Article

Examining QRS amplitude criteria for electrocardiographic left ventricular hypertrophy in recommendations for screening criteria in athletes

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Abstract

Current guidelines for interpretation of the ECGs of athletes recommend that isolated R and S wave amplitudes that exceed traditional criteria for left ventricular hypertrophy be accepted as a physiological response to exercise training. This is based on training and echocardiographic studies but not on long term follow up. Demonstration of the prognostic characteristics of the amplitude criteria in a non-athletic population could support the current guidelines. To evaluate the prognostic value of the R and S wave voltage criteria for electrocardiographic left ventricular hypertrophy (ECG-LVH) in an ambulatory clinical population. The target population consisted of 20,903 ambulatory subjects who had ECGs recorded between 1987 and 1999 and were followed for cardiovascular death until 2013. During the mean follow up of 17years, there were 881 cardiovascular deaths. The mean age was 43±10, 91% were male and 16% were African American. Of the 2482 (12%) subjects who met the Sokolow-Lyon criteria, 241 (1.2%) subjects with left ventricular (LV) strain had an HR of 5.4 (95% CI 4.1-7.2, p<0.001), while 2241 (11%) subjects without strain had an HR of 1.4 (95% CI 1.2-1.8, p<0.001). Of the 4836 (23%) subjects who met the Framingham voltage criteria, 350 (2%) subjects with LV strain had an HR of 5.1 (95% CI 4.0-6.5, p<0.001), while 4486 (22%) subjects without strain had an HR of 1.1 (95% CI 0.9-1.3, p=0.26). The individual components of the Romhilt-Estes had HRs ranging from 1.4 to 3.6, with only the voltage component not being significant (HR 1.1, 95% CI 0.9-1.5, p=0.35). This study demonstrates that the R and S wave voltage criteria components of most of the original classification schema for electrocardiographic left ventricular hypertrophy are not predictive of CV mortality. Our findings support the current guidelines for electrocardiographic screening of athletes. Copyright © 2014 Elsevier Inc. All rights reserved.

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... Interestingly, some resting ECG features, such as sinus bradycardia, first and second (Mobitz I) degree atrioventricular blocks, early repolarization, and isolated high QRS voltages, that are usually found in both amateur and professional athletes, were reported in some studies (8,11). Many ECGs that fulfill the Sokolow-Lyon voltage criteria for LVH in trained athletes have been reported (8,(13)(14)(15)(16). Although the previous finding by Pelliccia et al. (8) verified that there were 20% more abnormal ECGs when using the criterion of an isolated QRS voltage increase, Calore et al. (14) suggested that positive results for an isolated QRS voltage increase should not be used in highly trained athletes when evaluating LVH. ...
... Accordingly, the Sokolow-Lyon criterion (QRS voltage analysis) seems to be inadequate for young competitive athletes (15). Singla et al. (16) confirmed that a high isolated QRS amplitude is a physiological exercise training response, rather than a pathological risk factor, as was postulated for athletes (11). Nevertheless, there is no clear information regarding the usefulness of other ECG criteria or regarding which criteria is the most appropriate for detecting LVH in athletes. ...
... Thus, our results demonstrate that the Sokolow-Lyon criterion should be used with caution, as previously demonstrated (14), and any ECG alteration identified by this set of criteria might mainly be due to physiological adaptations related to exercise training (16). The sport modality subgroup analyses showed higher negative predictive values for the Perugia and Cornell criteria in the LSHD subgroup, mainly when LVDDI and/or septum and/or PWT echocardiographic criteria were used. ...
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OBJECTIVES In athletes, isolated electrocardiogram high voltage criteria are widely used to evaluate left ventricular hypertrophy, but positive findings are thought to represent normal electrocardiogram alterations. However, which electrocardiogram criterion can best detect left ventricular hypertrophy in athletes of various sport modalities remains unknown. METHODS Five electrocardiogram criteria used to detect left ventricular hypertrophy were tested in 180 male athletes grouped according to their sport modality: 67% low-static and high-dynamic components and 33% high-static and high-dynamic components of exercise. The following echocardiogram parameters are the gold standard for diagnosing left ventricular hypertrophy: left ventricular mass index ≥134 g.m⁻², relative wall thickness ≥0.42 mm, left ventricular diastolic diameter index ≥32 mm.m⁻², septum wall thickness ≥13 mm, and posterior wall thickness ≥13 mm. Results for the various criteria were compared using the kappa coefficient. Significance was established at p<0.05. RESULTS Fifty athletes (28%) presented with left ventricular hypertrophy according to electrocardiogram findings, with the following sensitivities and specificities, respectively: 38-53% and 79-83% (Perugia), 22-40% and 89-91% (Cornell), 24-29% and 90% (Romhilt-Estes), 68-87% and 20-23% (Sokolow-Lyon), and 0% and 99% (Gubner). The Perugia and Cornell criteria had higher negative predictive values for the low-static and high-dynamic subgroup. Kappa coefficients were higher for Romhilt-Estes, Cornell and Perugia criteria than for Sokolow-Lyon and Gubner criteria. CONCLUSION All five evaluated criteria are inadequate for detecting left ventricular hypertrophy, but the Perugia, Cornell and Romhilt-Estes criteria are useful for excluding its presence. The Perugia and Cornell criteria were more effective at excluding left ventricular hypertrophy in athletes involved in a sport modality with low-static and high-dynamic component predominance.
... It has been widely used as a standard test for disease identification, risk stratification, and cardiovascular disease management such as arrhythmias [16][17][18][19]. ECG mainly uses the amplitude of the QRS complex as a measure of the classification criteria for screening for LVH [20][21][22][23]. However, it is known to be significantly affected by the thickness of the chest wall [24,25]. ...
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Left ventricular hypertrophy is a significant independent risk factor for all-cause mortality and morbidity, and an accurate diagnosis at an early stage of heart change is clinically significant. Electrocardiography is the most convenient, economical, and non-invasive method for screening in primary care. However, the coincidence rate of the actual left ventricular hypertrophy and diagnostic findings was low, consequently increasing the interest in algorithms using big data and deep learning. We attempted to diagnose left ventricular hypertrophy using big data and deep learning algorithms, and aimed to confirm its diagnostic power according to the differences between males and females. This retrospective study used electrocardiographs obtained at Yonsei University Wonju Severance Christian Hospital, Wonju, Korea, from October 2010 to February 2020. Binary classification was performed for primary screening for left ventricular hypertrophy. Three datasets were used for the experiment: the male, female, and entire dataset. A cutoff for binary classification was defined as the meaningful as a screening test (<132 g/m² vs. ≥132 g/m², <109 g/m² vs. ≥109 g/m²). Six types of input were used for the classification tasks. We attempted to determine whether electrocardiography had predictive power for left ventricular hypertrophy diagnosis. For the entire dataset, the model achieved an area under the receiver operating characteristic (AUROC) curve of 0.836 (95% CI, 0.833–838) with a sensitivity of 78.37% (95% CI, 76.79–79.95). For the male dataset, the AUROC was 0.826 (95% CI, 0.822–830) with a sensitivity of 76.73% (95% CI, 75.14–78.33). For the female dataset, the AUROC was 0.772 (95% CI, 0.769–775) with a sensitivity of 72.90% (95% CI, 70.33–75.46). Our model confirmed that left ventricular hypertrophy can be classified to some extent using electrocardiography, demographics, and electrocardiography features. In particular, a learning environment that considered gender differences was constructed. Consequently, the difference in diagnostic power between men and women was confirmed. Our model will help patients with suspected left ventricular hypertrophy to undergo screening tests at a low cost. In addition, our research and attempts will show the expected effect that gender-consideration approaches can help with various currently proposed diagnostic methods.
... Pathologies that could influence aortic root diameter were considered exclusion criteria (bicuspid aorta, Loeys-Dietz syndrome, Ehler-Danlos syndrome, syphilis, tuberculosis, ankylosing spondylitis, Takayasu arteritis, giant cells arteritis, smoking). Additionally, other exclusion causes were those that could modify electrocardiographic criteria for left ventricular hypertrophy such as athletic hypertrophy due to its controversial results (13,14), stenotic valve disease (15), hypertrophic cardiomyopathy, and congenital heart disease. ECG recordings with complete bundle branch block, myocardial infarction, Wolff-Parkinson-White syndrome, atrial fibrillation, and digitalis used were also excluded. ...
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Introduction: In addition to left ventricular hypertrophy (LVH), dilated aortic root (DAo) is a risk factor for cardiovascular events. There is a lack of a practical index that considers both scenarios. Objective: To assess an electrocardiographic index in DAo and LVH considering echocardiographic guidelines and those values stemming from the chest wall thickness (CT). Methodology: The population
... Pathologies that could influence aortic root diameter were considered exclusion criteria (bicuspid aorta, Loeys-Dietz syndrome, Ehler-Danlos syndrome, syphilis, tuberculosis, ankylosing spondylitis, Takayasu arteritis, giant cells arteritis, smoking). Additionally, other exclusion causes were those that could modify electrocardiographic criteria for left ventricular hypertrophy such as athletic hypertrophy due to its controversial results (13,14), stenotic valve disease (15), hypertrophic cardiomyopathy, and congenital heart disease. ECG recordings with complete bundle branch block, myocardial infarction, Wolff-Parkinson-White syndrome, atrial fibrillation, and digitalis used were also excluded. ...
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Introduction: In addition to left ventricular hypertrophy (LVH), dilated aortic root (DAo) is a risk factor for cardiovascular events. There is a ack of a practical index that considers both scenarios. Objective: To assess an electrocardiographic index in DAo and LVH considering echocardiographic guidelines and those values stemming from the chest wall thickness (CT). Methodology: The population was 631 patients, 236 hypertensives (HT) and 395 non-hypertensives (NHT), the diameter of the aortic root was based on the Phi number and a derived formula CT x 1.33 = Ao, using a cut-off >15%.
... 15 The presence of concomitant T wave inversion (TWi) or ST segment depression in the inferior and/or lateral leads, atrial enlargement, QrS axis deviation, pathological Q waves, should however raise suspicion for hypertrophic cardiomyopathy (HCM). 15,[34][35][36][37] Voltage criteria for right ventricular hypertrophy (rVH) (r wave in lead V 1 and S wave in lead V 5 /V 6 >1.05 mV) is identified in at least 10% of healthy athletes 38 and does not warrant axis and an inadequate increase in sinus rate following mild exercise are all useful in confirming cardiac conduction tissue disease. This eCg pattern is uncommon in healthy athletes and should always be evaluated fully for the possibility of conduction disease. ...
Article
Participation in regular exercise of moderate intensity is associated with a plethora of systemic benefits, including a reduction in risk factors for coronary atherosclerosis; however, intensive exercise may paradoxically culminate in sudden cardiac arrest among individuals harboring arrhythmogenic substrates. The precise mechanism for arrhythmogenesis is likely multifactorial, however, surges in catecholamines, electrolyte shifts, acid-base disturbances, increased core temperature and demand myocardial ischemia are potential contributors. Although most deaths occur in middle aged and older males with atherosclerotic coronary artery disease, a significant proportion also affect young athletes with inherited or congenital cardiac abnormalities. The impact of such catastrophes on society, particularly when a young high-profile athlete is affected could be considered a justified reason for identifying individuals who may be at risk. Given the rarity of deaths in young athletes, only the simplest screening test, such as the 12-lead electrocardiography (ECG) may be considered to be cost effective. The ECG is effective for detecting serious electrical diseases in young athletes such as congenital electrical accessory pathways and ion channel diseases but can also identify athletes with potential life-threatening structural diseases such as hypertrophic and arrhythmogenic cardiomyopathy. One of the concerns about ECG screening is that regular intensive exercise results in several physiological alterations in cardiac structure and function that are reflected on the athlete’s ECG. Sinus bradycardia, first-degree atrioventricular block, incomplete right bundle branch block, minor J-point elevation and large QRS voltages are common. Conversely, some repolarization anomalies affecting the ST segment, T waves and QT interval may overlap with patterns observed in patients with serious cardiac diseases. The situation is complicated further because age, sex and ethnicity of the athletes also influence the ECG and there is a risk that erroneous interpretation could have serious consequences. This review will describe the normal electrical patterns of the “athlete’s heart” and provide insights into differentiation physiological electrical patterns from those observed in serious cardiac disease.
... Voltage criteria for LVH in athletes are not accompanied by ST-segment depression or T-wave inversion (TWI) in the lateral leads. In contrast, most individuals with hypertrophic cardiomyopathy (HCM) reveal concomitant abnormalities such as axis deviation, left atrial enlargement, TWI in the inferolateral leads, ST-segment depression and pathological Q waves [1,[22][23][24][25]. Only 2% of patients with HCM have isolated Sokolow-Lyon voltage criterion for LV hypertrophy [9,24,26]. ...
Chapter
Exercise-related sudden death from a previously quiescent cardiac disorder is a highly visible event, particularly when a high-profile athlete is affected. A comprehensive assessment to identify the diverse spectrum of potential causes is cost-prohibitive, given the rarity of such catastrophes. The 12-lead ECG, which is among the simplest of cardiac diagnostic tests, is effective at detecting electrical faults and raise suspicion of structural heart disease; however, participation in regular intensive exercise is associated with physiological, electrical and structural adaptations within the heart that are manifest on the surface ECG and may overlap with disease processes. Such athletes pose a diagnostic dilemma whereby erroneous interpretation of the ECG and subsequent tests has potentially serious consequences. Furthermore, ECG findings in athletes are influenced by age, sex, ethnicity and type of sport. The aim of this chapter is to provide an overview of electrical changes that are considered normal in athletes, after accounting for demographics, and those that should be investigated to exclude serious cardiac disease.
... Voltage criteria for LVH in athletes are not accompanied by ST-segment depression or T-wave inversion (TWI) in the lateral leads. In contrast, most individuals with hypertrophic cardiomyopathy (HCM) reveal concomitant abnormalities such as axis deviation, left atrial enlargement, TWI in the inferolateral leads, ST-segment depression and pathological Q waves [1,[22][23][24][25]. Only 2% of patients with HCM have isolated Sokolow-Lyon voltage criterion for LV hypertrophy [9,24,26]. ...
Chapter
Exercise-related sudden death from a previously quiescent cardiac disorder is a highly visible event, particularly when a high-profile athlete is affected. A comprehensive assessment to identify the diverse spectrum of potential causes is cost-prohibitive, given the rarity of such catastrophes. The 12-lead ECG, which is among the simplest of cardiac diagnostic tests, is effective at detecting electrical faults and raise suspicion of structural heart disease; however, participation in regular intensive exercise is associated with physiological, electrical and structural adaptations within the heart that are manifest on the surface ECG and may overlap with disease processes. Such athletes pose a diagnostic dilemma whereby erroneous interpretation of the ECG and subsequent tests has potentially serious consequences. Furthermore, ECG findings in athletes are influenced by age, sex, ethnicity and type of sport. The aim of this chapter is to provide an overview of electrical changes that are considered normal in athletes, after accounting for demographics, and those that should be investigated to exclude serious cardiac disease.
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Left ventricular hypertrophy, particularly on the electrocardiogram, is an ominous, not an incidental accompaniment of hypertension and cardiovascular disease. The prevalence of electrocardiographic left ventricular hypertrophy increases with age with a slight male predominance, and one in 10 persons aged 30 to 62 can expect to have it within 12 years. At any age, cardiac enlargement on roentgenograms is twice as prevalent as electrocardiographic left ventricular hypertrophy, and in only 16 percent of those with x-ray evidence of cardiac enlargement does electrocardiographic left ventricular hypertrophy subsequently develop. Hypertension predisposes and at systolic pressures exceeding 180 mm Hg evidence of electrocardiographic left ventricular hypertrophy develops in 50 percent, with no closer relation to diastolic, than to systolic pressure. In addition to drastic curtailment of life expectancy, electrocardiographic left ventricular hypertrophy is a harbinger of serious cardiovascular disease. Definite electrocardiographic left ventricular hypertrophy is associated with an eightfold increase in cardiovascular mortality and a sixfold increase in coronary mortality. Electrocardiographic left ventricular hypertrophy with repolarization criteria more than doubles the risk of hypertension alone and carries a greater risk of cardiovascular morbidity and mortality than cardiac enlargement. It identifies hypertensive patients with a compromised coronary circulation and myocardial damage. Risk of stroke, cardiac failure, and every clinical manifestation of coronary heart disease is substantially increased. In those with electrocardiographic left ventricular hypertrophy risk of cardiac failure is three times that in those with hypertension alone. Electrocardiographic left ventricular hypertrophy based solely on voltage criteria reflects chiefly the severity and duration of associated hypertension, carrying only half the cardiovascular risk of electrocardiographic left ventricular hypertrophy with repolarization abnormality. The precise pathologic and anatomic meaning of electrocardiographic left ventricular hypertrophy is unclear in view of the modest correlations with anatomic, x-ray, ventriculographic, and electrocardiographic measures of cardiac hypertrophy. The electrocardiographic aberrations are as much a product of myocardial damage as hypertrophy, and their appearance must be regarded as a grave prognostic sign in the course of cardiovascular disease.
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To date there has been no comprehensive review of the association between left ventricular hypertrophy (LVH) at baseline and subsequent adverse clinical events. A total of 20 studies (with 48,545 participants) published between January 1960 and January 2000, identified through MEDLINE and other sources, related baseline electrocardiographic (ECG) or echocardiographic data on LVH to subsequent cardiovascular morbidity and all-cause mortality. The prevalence of baseline LVH was higher in echocardiographic studies than in ECG studies (16%-74% vs 1%-44%, respectively). The adjusted risk of future cardiovascular morbidity associated with baseline LVH ranged from 1.5 to 3.5, with a weighted mean risk ratio of 2.3 for all studies combined. The adjusted risk of all-cause mortality associated with baseline LVH ranged from 1.5 to 8.0, with a weighted mean risk ratio of 2.5 for all studies combined. There was a trend toward a worse prognosis among women with baseline LVH compared with men. These findings persisted in the various population and ethnic groups studied. With the exception of one study in dialysis patients, LVH consistently predicted high risk, independently of examined covariates, with no clear difference in relation to race, presence or absence of hypertension or coronary disease, or between clinical and epidemiologic samples. These results clarify the strong relation between LVH and adverse outcome and emphasize the clinical importance of its detection.
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Given renewed interest in the primary prevention of cardiovascular disease, we comprehensively reviewed the utility of the electrocardiogram (ECG) for screening considering the seminal epidemiologic studies. It appears that conventional risk factors relate to long-term risk, while ECG abnormalities are better predictors of short-term risk. For individual ECG abnormalities as well as for pooled categories of ECG abnormalities, the sensitivity of the ECG for future events was too low for it to be practical as a screening tool. This almost certainly relates to the low prevalence of these abnormalities. However, all ECG abnormalities increase with age and pre-test risk. Also screening with the ECG is of minimal cost and likely to decrease further as stand-alone machines are replaced by integration into personal computers (PC). Another potential impact on performing screening ECGs would be distribution and availability of digitized ECG data via the World Wide Web. For clinical utility of ECG data, comparison with previous ECGs can be critical but is currently limited. PC based ECG systems could very easily replace many of the ECG machines in use that only have paper output. PC-ECG systems would also permit interaction with computerized medical information systems, facilitate emailing and faxing of ECGs as well as storage at a centralized web-server. Web-enabled ECG recorders similar to the new generation of home appliances could follow this quick PC solution. A serious goal for the medical industry should be to end the morass of proprietary ECG digital formats and follow a standardized format. This could lead to a network of web-servers from which every patient's ECGs would be available. Such a situation could have a dramatic effect on the advisability of performing screening ECGs.
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1. A statistical study is presented of the unipolar precordial and augmented limb leads in 147 cases of left ventricular hypertrophy. 2. The patterns of left ventricular hypertrophy are described with particular attention to the early abnormalities found (depressed RS-T segment with flat or low diphasic T waves, abnormally high voltage of the QRS complex, and delayed onset of the intrinsic deflection). 3. The characteristic and diagnostic changes in the precordial leads found in the cases of left ventricular hypertrophy studied include, in order of frequency: (a) A depressed RS-T segment and asymmetric inversion of the T wave in Lead V5 of V6. In early cases, the T wave may be low and diphasic or flat in association with depression of the RS-T segment. (b) Abnormalities in voltage of the QRS complex in which the R wave in V5 or V6 exceeds 26 mm. and/or the sum of the R wave in V5 and the S wave in V1 exceeds 35 mm. (c) The onset of the intrinsic deflection (the ventricular activation time) exceeds 0.05 second in Lead V5 or V6. 4. The same characteristics noted in V5 and V6 often appear in aVL in horizontal hearts and in aVF in vertical hearts. The changes in these unipolar extremity leads usually are less striking but occasionally may be more abnormal than the changes in the precordial leads. 5. Abnormalities in the left arm lead (aVL usually are reflected in Lead I, and the pattern of left ventricular hypertrophy in the standard leads described as "typical" in the literature occurs in individuals with horizontal hearts. The abnormalities seen in Lead aVL usually are more striking than those found in Lead I. 6. Abnormalities in the left leg lead (aVF) usually are reflected in Lead II and III, but to a lesser degree. Individuals with abnormalities in these leads have been shown to have vertical hearts and the standard leads will disclose no axis deviation or right axis deviation, and the pattern described in the literature as "atypical" will appear. 7. The diagnostic significance of the voltage of the left ventricular potentials as reflected by the sum of the R wave in V5 or V6 and the S wave in V1 is emphasized. Thirty-two per cent of patients with left ventricular hypertrophy had the sum of these two potentials exceed 35 mm., whereas in no normal person did this sum exceed 35 mm.; in 96 per cent of normal individuals the sum was found to be below 30 millimeters. 8. The voltage of the R wave in V5 and in aVL was helpful in the diagnosis of left ventricular hypertrophy. In 20 per cent of the patients with left ventricular hypertrophy, the voltage of R exceeded 26 mm. in V5 and in 22 per cent this voltage exceeded 10 mm. in aVL the maximum values found in normal subjects according to our data. 9. The importance of the time of onset of the intrinsic deflection (ventricular activation time) is discussed. In 35 per cent of patients with left ventricular hypertrophy the ventricular activation time was 0.06 second or more, in contrast to the fact that this delayed time was not encountered in any of 150 normal subjects. 10. In the evaluation of left axis deviation and RST-T abnormalities in the standard limb leads, unipolar extremity and precordial leads are confirmatory and often of critical diagnostic importance. 11. Horizontal or semihorizontal hearts were found in eighty-three (56 per cent) while vertical or semivertical hearts were found in thirty-two (22 per cent) of the patients with left ventricular hypertrophy in this series. 12. Low T waves were frequently noted in Leads V5 and V6 in association with tall R waves, resulting in a high R/T ratio. Fifty per cent of the patients in this series had an R/T ratio in V5 and/or V6 exceeding the maximum ratio of 10 found in the normal subjects.
Article
To evaluate the prevalence and the independent prognosis of electrocardiographic left ventricular hypertrophy by voltage only, ST depression and negative T wave, isolated negative T wave and left ventricular hypertrophy plus ST depression and negative T wave for cardiac morbidity and mortality, without known ischaemic heart disease at baseline. METHODS and Follow-up data from the Copenhagen City Heart Study were used. Subjects were 5243 men and 6391 women, age range 25-74 years. End-points were (1) myocardial infarction, (2) ischaemic heart disease and (3) cardiovascular disease mortality. Relative risk was age- and sex-adjusted, and multivariately adjusted for known cardiovascular risk factors. During 7 years follow-up, left ventricular hypertrophy plus ST depression and negative T wave had an age-adjusted relative risk of 3.78 (95% confidence interval 2.29-6.25) for myocardial infarction, 4.27 (2.95-6.16) for ischaemic heart disease and 3.75 (2.41-5.85) for cardiovascular disease. A negative T wave, ST depression and negative T wave changes, and left ventricular hypertrophy with negative T wave also carry independent prognostic information for myocardial infarction, ischaemic heart disease and cardiovascular disease. Electrocardiographic left ventricular hypertrophy with ST depression and negative T wave changes are the electrocardiographic abnormalities with the greatest prognostic information for future cardiac events. Electrocardiographic negative T waves, ST depression and negative T wave abnormalities and left ventricular hypertrophy with negative T waves, also have prognostic information.
Article
Many electrocardiographic (ECG) criteria for left ventricular hypertrophy (LVH) exist, but few studies have compared their relative prognostic value for predicting cardiovascular (CV) mortality. We analyzed the first ECG on 46950 consecutive veterans. We targeted male outpatients with a body mass index > 20 to avoid confounding by complicating catabolic illnesses and further excluded those with conduction abnormalities. Using Cox regression models adjusted for age, heart rate, and body mass index, we compared the hazard ratios (HRs) for CV mortality obtained from seventeen commonly used ECG criteria for LVH. During a mean follow-up of 7 +/- 4 years, in a total population of 19434 patients (mean age 54 +/- 14 years), 1254 (6%) patients died of CV causes. The adjusted HR for CV mortality ranged from 1.4 (95% CI 1.2-1.6) to 3.7 (95% CI 2.7-5.0) among the various criteria. Left ventricular hypertrophy defined by composite criteria was generally associated with higher adjusted HRs compared with voltage-only criteria. Among patients with ECG-LVH, the presence of a left ventricular strain pattern or increased negative P-terminal force were most predictive of CV mortality (HR 3.9 and 3.5, 95% CI 3.3-4.6 and 2.8-4.2). Compared with voltage-only criteria for detecting LVH, composite ECG criteria are more strongly predictive of CV mortality. By applying these ECG criteria into routine clinical practice, individuals with LVH who are at higher risk for CV mortality can be identified and appropriately treated.