ECG Left Ventricular Hypertrophy Research Articles

Evaluation of sensitivity and specificity of ECG left ventricular hypertrophy criteria in obese and hypertensive patients

Evaluation of sensitivity and specificity of ECG left ventricular hypertrophy criteria in obese and hypertensive patients

A New Inherited Syndrome Causing Sudden Cardiac Death with Distinct ST-Segment Depression and Ankyrin-2-Mutation.

Sudden cardiac death (SCD) is a serious threat. In individuals under the age of 35 years sudden arrhythmic death is the most frequent cause. In younger persons, genetically determined cardiac diseases (eg, cardiomyopathies and ion-channel diseases) account for an important proportion of these cases. We investigated the case of a 23-year-old male with SCD, specific ECG changes and left ventricular hypertrophy. Family history was significant for SCD in the paternal line. A precise analysis was performed by an international multidisciplinary expert panel including autopsy of the index patient's heart, molecular autopsy, whole-exome sequencing, analysis of the pedigree and examination of available family members. Three cases of SCD were reported in paternal relatives. The index patient exhibited specific ECG changes (ST-depression), which were also found in five paternal relatives and the brother of the index patient. Post-mortem analysis of the heart yielded mild idiopathic concentric hypertrophy without myocardial disarray. The genetic analysis of the index patient showed two nucleotide variations in two different genes (ANK2: c.11791G>A, MYO18B: c.3761G>A), which were also expressed in five relatives. Two family members had showed all indicators of the inherited syndrome including distinct ECG changes and genetic changes. We describe a distinct inheritable syndrome causing SCD, characterized by specific ECG changes and mutations of ANK2 and MYO18. As far as we know this is the first description of this syndrome.

FEATURES OF THE ASSOCIATION OF TYPE 2 DIABETES AND ARTERIAL HYPERTENSION IN ELDERLY IN THE AREA OF BLIDA (ALGERIA)

Objective: Arterial hypertension is frequent and serious in elderly diabetic patients, responsible for an increase in cardiovascular risk and an acceleration of the degenerative damage of diabetes. The aim of this study was to determine the characteristics of hypertension with dyslipidemia in elderly diabetics and to study its impact. Design and method: Cohort study, including 1884 type 2 diabetic patients with hypertension aged 65 years old or over, hospitalized in the internal medicine department in Blida (Algeria), between the year 2019 and the year 2022. Results: Most of our patients were female with a sex ratio of 1.62. The mean age was 58±3.2 years. The duration of diabetes was 8.1 ± 2.6 years. The diagnosis of diabetes preceded that of hypertension in 61.4% of cases. Only 10.8% had an HbA1c less than or equal to 7%. The mean BMI was 29.2±3.5 kg/m2. Dyslipidemia was present in 62.2% of our patients with essentially hypoHDLemia (70.5%). Macroangiopathy was observed in 40% of patients with mainly ischemic heart disease (33%). It was significantly more frequent in patients with HbA1c greater than 8.5%, LDL-c greater than or equal to 1.2 g/l and hypoHDLemia. The microangiopathy present in 72% of cases was significantly related to HbA1c, GFR and triglyceride levels. During a 2 years follow-up, we observed 212 deaths. Kaplan-Meier curves demonstrated that total cholesterol level was associated at an increased risk of all-cause and cardiovascular death (p<0.001 for all curves). Then, we performed a multivariate Cox regression analysis adjusted for all cardiovascular risk factors, ECG left ventricular hypertrophy, secondary prevention, MDRD and antihypertensive treatment. Conclusions: Our results confirmed the prognostic value of total cholesterol on long-term mortality in elderly patients with diabetes and hypertension. Complete management of cardiovascular risk factors in elderly subjects reduces cardiovascular morbidity and mortality.

Urinary proteomics combined with home blood pressure telemonitoring for health care reform trial-First progress report.

High blood pressure (BP) and type-2 diabetes (T2DM) are forerunners of chronic kidney disease and left ventricular dysfunction. Home BP telemonitoring (HTM) and urinary peptidomic profiling (UPP) are technologies enabling risk stratification and personalized prevention. UPRIGHT-HTM (NCT04299529) is an investigator-initiated, multicenter, open-label, randomized trial with blinded endpoint evaluation designed to assess the efficacy of HTM plus UPP (experimental group) over HTM alone (control group) in guiding treatment in asymptomatic patients, aged 55-75 years, with ≥5 cardiovascular risk factors. From screening onwards, HTM data can be freely accessed by all patients and their caregivers; UPP results are communicated early during follow-up to patients and caregivers in the intervention group, but at trial closure in the control group. From May 2021 until January 2023, 235 patients were screened, of whom 53 were still progressing through the run-in period and 144 were randomized. Both groups had similar characteristics, including average age (62.0 years) and the proportions of African Blacks (81.9%), White Europeans (16.7%), women 56.2%, home (31.2%), and office (50.0%) hypertension, T2DM (36.4%), micro-albuminuria (29.4%), and ECG (9.7%) and echocardiographic (11.5%) left ventricular hypertrophy. Home and office BP were 128.8/79.2mmHg and 137.1/82.7mmHg, respectively, resulting in a prevalence of white-coat, masked and sustained hypertension of 40.3%, 11.1%, and 25.7%. HTM persisted after randomization (48 681 readings up to 15 January 2023). In conclusion, results predominantly from low-resource sub-Saharan centers proved the feasibility of this multi-ethnic trial. The COVID-19 pandemic caused delays and differential recruitment rates across centers.

S-52-1: CARDIOVASCULAR OUTCOMES IN HYPERTENSIVE PATIENTS WHO DISCONTINUE STUDY MEDICATION IN A LARGE OUTCOME TRIAL. THE LIFE STUDY.

Objective: Patient discontinuation of study medication during an outcome trial has significant implications for study power. However, patients who discontinue cardiovascular outcome trials are not well described. We aimed to assess readily available patient characteristics and outcomes in patients with hypertension and left ventricular hypertrophy (LVH) who discontinued the study drug but otherwise remained in the study until the end of follow-up. Methods: In patients who discontinued vs. those continuing, Cox proportional hazards models identified baseline variables that had a significant impact on the occurrence of the primary composite endpoint (cardiovascular death, stroke, and myocardial infarction) in 9,193 hypertensive patients and LVH in the LIFE study. Results: During a mean follow-up of 4.8 years, 3,281 patients (35.7%) discontinued one or more days during the trial, not counting death as a reason for discontinuation. The distribution of days to discontinuation was highly skewed towards the first part of the study; the 25th percentile was at day 161, and the median was at day 669. Reasons for discontinuation were a clinical adverse event (50%), a secondary study endpoint (19%), required study therapy (11%), withdrawal (2%), administrative (18%), and lost to follow-up (0.2%). Those who discontinued were older, more often male, had slightly lower body mass index, higher systolic and lower diastolic pressure, higher Framingham Risk Score (FRS), and more ECG LVH determined by either Cornell voltage-duration product or Sokolow-Lyon criteria compared to those who continued in the study. Of particular note, the discontinuation rate between the two study drugs was not equal. Patients randomized to losartan discontinued less than those randomized to atenolol. Multivariate analyses showed that older age, male gender, FRS, Sokolow-Lyon criteria, atenolol treatment as well as a history of pre-study myocardial infarction, cerebral vascular disease, peripheral vascular disease, and atrial fibrillation as well as lower levels of hemoglobin, higher serum creatinine and lower cholesterol all independently predicted discontinuation from the study drug. Conclusions: Patients discontinued during the first part of the study mainly due to experience of a clinical adverse event. Patients who discontinued the study drug had, on average, more previous and concurrent cardiovascular disease than those who continued until the study ended. There is no risk reduction and futility if an outcome study recruits patients with too little risk. However, too high risk implies early drug discontinuation and thus reduction in the study power.

Machine learning models of 6-lead ECGs for the interpretation of left ventricular hypertrophy (LVH)

BackgroundLeft Ventricular Hypertrophy (LVH) is closely linked to the cardiovascular disease prognosis, and thus, timely diagnosis improves outcomes. Diagnosis is challenging due to dependency on doctor's visits and a 12‑lead ECG. In addition, the interpretation of LVH from ECGs is challenging due to variability of ECG measurements, body habitus, electrode positioning, several LVH ECG criteria and EP mechanisms. The aims of this study are to evaluate different big data-driven machine learning models for ECG LVH interpretation based on limb leads only, and to compare the performance of an ECG parameter-based statistical model with a deep learning-based model. Methods and dataThe first two models are binary class Random Forest (RF) models, an ensemble learning method which constructs many decision trees at training time and predicts the class chosen by the greatest number of trees at inference time. One random forest is trained using the following five features: lead aVL R-wave amplitude, lead I, II, aVL ST segment amplitude, and QRS duration. The second RF model uses 54 features across all limb leads, including the five features used by the smaller model. The second type of model is a multi-class deep neural network (DNN) which takes median beats of 6 limb leads arranged in Cabrera sequence as input. The signal preprocessing included forming median beats, filtering with a 40-Hz lowpass filter, and down-sampling to 125 Hz. The DNN models consist of 1 lead-formation convolutional layer, 5 downsampling convolutional resnet blocks with skip connections, and 3 fully connected layers. The training dataset consisted of 1 million 10-s 12‑lead ECGs, and an independent test dataset consisted of 250,000 10-s ECGs from the Mayo Clinic. ResultsThe five-parameter RF model has the prediction performance of Area Under the Receiver-Operator Curve (AUC) 0.78, and the larger RF model had AUC of 0.83. The DNN model for ECG LVH detection achieves AUC 0.92 using only the limb leads, compared to an AUC of 0.98 for the full 12‑lead DNN. ConclusionThe study shows that machine learning models trained only on limb leads achieve promising results with potential to add clinical value to early detection mechanisms. We also observe that the RF model splits parameters by thresholds known to be characteristic of LVH, and that the DNN model can automatically detect morphology differences from 6 limb lead ECGs. This will be meaningful for expanding the capabilities of potential electrical LVH detection in mobile 6‑lead ECG devices.

Abstract P221: Cardiovascular Outcomes In Hypertensive Patients Who Discontinue Study Medication In A Large Outcome Trial. The Life Study.

Objective: Patient discontinuation of study medication during a hypertension outcome trial has implications for study power. We aimed to assess patient characteristics and outcomes in patients with hypertension and left ventricular hypertrophy (LVH) who discontinued the study drug but otherwise remained in the study until the end of follow-up. Methods: In patients who discontinued vs. those continuing, Cox proportional hazards models identified baseline variables that had a significant impact on the occurrence of the primary composite endpoint (cardiovascular death, stroke, and myocardial infarction) in 9,193 hypertensive patients and LVH in the LIFE study. Results: During a mean follow-up of 4.8 years, 3,281 patients (35.7%) discontinued one or more days, not counting death as a reason for discontinuation. The distribution of days to discontinuation was highly skewed towards the first part of the study; the 25 th percentile was at day 161, and the median was at day 669. Reasons for discontinuation were a clinical adverse event (50%), a secondary study endpoint (19%), required study therapy (11%), withdrawal (2%), administrative (18%), and lost to follow-up (0.2%). Those who discontinued were older, more often male, had slightly lower body mass index, higher systolic and lower diastolic pressure, higher Framingham Risk Score (FRS), and more ECG LVH determined by either Cornell product or Sokolow-Lyon criteria. Patients randomized to losartan discontinued less than those randomized to atenolol. Multivariate analyses showed that older age, male gender, FRS, Sokolow-Lyon criteria, atenolol treatment as well as a history of pre-study myocardial infarction, cerebral vascular disease, peripheral vascular disease, and atrial fibrillation as well as lower levels of hemoglobin, higher serum creatinine and lower cholesterol independently predicted discontinuation. Conclusions: Patients discontinued during the first part of the study mainly due to a clinical adverse event. Patients who discontinued the study drug had, on average, more previous and concurrent cardiovascular disease than those who continued until the study ended. Thus, too high risk in an outcome study implies early drug discontinuation and thus reduction in the study power.

Interatrial block and P terminal force in the general population – Longitudinal changes, risk factors and prognosis

BackgroundPartial and advanced interatrial block (IAB) and P terminal force (PTF) in lead V1 are markers of atrial remodeling and risk factors for atrial fibrillation (AF). There is a lack of information about constancy and possible factors influencing the development of these P-wave abnormalities. MethodsThe study sample consisted of 6058 Finnish participants (mean age 52.16 ± 14.60 years, 45.0% male) from the general population with an ECG taken in a health examination, and from 3224 of these participants, who had a re-examination 11 years later. Risk factors for incident partial and advanced IAB and PTF were studied using binomial logistic regression analysis, and the prognostic significance of these ECG changes for new AF was studied using time-varying Cox regression analysis. ResultsThe rate of reversal to normal of the studied ECG parameters were 47.4% for partial IAB, 40.0% for advanced IAB and 79.3% for PTF. Age, male sex, hypertension, higher BMI, higher LDL cholesterol, ECG left ventricular hypertrophy, use of beta blocker, and use of angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist were independently associated with a risk to develop incident P-wave abnormality. Partial IAB was independently associated with increased AF risk (HR 1.28 [95% CI 1.04–1.58]), as was also advanced IAB (HR 1.72 [95% CI 1.07–2.75]). ConclusionTraditional cardiovascular risk factors increase the risk of a new P-wave abnormality. Partial and advanced IAB are associated with increased AF risk. Surprisingly, P-wave abnormalities are often reversible during long-term follow-up in the general population.

Implication of Different ECG Left Ventricular Hypertrophy in Patients Undergoing Transcatheter Aortic Valve Replacement.

BackgroundVarious ECG criteria for left ventricular hypertrophy (LVH) have been proposed, but their association with clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement is unknown. We investigated the prevalence of ECG LVH according to different criteria and its prognostic impact on clinical outcomes after transcatheter aortic valve replacement.Methods and ResultsIn this prospective observational cohort, we evaluated 700 patients who underwent transcatheter aortic valve replacement between March 2010 and December 2019. Baseline preprocedural LVH was defined by 3 ECG criteria—Sokolow‐Lyon, Romhilt‐Estes, and Cornell voltage criteria. The primary outcome was major adverse cardiac or cerebrovascular event (MACCE; composite of death, myocardial infarction, stroke, or rehospitalization from cardiovascular cause); the key secondary outcome was all‐cause and cardiovascular mortality. Among 596 eligible patients, the prevalence of LVH was determined as 56.3% by Sokolow‐Lyon, 31.1% by Romhilt‐Estes, and 48.1% by Cornell criteria. Regardless of the criteria, patients with ECG LVH had more severe aortic stenosis hemodynamics and higher left ventricular mass index. After multivariate adjustment, the presence of LVH by the Cornell criteria was significantly associated with lower risks of MACCE (adjusted hazard ratio [HR], 0.68; 95% CI, 0.51–0.91; P=0.009), all‐cause mortality (adjusted HR, 0.55; 95% CI, 0.34–0.90 [P=0.017]), and cardiovascular mortality (adjusted HR, 0.40; 95% CI, 0.20–0.79 [P=0.008]). However, this association was absent with the Sokolow‐Lyon and Romhilt‐Estes criteria.ConclusionsECG LVH by Cornell criteria only was significantly associated with lower risks of MACCE and all‐cause or cardiovascular mortality.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT03298178.

Development and external validation of prognostic models to predict sudden and pump-failure death in patients with HFrEF from PARADIGM-HF and ATMOSPHERE

BackgroundSudden death (SD) and pump failure death (PFD) are the two leading causes of death in patients with heart failure and reduced ejection fraction (HFrEF).ObjectiveIdentifying patients at higher risk for mode-specific death would allow better targeting of individual patients for relevant device and other therapies.MethodsWe developed models in 7156 patients with HFrEF from the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM-HF) trial, using Fine-Gray regressions counting other deaths as competing risks. The derived models were externally validated in the Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure (ATMOSPHERE) trial.ResultsNYHA class and NT-proBNP were independent predictors for both modes of death. The SD model additionally included male sex, Asian or Black race, prior CABG or PCI, cancer history, MI history, treatment with LCZ696 vs. enalapril, QRS duration and ECG left ventricular hypertrophy. While LVEF, ischemic etiology, systolic blood pressure, HF duration, ECG bundle branch block, and serum albumin, chloride and creatinine were included in the PFD model. Model discrimination was good for SD and excellent for PFD with Harrell’s C of 0.67 and 0.78 after correction for optimism, respectively. The observed and predicted incidences were similar in each quartile of risk scores at 3 years in each model. The performance of both models remained robust in ATMOSPHERE.ConclusionWe developed and validated models which separately predict SD and PFD in patients with HFrEF. These models may help clinicians and patients consider therapies targeted at these modes of death.Trial registration numberPARADIGM-HF: ClinicalTrials.gov NCT01035255, ATMOSPHERE: ClinicalTrials.gov NCT00853658.Graphics abstract

A new inherited syndrome causing sudden cardiac death with specific ECG changes and idiopathic left ventricular hypertrophy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Sudden cardiac death (SCD) is a serious threat. In individuals under the age of 35 years sudden arrhythmic death is the most frequent cause. In younger persons, genetically determined cardiac diseases (e.g., cardiomyopathies, ion-channel diseases) account for an important proportion of these cases. Purpose We discovered a unusual combination of ECG changes and left ventricular hypertrophy that lead to a cumulation of sudden cardiac death in a single family. We therefore did a scientific work-up of this finding. Methods We investigated the case of a 23 year-old male with SCD, specific ECG changes and left ventricular hypertrophy (Figure 1). Family history was significant for SCD in the paternal line. A precise analysis was performed by an international multidisciplinary expert panel including autopsy of the index patient’s heart, molecular autopsy, whole exome sequencing, analysis of the pedigree and examination of available family members (Figure 2). Results Three cases of SCD were reported in paternal relatives. The index patient exhibited specific ECG changes (ST-depression), which were also found in five paternal relatives and the brother of the index Patient (Figure 3). Post-mortem analysis of the heart yielded mild idiopathic concentric hypertrophy without myocardial disarray. The genetic analysis of the index patient showed two nucleotide variations in two different genes (ANK2: c.11791G > A , MYO18B: c.3761G > A), which were also expressed in five relatives. Two family members had showed all indicators of the inherited syndrome including specific ECG changes, genetic changes and left ventricular hypertrophy. Conclusions We described a distinct inheritable syndrome causing SCD, characterized by specific ECG changes, idiopathic left ventricular hypertrophy and mutations of ANK2 and MYO18. As far as we know this is the first description of this syndrom. We hypothesize that if all features (ECG-changes, described genetic mutations, left ventricular hypertrophy) are positive, the risk for SCD may be considerably increased. Abstract Figure. ECG of index patient and pedigree

Complementary value of ECG and echocardiographic left ventricular hypertrophy for prediction of adverse outcomes in the general population.

To investigate whether ECG left ventricular hypertrophy (ECG-LVH) has prognostic value independent of echocardiography LVH (Echo-LVH). Participants (N = 9744, mean age, 53.81 ± 10.49 years and 45.5% male) from the Northeast China Rural Cardiovascular Health Study were included. Associations between Echo-LVH (sex-specific left ventricular mass normalized to BSA) and ECG-LVH (diagnosed using the Cornell-voltage duration product) and adverse outcomes were evaluated using Cox regression. The value of ECG-LVH for predicting adverse events was evaluated by reclassification and discrimination analyses. Median follow-up was 4.65 years; 563 participants developed incident stroke or coronary heart disease (CHD) and 402 died. Compared with participants without either condition, those with both Echo-LVH and ECG-LVH had a significantly increased risk of incident stroke or CHD (hazard ratio, 2.42; 95% confidence interval, 1.82-3.22) and mortality (2.58; 1.85-3.60). ECG-LVH remained an independent risk factors for both outcomes when ECG-LVH and Echo-LVH were included in the model as separate variables [incident stroke or CHD (1.43; 1.14-1.79); mortality (1.41; 1.08-1.84)]. Reclassification and discrimination analyses indicated ECG-LVH addition could improve the conventional model for predicting adverse outcomes within 4 years. These relationships persisted after excluding participants with cardiovascular disease history or taking antihypertension drugs or upon applying other ECG-LVH and Echo-LVH diagnostic criteria. Our study provides strong evidence that ECG-LVH is associated with adverse outcomes, independent of Echo-LVH. Clinically, ECG-LVH could be considered as a consequential factor, especially in those with Echo-LVH. These findings have potential clinical relevance for risk stratification.

Association of P-Wave Abnormalities With Sudden Cardiac and Cardiovascular Death: The ARIC Study.

Association of P-Wave Abnormalities With Sudden Cardiac and Cardiovascular Death: The ARIC Study.

Hypertension in adolescents and young adults referred to a tertiary hypertension clinic in Cape Town, South Africa.

To audit the young patients referred to the Hypertension Clinic at Groote Schuur Hospital that predominately serves the underprivileged communities of Cape Town.Folders of patients between the ages of 15 and 30 years over a 2 year period were reviewed. The data collected included demographic, clinical and laboratory data, investigations, causes of hypertension, and presence of hypertensive organ damage.Of the 110 patients reviewed, 61 (55.5%) were females, 22 (20%) Black African, and 88 (80%) of Mixed Ancestry. Eight (7.3%) were found to be normotensive, 16 (14.5%) had a secondary cause and 86 (78.2%) had essential hypertension. Thirty five (31.8%) were current or previous smokers, and 11 (10%) admitted to current or prior use of metamphetamines. A family history of hypertension in a first degree relative was present in 80 (72.7%) patients. Comorbidities present were diabetes in 7 (6.4%) patients, metabolic syndrome in 13 (11.8%), and obesity in 26 (23.6%), but 42.6% had a body mass index (BMI) <25 kg/m2. Chronic kidney disease (CKD) was present in 29 (26.4%) patients and ECG left ventricular hypertrophy in 56 (50.9%). Overall organ damage was present in 72 (65.5%) patients.In this cohort of young hypertensives most patients had essential hypertension with a strong family history. Significant organ damage was identified. High risk behavior, including smoking and illicit drug use, and obesity were identified as contributing factors. Secondary causes were identified in 14.2%. These results suggest a targeted approach to the investigation of young hypertensives for secondary causes, and significant opportunities for lifestyle intervention.

107 Electrocardiographic Characteristics in Fabry Disease; Gender Based Differences

Fabry disease (FD), an X-linked disorder, with α-galactosidase A deficiency results in the accumulation of lysosomal glycosphingolipids. Males >30 years and females >40 years often present with cardiac manifestations, predominantly LV hypertrophy (LVH)1. The aim of our study was to analyse ECG parameters in FD patients, to establish 1) if there were gender differences and 2) determine the sensitivity and specificity of ECG in detecting LVH. Retrospective analysis of ECGs (prior to patients receiving ERT) was performed for FD patients reviewed at Westmead Hospital Genetics Clinic. The cohort (n=50) consisted of 21 females and 29 males (mean age of 41 years for both). The PQ interval corrected for heart rate (HR) was shorter (130.1 ms vs 164.1 ms, p=0.001), the p-wave duration corrected for HR (93.8 ms vs 126.6 ms, p=0.003), and the QRS duration in lead II were shorter (79.3 ms and 96.1 ms, p=0.001) in females vs males. Although more males met the Sokolow-Lyon LVH criteria than females (37.9% vs 19.0%), this was not significant (p=NS). Only males had right bundle branch block compared to females (24.1% vs 0%, p=0.017). 32/50 patients had simultaneous transthoracic echocardiography (TTE) and ECG. There was a significant association between ECG LVH criteria and LVH on TTE (p-value 0.018). The sensitivity of ECG for detecting LVH was 47.1% and the specificity was 93.3%.

Marked variation in heritability estimates of left ventricular mass depending on modality of measurement

Left ventricular (LV) hypertrophy is a strong risk factor for heart failure and cardiovascular death. ECG measures of LV mass are estimated as heritable in twin and family-based analyses and heritability estimates of LV mass measured by echocardiography are lower. We hypothesised that CMR-derived measurements, being more precise than echocardiographic measurements, would advance our understanding of heritable LV traits. We phenotyped 116 British families (427 individuals) by CMR and ECG, and undertook heritability analyses using variance-components (QTDT) and GWAS SNP-based (GCTA-GREML) methods. ECG-based traits such as LV mass and Sokolow-Lyon duration showed substantial estimates of heritability (60%), whereas CMR-derived LV mass was only modestly heritable (20%). However, the ECG LV mass was positively correlated with the lateral diameter of the chest (rho = 0.67), and adjustment for this attenuated the heritability estimate (42%). Finally, CMR-derived right ventricular mass showed considerable heritability (44%). Heritability estimates of LV phenotypes show substantial variation depending on the modality of measurement, being greater when measured by ECG than CMR. This may reflect the differences between electrophysiological as opposed to anatomical hypertrophy. However, ECG LV hypertrophy traits are likely to be influenced by genetic association with anthropometric measures, inflating their overall measured heritability.

Best LVH-ECG criteria for Indonesian hypertensives

Most of available left ventricular hypertrophy electrocardiographic (LVH-ECG) criteria which have different sensitivities and specificities have not been applied in Indonesian population. Left ventricular hypertrophy (LVH) happens as a pathophysiologic adjustment to the increased afterload in arterial hypertension. There are ECG and echocardiogram data gained including 19 hypertensive persons and 6 for control measurements. These criteria were Sokolov Lyon (SL), Cornell Voltages (SV), and Romhillt Estees (SE). ECG LVH was pronounced as mass of LV with index for height at 95 percent as the control. The value of electrocardiographic LVH prevalence found in the hypertensive sick persons with electrocardiographic criteria as 47% for SL, 21% for CV, and 16% for RE. SL criteria had the best sensitivity (80%) while the RE score with specificity of 93% as the best. The best ECG LVH for sensitivity and specificity is Sokolov Lyon criteria which could be the best in ECG criteria for LVH diagnosis in Indonesia.

Sudden Cardiac Death in Hypertensive Patients

In patients with hypertension, but without established cardiovascular disease, predictive factors for sudden cardiac death (SCD) remain undefined. We followed for an average of 10.3 years a cohort of 3242 initially untreated hypertensive patients without evidence of coronary or cerebrovascular heart disease at entry. All patients underwent a complete clinical examination which included ECG and 24-hour ambulatory blood pressure monitoring. At entry, the mean age of patients was 50.0 years, 45% were women, and 6.1% had type 2 diabetes mellitus. Average office blood pressure was 154/96 mm Hg, and average 24-hour ambulatory blood pressure was 136/86 mm Hg. Prevalence of left ventricular hypertrophy at ECG was 13.9%. During follow-up, SCD occurred in 33 patients at a rate of 0.10 per 100 patient-years (95% CI, 0.07-0.14). The rate of SCD was 0.07 and 0.30 per 100 patient-years, respectively, in the cohort of patients without and with ECG left ventricular hypertrophy ( P<0.01). In a multivariable Cox model with Firth penalized maximum bias reduction method for rare outcome events, left ventricular hypertrophy almost tripled the risk of SCD (adjusted hazard ratio, 2.99; 95% CI, 1.47-6.09; P=0.002) after adjustment for age ( P<0.0001), sex ( P=0.019), diabetes mellitus ( P<0.0001), and 24-hour ambulatory pulse pressure ( P=0.036). For each 10 mm Hg increase in 24-hour ambulatory pulse pressure, the risk of SCD increased by 35%. The time-dependent area under the receiver operating characteristic curve was 0.85 (95% CI, 0.74-0.96). We conclude that in patients with hypertension without established cardiovascular disease, age, diabetes mellitus, ECG left ventricular hypertrophy, and 24-hour ambulatory pulse pressure are independent prognostic markers for SCD in the long-term.

Electrocardiography for diagnosis of left ventricular hypertrophy in hypertensive patients with atrial fibrillation

Left ventricular (LV) hypertrophy at electrocardiography (ECG) predicts incident atrial fibrillation (AF). However, the diagnostic performance of ECG for diagnosis of LV hypertrophy in patients with AF is still not well characterized.We analyzed 563 hypertensive patients enrolled in the Umbria-Atrial Fibrillation (Umbria-FA) registry, an ongoing prospective observational registry in patients with AF. All patients underwent ECG and standard echocardiography at their entry in the Register. Mean age was 74 years and 43% of patients were women. Prevalence of ECG-LV hypertrophy, defined by Perugia criterion corrected for body mass index, was 23%. Echocardiographic LV mass was the reference standard. Sensitivity, specificity and diagnostic accuracy of ECG-LV hypertrophy were 37.4% (95% confidence interval [CI]: 31.6–43.4), 90.0% (95% CI: 86.0–93.2) and 64.5% (95% CI: 60.4–68.3), respectively. Performance was comparable in patients with AF or sinus rhythm at ECG recording. The area under the receiver-operating characteristic (ROC) curve was 0.622 (95% CI: 0.580–0.664) in the group with AF and 0.662 (95% CI: 0.605–0.720) in that with sinus rhythm (p ​= ​0.266 for comparison). These data suggest that standard ECG is reliable for diagnosis of LV hypertrophy in patients with a history of AF, regardless of the presence of AF or sinus rhythm at the time of ECG recording.

Prevention of Heart Failure in Hypertension-Disentangling the Role of Evolving Left Ventricular Hypertrophy and Blood Pressure Lowering: The ALLHAT Study.

BackgroundHypertension is a known risk factor for heart failure (HF), possibly via the mechanism of cardiac remodeling and left ventricular hypertrophy (LVH). We studied the extent to which blood pressure (BP) change and evolving LVH contribute to the effect that lisinopril, doxazosin, and amlodipine have on HF compared with chlorthalidone.Methods and ResultsWe conducted causal mediation analysis of ALLHAT (Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial) data (1994‐2002; in‐trial follow‐up). ALLHAT participants with available serial ECGs and BP measurements were included (n=29 892; mean age 67±4 years; 32% black; 56% men): 11 008 were randomized to chlorthalidone, 5967 to doxazosin, 6593 to amlodipine, and 6324 to lisinopril. Evolving ECG LVH and BP lowering served as mediators. Incident symptomatic HF was the primary outcome. Linear regression (for mediator) and logistic regression (for outcome) models were adjusted for mediator‐outcome confounders (demographic and clinical characteristics known to be associated both with both LVH/hypertension and HF). A large majority of participants (96%) had ECG LVH status unchanged, but 4% developed evolving ECG LVH. On average, BP decreased by 11/7 mm Hg. In adjusted Cox regression analyses, progressing ECG LVH (hazard ratio [HR] 1.78 [95% CI 1.43‐2.22]), resolving ECG LVH (HR 1.33 [95% CI 1.03‐1.70]), and baseline ECG LVH (1.17 [95% CI 1.04‐1.31]) carried risk of incident HF. After full adjustment, evolving ECG LVH mediated 4% of the effect of doxazosin on HF. Systolic BP lowering mediated 12% of the effect of doxazosin, and diastolic BP lowering mediated 10% of the effect of doxazosin, 7% of the effect of amlodipine, and borderline 9% of the effect of lisinopril on HF.ConclusionsEvolving ECG LVH and BP change account for 4% to 13% of the mechanism by which antihypertensive medications prevent HF.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.