolated (44 cases) or associated (31 cases) with left anterior hemiblock. Left ventricular hypertrophy defined as an echocardiographically determined left ventricular mass greater than 261 g in men and 172 g in women or left ventricular mass index greater than 125 g/m2 in men and 112 g/m2 in women was present in 48 subjects (57%) with isolated left anterior hemiblock and 33 subjects (44%) with right bundle branch block. In patients with isolated left anterior hemiblock the best results were obtained using the SV1 or SV2 + (RV6 + SV6) greater than 25 mm with 74% in sensitivity and 67% in specificity; the criterion SIII + (R + S) maximal in a precordial lead greater than or equal to 30 mm showed a sensitivity of 74% but a specificity of 47%. In the whole group of patients with right bundle branch block none of the criteria nor combination of criteria achieved an acceptable performance (sensitivities ranged from 17% to 41% and specificities ranged from 54% to 85%). When these patients were divided according to the presence or absence of concomitant left anterior hemiblock the electrocardiographic indexes mostly showed, in comparison to whole group, higher values in sensitivity and lower values in specificity in right bundle branch block plus left anterior hemiblock and an opposite behaviour in isolated right bundle branch block.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary arterial anatomy in bicuspid aortic valve. Necropsy study of 100 hearts.

In a necropsy study, the conjoined cusps of 50 congenitally and 50 acquired bicuspid aortic valves most commonly involved the right and left aortic cusps. In hearts with congenitally bicuspid aortic valves, the left coronary ostium arose at or above the aortic sinotubular junction in 44 per cent, whereas the incidence for the left coronary ostium in the acquired group was 20 per cent and that for the right coronary ostium in both groups was less than 20 per cent. In hearts with congenitally bicuspid aortic valves, the incidence of left coronary dominance (26%) was higher than in normal hearts. In hearts with apparently acquired bicuspid aortic valves, this incidence was also higher than normal, possibly because of acquired fusion of atypical congenitally bicuspid valves in some cases. In both types of aortic valve disease, the length of the left main coronary artery was similar; this length, however, was significantly shorter in hearts with left coronary dominance than in those with right or shared dominance.     

Left ventricular hypertrophy An electrocardiographic and angiocardiographic study in children with systolic overload of the left ventricle

The left ventricular wall thickness was measured on angiocardiograms in 83 children and infants with coarctation of the aorta or aortic valvular stenosis. The measurements were not corrected for image distortion from the nonparallel roentgen rays. The degree of hypertrophy was assessed by comparison with “normal” subjects in the same weight group. Twenty-five of the patients were found to have a left ventricular wall thickness within normal limits; 44 cases had a left ventricular wall not more than 50 per cent thicker than normal; in the remaining 14 cases it was more than 50 per cent greater than normal. The most advanced hypertrophy recorded was slightly more than twice the upper normal limit for corresponding weight. A comparison was made between the degree of hypertrophy as assessed by angiocardiography and the electrocardiographic criteria of hypertrophy. Although there seemed to be a general agreement between the degree of anatomic hypertrophy and the R amplitude in left precordial leads, the sum of (RV_5/6+ SV₁) and the recorded S-T changes, there was no statistically significant correlation between any one of these electrocardiographic criteria and the presence or absence of hypertrophy of the left ventricle.

It is concluded that the electrocardiographic changes in patients with increased systolic overload of the left ventricle are probably related to myocardial factors other than the anatomic dimensions of the left ventricular wall. In our present state of development, the interpretation of the electrocardiogram with respect to moderate left ventricular hypertrophy is unsatisfactory and may be erroneous.     

Electrocardiographic criteria for diagnosis of left ventricular hypertrophy in the presence of complete right bundle branch block

The usual electrocardiographic criteria recommended for left ventricular (LV) hypertrophy may be unreliable in the presence of complete right bundle branch block (BBB). Thirty-six standard electrocardiographic criteria for LV hypertrophy were evaluated in 100 patients (mean age +/- standard deviation 67 +/- 11 years) with right BBB and technically satisfactory echocardiograms. Eight additional electrocardiographic criteria derived from this study also were evaluated. LV mass index was determined from the echocardiogram using the Penn method. LV hypertrophy defined as LV mass index greater than 132 g/m2 in men and 109 g/m2 in women was present in 56 of the 100 patients. Electrocardiographic criteria with the highest sensitivity were SIII + (R + S) maximal precordial lead greater than or equal to 30 mm (sensitivity 68%), specificity 66%), left axis deviation of -30 degrees to -90 degrees (sensitivity 59%, specificity 71%) and combination of left axis deviation and SIII + (R + S) maximal precordial lead greater than or equal to 30 mm (sensitivity 52%, specificity 84%). The electrocardiographic criteria with the highest sensitivity and specificity greater than 90% were left axis deviation of -30 degrees to -90 degrees and SV1 greater than 2 mm (sensitivity 34%), point-score system, RaVL greater than 12 mm and RI + SIII greater than 25 mm (each with a sensitivity of 27%). In general, limb lead voltage criteria such as RaVL greater than 11 mm (sensitivity 29%, specificity 86%) had higher sensitivities than criteria using right precordial lead S-wave voltage criteria such as SV1 + RV5, V6 greater than 35 mm (sensitivity 2%, specificity 100%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Left ventricular hypertrophy by electrocardiography and echocardiography in the African American Study of Kidney Disease Cohort Study

Although electrocardiographic criteria for diagnosing left ventricular hypertrophy have a low sensitivity in the general population, their test characteristics have not been evaluated in the high-prevalence group of American Americans with chronic kidney disease. The purpose of the current study was to evaluate these test characteristics among African Americans (n = 645) with hypertensive kidney disease as part of the African-American Study of Kidney Disease and Hypertension cohort. Electrocardiograms were read by 2 cardiologists at an independent core laboratory using the 2 Sokolow-Lyon criteria and the Cornell criteria. Left ventricular hypertrophy on echocardiography was defined as left ventricular mass index greater than 49.2 and greater than 46.7 g/m^2.7 in men and women, respectively. Sixty-nine percent of the population had left ventricular hypertrophy on echo, whereas 34% had left ventricular hypertrophy by any of the electrocardiographic criteria. Sensitivity by individual electrocardiographic criteria was 16.5% by Sokolow-Lyon-1, 19.3% by Sokolow-Lyon-2, and 24.7% by Cornell criteria, with specificity ranging from 89% to 92%. When using any of the 3 criteria, sensitivity increased to 40.4% with a decrease in specificity to 78.0%. Consistent with findings in a general population, left ventricular hypertrophy by electrocardiography had low sensitivity and high specificity in this cohort of African Americans with hypertensive kidney disease.     

老年男性心电图Cornell电压标准及其应用价值

目的 探讨老年男性心电图Comell电压标准及其诊断老年男性左室肥厚的价值.方法 回顾性分析北京医院自1990年来进行尸体解剖的老年男性患者资料,排除心电图ORS波时限≥0.12 s及起搏心电图的患者.测量死亡前3个月内标准12导联心电图QRS波振幅,分析老年男性Comell、Sokolow-Lyon电压值与左室前壁厚度的相关性.计算老年男性无器质性心脏病组Comell电压值的均数及其97.5%的上限值,分析老年男性心电图Comell电压标准诊断老年男性左室肥厚的敏感性、准确性.结果 老年男性心电图Comell、Sokolow-Lyon电压值与左室前壁厚度相关.老年男性无器质性心脏病组心电图Sv3+RaVL平均值为(1.32±0.79)mV,以其97.5%的上限值2.9 mV为Comell标准诊断老年男性左室肥厚的敏感性、准确性分别为34.3%、77.5%,高于Sokolow-Lyon标准.结论 心电图Comell电压标准诊断中国老年男性左室肥厚的界值可采用2.9 mV,其诊断老年男性左室肥厚的敏感性、准确性高于Sokolow-Lyon标准.     

Quantitative study on the size of coronary artery supplying areas postmortem.

The relative amount of myocardium perfused by the three large coronary arteries was determined in 171 human hearts postmortem. Roentgenograms of transverse serial sections of the ventricular myocardium enabled planimetrical measurements. With little variation, an average of 41.5 per cent of the entire ventricular myocardium was supplied by the left descending coronary artery. Both left branches supplied an average of 63.8 per cent and the right coronary artery supplied 36.2 per cent of the myocardium. The size of supplying areas, in particular that of the right coronary artery and the left circumflex branch, was mainly dependent upon the coronary artery types. As a rule cardiac hypertrophy did not influence the size of coronary supplying areas as much as did the coronary artery types. Only very few hearts revealed that the myocardium was supplied to a greater extent by the right coronary artery than by the left (5.3 per cent). There is a close relationship between the size of the myocardial supplying area and the lumen of the corresponding coronary artery.     

Recent progress in the electrocardiographic diagnosis of ventricular hypertrophy

The surface electrocardiogram remains an insensitive method for detection of ventricular hypertrophy. Technical problems related to body size and habitus and distance from the heart cannot be overcome. Coronary arterty disease and amyloidosis, although frequently associated with hypertrophy, tend to obscure the electrocardiographic changes because of the attendant loss of voltage. The progress made in the last 20 years is due primarily to re-evaluation of traditional criteria in terms of careful anatomic correlation. The studies cited have the advantage of using specific clinical diagnoses in a defined population, specific chamber weights, and a 97.5 percentile confidence level for distinguishing normal pathologic and electrocardiographic data from abnormal. They are limited because the results may not apply to females or patients with mitral stenosis and congenital heart disease. In general, the electrocardiogram can be expected to detect left ventricular hypertrophy in six out of ten patients with the disease, and will misdiagnose the problem in about one out of every ten without the disease. Methodology using multiple criteria will achieve the best sensitivity and specificity. Several methods are available and of comparable accuracy. Simplicity of these methods varies widely and will be a factor in the choice of the method selected. The electrocardiogram will perform best in the population of patients with hypertension and aortic stenosis or regurgitation and have its greatest limitation in patients with coronary artery disease and myocardial infarctions. Echocardiography is proven to be more sensitive than the electrocardiogram for detection of left ventricular hypertrophy. Sensitivity is around 90 per cent with 95 per cent specificity. Its major limitations lie in the expense as compared to the electrocardiogram and in inadequate image resolution in a small proportion of patients. In order to achieve the results reported by centers proficient in this technique, careful attention must be paid to precise standardization of measurements and selection of images to be measured. When this is done the echocardiogram certainly offers a distinct advantage over the electrocardiogram in detecting left ventricular hypertrophy. We recommend the use of left atrial abnormality as a criterion to diagnose left ventricular hypertrophy when there is right bundle branch block. When left bundle branch block is present on the electrocardiogram, traditional criteria are probably no more accurate than the bundle branch block itself.(ABSTRACT TRUNCATED AT 400 WORDS)     

The orthogonal electrocardiogram in normal women. Implications of sex differences in diagnostic electrocariodgraphy.

Normal limits of the orthogonal electrocardiogram and vectorcardiogram in adult women, ranging in age from 18 to 90 years, are presented. A comparison of results is made with those of normal age-matched men, and sex differences are analyzed from a total of 960 normal records (510 men and 450 women). For the majority of scalar and vectorial items, significant sex differences were found which in women included shorter QRS duration, smaller vector loops, and decreased P, Q, R, S, and T deflections. The upper normal limits of R_x, R_y, and R_z amplitudes were 11 per cent, 20 per cent, and 30 per cent less, respectively, in women than in men.The sensitivity and specificity of electrocardiographic criteria, for high and low voltage, were significantly affected by these sex differences in amplitudes. For example, as a discriminator between normals and subjects with left ventricular hypertrophy, the upper normal limit of R_x + R_z amplitude sum was 3.10 millivolts in men but 2.50 millivolts in women. Hence, the use of the limit derived from males in a female population would decrease its sensitivity drasticially. Similar discrepancies existed in the sensitivity and specificity of electrocardiographic criteria for low voltage. Since the lower normal limit of R_x amplitude was 0.51 millivolt in men but only 0.35 millivolt in women, a substantial number of normal women would be misclassified as having right ventricular hypertrophy or chronic obstructive pulmonary disease if the limit derived from males was used as a criterion.The absence of Q waves in Leads x and y was a common finding in each age and sex group and carries no diagnostic significance. While initial anterior QRS forces in Lead z were present in all normal men, they were smaller and even absent in 1 per cent of normal women. Hence, greater difficulties in electrocardiographic diagnosis of anteroseptal myocardial infarction in women may be encountered.Mean vectors at the end of QRS (point J) and early part of the ST segment were more inferiorly and anteriorly directed in men than in women. T waves in Lead z were always negative in men, but flat or positive T waves were observed in some of the normal women. Sex differences in the level of point J and the ST segment may have important bearings on the interpretation of exercise electrocardiograms.The shorter QRS duration in women signified the importance of sex-specific limits for ventricular conduction delays.     

Electrocardiographic detection of left ventricular hypertrophy in the presence of left anterior fascicular block

The hitherto available electrocardiographic indexes for the detection of left ventricular hypertrophy in the presence of left anterior fascicular block do not provide a reliable diagnosis. Consequently, a new index based on the behavior of the QRS complex in left anterior fascicular block in the frontal and horizontal plane was constructed and its value assessed by echocardiographic measurements. The new index SIII + (R + S) maximal precordial greater than or equal to 30 mm was applied to the electrocardiograms of 50 patients without myocardial infarction and without right bundle branch block, showing a specificity of 87%, a sensitivity of 96%, a positive predictive value of 89% and a negative predictive value of 95%. Echocardiographic measurements were used as reference. Compared with the electrocardiographic indexes used so far (which were also applied to the 50 electrocardiograms), the new index showed a comparable high specificity and a distinctly superior sensitivity. The apparent paradox--why the electrocardiographic diagnosis of left ventricular hypertrophy is easier in the presence rather than in the absence of left anterior fascicular block--is discussed.     

Sensitivity and specificity of electrocardiographic criteria for left and right ventricular hypertrophy in morbid obesity

To determine the sensitivity and specificity of standard electrocardiographic criteria for left ventricular (LV) and right ventricular (RV) hypertrophy in morbid obesity, resting electrocardiograms and M-mode echocardiograms were obtained in 65 patients whose actual body weight was more than twice their ideal body weight and who were free from hypertension and organic heart disease not directly attributable to obesity. Electrocardiographic criteria for LV hypertrophy were tested using increased LV wall thickness, LV enlargement and increased LV mass (all determined echocardiographically) as diagnostic standards. Electrocardiographic criteria for RV hypertrophy were tested using echocardiographic RV enlargement or RV hypertrophy as a diagnostic standard. Sensitivity values for the electrocardiographic criteria for LV hypertrophy ranged from 0 to 13%, 0 to 20% and 0 to 12% using echocardiographic increased LV wall thickness, LV enlargement and increased LV mass, respectively, as diagnostic standards. Specificity values ranged from 73 to 100%, 87 to 100% and 83 to 100%, respectively, using these diagnostic standards. Sensitivity values for the electrocardiographic criteria for RV hypertrophy ranged from 0 to 16% and specificity values ranged from 95 to 100%. Combining electrocardiographic criteria within groups did not appreciably increase sensitivity and often decreased specificity to unacceptably low levels. The electrocardiogram is very limited in its ability to detect ventricular hypertrophy and chamber enlargement in morbidly obese patients.     

Echocardiographic assessment of the left ventricle in juvenile hypertension

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

Quantification of coronary arterial narrowing and of left ventricular myocardial scarring in healed myocardial infarction with chronic,eventually fatal,congestive cardiac failure

A qualitative and quantitative analysis is described of the amount of ventricular wall myocardial scarring and the degree and extent of coronary arterial narrowing by atherosclerotic plaques in the entire lengths of each of the four major epicardial coronary arteries in 18 necropsy patients with healed transmural myocardial infarcts, and chronic, eventually fatal, congestive heart failure. In all 18 patients, the healed infarcts involved greater than 40 per cent of the left ventricular wall, all had very dilated right and left ventricular cavities, all had hearts weighing more than 450 g (average = 587 g), all had intractable congestive heart failure for longer than three months (average = 2.3 years), and half had intraventricular mural thrombi. Of 1,012 five millimeter segments of the four major epicardial coronary arteries examined in the 18 patients (average 54 segments per patient), 298 segments (29 per cent) were 76 to 100 per cent narrowed in cross-sectional area by atherosclerotic plaques (in 16 control subjects = 6 per cent), 370 (37 per cent) were 51 to 75 per cent narrowed (controls = 35 per cent), 227 (23 per cent) were 26 to 50 per cent narrowed (controls = 43 per cent), and 117 (11 per cent) were 0 to 25 per cent narrowed (controls = 16 per cent). The amount of severe (>75 per cent) narrowing of the right, left anterior descending and left circumflex coronary arteries was similar in the 18 study patients. The left main coronary artery was not severely narrowed in any patient. The amount of severe narrowing in the distal one half of the right, left anterior descending and left circumflex coronary arteries was similar to that in the proximal halves of these three arteries. The per cent of 5 mm segments of coronary artery narrowed 76 to 100 per cent in cross-sectional area in the nine patients was similar to that in the nine patients without left ventricular aneurysm.     

Performance of new criteria for right ventricular hypertrophy and myocardial infarction in patients with pulmonary hypertension due to cor pulmonale and mitral stenosis.

Historically, electrocardiographic criteria for right ventricular (RV) hypertrophy has achieved high specificity but low sensitivity. Recently, however, Butler-Leggett et al. have introduced three criteria that attained a 66% sensitivity in a population with RV hypertrophy due to mitral stenosis while maintaining a 95% specificity in an extensive normal control group. Electrocardiographic diagnosis of RV hypertrophy is principally dependent on changes in the QRS complex that may be masked or mimicked by myocardial infarction (MI). This dilemma has been confirmed by documentation of the low specificity of both the Selvester QRS scoring system for MI size estimation (greater than 3 points) and its screening subset (greater than 0 points) in a pure mitral stenosis population. This study introduces the population characterized by RV hypertrophy due to cor pulmonale, which has a mean pulmonary arterial systolic pressure that is higher than the mean for the mitral stenosis population and consequently suggests more severe RV hypertrophy. When compared, the Butler-Leggett criteria for RV hypertrophy are more sensitive in the new population than in the mitral stenosis population (89% versus 60%) and the Selvester QRS scoring system is less specific (12% versus 60%). Three sequential steps are suggested for electrocardiographic analysis: (1) diagnosis of RV hypertrophy using the Butler-Leggett criteria, (2) diagnosis of MI using the Selvester screening criteria in those patients with step 1 negative, and (3) estimation of MI size using the complete Selvester scoring system in patients with step 1 negative and step 2 positive.