Electrocardiographic left ventricular hypertrophy in patients with suspected acute cardiac ischemia—Its influence on diagnosis, triage, and short-term prognosis

the Department of Mathematics, Boston University, Boston, Massachusetts
Journal of General Internal Medicine (Impact Factor: 3.42). 12/1994; 9(12):666-673. DOI: 10.1007/BF02599006

ABSTRACT Objective: To understand the diagnostic and short-term prognostic significance of electrocardiographic left ventricular hypertrophy
(ECG-LVH) for patients who present to the emergency department with symptoms suggesting acute cardiac ischemia, defined as
new or unstable angina pectoris or acute myocardial infarction.

Design: Subgroup analysis of a multicenter, prospective study of coronary care unit admitting practices in the prethrombolytic era.

Setting: The emergency departments of six New England hospitals: two urban medical school teaching hospitals, two medical school—affiliated
community hospitals in smaller cities, and two rural nonteaching hospitals.

Patients: 5,768 patients presenting with symptoms suggesting possible acute cardiac ischemia, including 413 patients who had ECG-LVH
defined by the Romhilt-Estes point score criteria and 5,355 patients who had other electrocardiogram (ECG) findings.

Main results: Only 26% of the 413 patients who had ECG-LVH were ultimately judged to have had acute cardiac ischemia, compared with 72%
of patients who had primary ST-segment and T-wave abnormalities (p<0.001) and 36% of those who had other ECG abnormalities
(p<0.001). Overall, the ECG-LVH patients were one-third less likely than the patients who did not have ECG-LVH to have had
acute cardiac ischemia, after controlling for other predictors of acute ischemia by logistic regression (relative risk=0.66,
95% CI 0.46 to 0.94). The patients who had ECG-LVH were only one-fourth as likely to have had acute myocardial infarctions
as were the patients presenting with primary ST-segment and T-wave changes (12% vs 48%, p<0.001). Instead, a much larger proportion
had had congestive heart failure or hypertension. The admitting physicians had identified ECG-LVH poorly on the admitting
ECGs: only 22% of those who had ECG-LVH had been correctly identified, and for more than 70%, the secondary ST-segment and
T-wave changes of ECG-LVH had been read as being primary. The short-term mortality for the patients who had ECG-LVH was 7.5%.
This was intermediate between the mortality for patients who had primary ST-segment and T-wave abnormalities (10.6%) and those
who had other ECG abnormalities (5.1%). Mortality was not affected by whether the admitting physician had recognized ECG-LVH

Conclusion: ECG-LVH was not a benign ECG finding among the patients who had presented with symptoms suggesting an acute cardiac ischemic
syndrome: short-term mortality among the patients who had ECG-LVH (7.5%) approached that for the patients who had primary
ST-segment and T-wave abnormalities (10.6%, p=0.10). However, the patients who had ECG-LVH were one-thirdless likely to have had any acute cardiac ischemia than were the patients who did not have ECG-LVH, after logistic regression
was used to control for other predictors of acute ischemia. Specifically, acute myocardial infarction was only one-fourth
as likely when LVH was present on the admitting ECG (12%) as it was when primary ST-segment and T-wave abnormalities were
present (48%, p<0.001). Instead, congestive heart failure and hypertensive heart disease were more common. Thus, routine use
of thrombolytic therapy for patients who have ECG-LVH does not seem warranted. ECG-LVH was poorly recognized (in only 22%
of cases) by the physicians in the present study. Better recognition of this common ECG finding may lead to more effective
patient management.

1 Follower
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    ABSTRACT: Data on the prognostic value of echocardiographic left ventricular (LV) hypertrophy (LVH) as defined by LV wall thickness rather than LV mass estimate are scarce and not univocal. Thus, we investigated the value of LV mass index, wall thickness, and relative wall thickness (RWT) in predicting cardiovascular events in the PAMELA population. At entry 1,716 subjects underwent diagnostic tests, including laboratory investigations, 24-hour ambulatory blood pressure (BP) monitoring, and echocardiography. For the purpose of this analysis, all subjects were divided into quintiles of LV mass, LV mass/ body surface area (BSA), LV mass/height(2.7), interventricular septum (IVS), posterior wall (PW) thickness, IVS+PW thickness, and RWT. Over a follow-up of 148 months, 139 nonfatal or fatal cardiovascular events were documented. After adjustment for age, sex, BP, fasting blood glucose, total cholesterol, and use of antihypertensive drugs, only the subjects stratified in the highest quintiles of LV mass indexed to body surface area (BSA) or height(2.7) exhibited a greater likelihood of incident cardiovascular disease (relative risk (RR) = 2.72, 95% confidence interval (CI) = 1.05-7.00, P = 0.03; RR = 4.83, 95% CI = 1.45-16.13, P = 0.01, respectively) as compared with the first quintile (reference group). The same was not true for the highest quintiles of IVS, PW thickness, IVS+PW thickness, and RWT. Similar findings were found when echocardiographic parameters were expressed as continuous variables. This study indicates that LV wall thickness, different from LV mass index, does not provide a reliable estimate of cardiovascular risk associated with LVH in a general population. From these data it is recommended that echocardiographic laboratories should provide a systematic estimate of LV mass index, which is a strong, independent predictor of incident cardiovascular disease.
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    ABSTRACT: Chest pain and other symptoms suggestive of acute cardiac ischemia (ACI, including acute myocardial infarction [AMI] and unstable angina pectoris) account for over 6 million emergency department (ED) visits per year. Of these, the approximately 30% who truly have ACI (just under half of whom will prove to have AMI) [1] must be quickly and accurately separated from the majority of ED patients who do not have ACI and then promptly treated and admitted to the hospital. This is not an easy task, the environment in which this must be done is not often optimal, and there are no perfect tests that completely handle all possible cases. However, as reviewed in this chapter, there are a number of tests and strategies, that, when combined with good clinical judgement, can be of significant assistance.
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    ABSTRACT: Left ventricular hypertrophy (LVH) is frequently associated with ST depression (STD) on the electrocardiogram (ECG), a so-called strain pattern. Although STD is a well-established adverse prognosticator in non-ST-elevation acute coronary syndrome (NSTE-ACS), the relative prognostic importance of LVH and associated STD has not been elucidated. A total of 7,761 patients with NSTE-ACS in the Global Registry of Acute Coronary Events (GRACE) and ACS-I registries had admission ECGs analyzed at a core laboratory. Left ventricular hypertrophy (determined by Sokolow-Lyon and/or Casale criteria) was observed in 296 (3.8%) patients. We examined the independent association between LVH (determined by the admission ECG) and outcomes in relation to STD. Patients with LVH were older, had more comorbidities and STD, and presented with a higher Killip class. They were less likely to undergo cardiac catheterization (43.1% vs 51.2%, P = .006) and percutaneous coronary intervention (18.3% vs 24.6%, P = .014). Patients with LVH had higher unadjusted mortality at 6 months (10.5% vs 7.1%, P = .038), but similar rates of in-hospital mortality (4.1% vs 3.4%, P = .54) and reinfarction (7.1% vs 7.6%, P = .75). Patients with LVH were more likely to have heart failure in-hospital (21.8% vs 11.8%, P < .001). Among LVH patients, degree of quantitative STD did not predict higher short- or long-term mortality, but was associated with in-hospital heart failure. Multivariable analysis adjusting for other clinical prognosticators of the GRACE risk models revealed that LVH was not a significant independent predictor of in-hospital mortality (adjusted odds ratio = 0.75, 95% CI 0.40-1.41, P = .37) or 6-month mortality (adjusted odds ratio = 0.83, 95% CI 0.52-1.35, P = .44). In contrast, STD remained a strong independent predictor of adverse outcomes. There was no significant interaction between STD and LVH. Across the broad spectrum of NSTE-ACS, LVH is associated with adverse prognostic factors including STD. Electrocardiographic-determined LVH provides no significant additional prognostic utility beyond comprehensive risk assessment using the GRACE risk score. The adverse prognosis associated with LVH in NSTE-ACS may be attributable to other prognosticators such as STD.
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