Regression of Electrocardiographic Left Ventricular Hypertrophy During Antihypertensive Treatment and the Prediction of Major Cardiovascular Events

Okin, Peter M.; Devereux, Richard B.; Jern, Sverker; Kjeldsen, Sverre E.; Julius, Stevo; Nieminen, Markku S.; Snapinn, Steven; Harris, Katherine E.; Aurup, Peter; Edelman, Jonathan M.; Wedel, Hans; Lindholm, Lars; Dahlöf, Björn

doi:10.1001/jama.292.19.2343

Cited by 586 publications

(417 citation statements)

References 46 publications

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“…In a substudy of LIFE, lower LVM during antihypertensive treatment was associated with lower rate of clinical end points independent of BP lowering effects. 21 In a separate study, the lack of decrease or the increase in LVM during antihypertensive treatment was associated with increased risk of cardiovascular events. 22 Thirdly, a hypothetical analysis suggests that identifying and regressing LVH in normotensive patients with angina should be worthwhile and cost-effective.…”

Section: Discussionmentioning

confidence: 92%

The electrocardiogram is an unreliable method of identifying left ventricular hypertrophy in stable, treated angina patients

Ang

Struthers

2008

J Hum Hypertens

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In coronary artery disease (CAD), a potentially reversible factor leading to cardiac death is left ventricular hypertrophy (LVH). While the electrocardiogram (ECG) is a widely available way to diagnose LVH, its sensitivity and specificity has never been assessed in this particular patient group where added ischaemic changes on ECG might complicate things. Furthermore, there are at least 11 different ECG criteria proposed to identify LVH. We sought to determine how many cases of echocardiography (echo) LVH would be missed if all of these different ECG criteria were applied in a group of stable, treated angina patients. A total of 241 consecutive patients with angiographically confirmed CAD were prospectively recruited and 11 ECG criteria were assessed on each subject and compared with the presence or absence of LVH on echo. Individual sensitivity, specificity, positive predictive value and negative predictive value were calculated for each ECG LVH criteria. The prevalence of echo LVH in the entire CAD population was 43%. All the proposed ECG criteria were poor at identifying echo LVH. The Cornell product yielded the highest rate of change value but still missed up to 80% of the echo LVH cases. We conclude that in a group of stable, treated angina patients, ECG is an unreliable method of identifying LVH. As LVH is very common in this patient population, screening by means of echo might be indicated. This will enable intensified efforts to ensure LVH regression, which is associated with reduction in both cardiovascular morbidity and mortality.

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Section: Discussionmentioning

confidence: 92%

The electrocardiogram is an unreliable method of identifying left ventricular hypertrophy in stable, treated angina patients

Ang

Struthers

2008

J Hum Hypertens

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“…8,37,38 The results of the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) Study 39 in patients with ECG LVH demonstrated that the risk of cardiovascular morbidity and death, especially the risk of stroke, was lower and reversing LVH more effective in those assigned losartan than assigned atenolol treatment. Regression of LVH by Sokolow-Lyon voltage criteria has been shown to result in a reduction of comorbidity in some 40,41 but not in all studies. 42 In elderly patients with systolic hypertension in the Systolic Hypertension In Europe (Syst-Eur) Trial, a decrease in ECG voltage (RaVL þ SV1 þ RV5) independently predicted a lower incidence of cardiac events.…”

Section: Discussionmentioning

confidence: 94%

Left ventricular hypertrophy determined by Sokolow–Lyon criteria: a different predictor in women than in men?

et al. 2006

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The clinical usefulness of the Sokolow-Lyon voltage criteria in the assessment of electrocardiographic left ventricular hypertrophy (ECG LVH) is addressed. We prospectively studied 3338 women and 3330 men referred with hypertension, with an average follow-up of 11.2 years. The voltage amplitude sum SV1 þ max (RV5 or RV6) was calculated and ECG LVH was defined as a sum X3.5 mV. We adjusted survival for age, treatment status before presentation and a previous myocardial infarction or cerebrovascular accident. The risk of stroke, coronary heart disease (CHD) and cardiovascular disease (CVD) mortality increased significantly for each quantitative 0.1 mV increase in baseline electrocardiogram (ECG) voltage, in women within the range of 1.6-3.9% and in men 1.4-3.0%. After further adjustments for race, body mass index, smoking and systolic blood pressure, increasing voltage independently predicted CVD mortality in both men and women. In women, both increasing voltage and the presence of left ventricular hypertrophy (LVH) were predictors of stroke mortality, whereas in men this risk was attenuated. In men, the adjusted association between increasing voltage and CHD mortality tended to be stronger than in women. The use of different thresholds for the two genders made little difference. For stroke and CHD mortality, the population attributable fractions associated with LVH were 15.2 and 5.4% in women and 12.8 and 8.5% in men, respectively. In conclusion, the greater the baseline ECG voltage sum, the greater the associated CVD mortality risk. Women tended to have a high risk of stroke mortality owing to LVH despite adjustments.

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“…In LIFE, lower Cornell product and Sokolow-Lyon voltage criterion during antihypertensive treatment were associated with lower risk of CV mortality, myocardial infarctions or strokes. 18 These findings were independent of BP reduction or treatment modalities. In HOPE, treatment with the ACE inhibitor, ramipril in a highrisk cohort was associated with significant regression or prevention of ECG LVH (defined using the Sokolow-Lyon voltage criterion).…”

Section: Ecg Lvh Regression and Prognosismentioning

confidence: 88%

“…Consequently, less severe ECG LVH using the above methods translated to a reduced likelihood of subsequent events. 18 It is fair to say that the prognostic value of an increase in voltage is not new as the Framingham Heart Study had previously shown that patients who were diagnosed with LVH at baseline and went on to develop increasing ECG voltage or re-polarization abnormalities had an increased risk of subsequent CV disease events. 19 Nevertheless, it is important to note that previous evidence has not consistently demonstrated the increased risk of CV mortality associated with voltage-only LVH criteria.…”

Section: Voltage Ecg Lvh Criteria As a Prognostic Indicatormentioning

confidence: 99%

The prognostic value of the ECG in hypertension: where are we now?

Ang

Lang

2008

J Hum Hypertens

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In hypertension, the presence of left ventricular hypertrophy (LVH) is associated with increased risk of both cardiovascular morbidity and mortality. To date, the electrocardiogram (ECG) remains the cornerstone of LVH diagnosis in clinical practice because it is universally available, technically easy to perform and highly specific. In the most recent European Society of Hypertension/European Society of Cardiology guidelines for the treatment of arterial hypertension, the Sokolow-Lyon voltage criterion was recommended as part of all routine assessment of subjects with hypertension. However, the use of the ECG in the diagnosis of LVH is somewhat limited by its poor sensitivity. In this review article, we discuss the individual strength and weaknesses of the commonly used ECG criteria in diagnosing LVH. In addition, we present the latest data on the prognostic significance of ECG LVH and the survival differences conferred in different genders. In view of the recent Losartan Intervention for Endpoint Reduction in Hypertension trial, the prognostic benefit of LVH regression will also be addressed. Finally, with the wider availability of echocardiography, the role of combining both modalities to improve risk stratification in hypertension is reviewed.

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Regression of Electrocardiographic Left Ventricular Hypertrophy During Antihypertensive Treatment and the Prediction of Major Cardiovascular Events

Cited by 586 publications

References 46 publications

The electrocardiogram is an unreliable method of identifying left ventricular hypertrophy in stable, treated angina patients

The electrocardiogram is an unreliable method of identifying left ventricular hypertrophy in stable, treated angina patients

Left ventricular hypertrophy determined by Sokolow–Lyon criteria: a different predictor in women than in men?

The prognostic value of the ECG in hypertension: where are we now?

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