Abstract
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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Devereux RB, Koren MJ, de Simone G, Okin PM, Kligfield P . Methods for detection of left ventricular hypertrophy: application to hypertensive heart disease. Eur Heart J 1993; 14 (Suppl D): 8–15.
Levy D, Labib SB, Anderson KM, Christiansen JC, Kannel WB, Castelli WP . Determinants of sensitivity and specificity of electrocardiographic criteria for left ventricular hypertrophy. Circulation 1990; 81: 815–820.
Levy D, Anderson KM, Savage DD, Kannel WB, Christiansen JC, Castelli WP . Echocardiographically detected left ventricular hypertrophy: prevalence and risk factors. The Framingham Heart Study. Ann Intern Med 1988; 108: 7–13.
Romhilt DW, Estes Jr EH . A point-score system for the ECG diagnosis of left ventricular hypertrophy. Am Heart J 1968; 75: 752–758.
Casale PN, Devereux RB, Kligfield P, Eisenberg RR, Miller DH, Chaudhary BS et al. Electrocardiographic detection of left ventricular hypertrophy: development and prospective validation of improved criteria. J Am Coll Cardiol 1985; 6: 572–580.
Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Gattobigio R, Zampi I et al. Prognostic value of a new electrocardiographic method for diagnosis of left ventricular hypertrophy in essential hypertension. J Am Coll Cardiol 1998; 31: 383–390.
Schillaci G, Verdecchia P, Borgioni C, Ciucci A, Guerrieri M, Zampi I et al. Improved electrocardiographic diagnosis of left ventricular hypertrophy. Am J Cardiol 1994; 74: 714–719.
Molloy TJ, Okin PM, Devereux RB, Kligfield P . Electrocardiographic detection of left ventricular hypertrophy by the simple QRS voltage-duration product. J Am Coll Cardiol 1992; 20: 1180–1186.
Sokolow M, Lyon TP . The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads. 1949. Ann Noninvasive Electrocardiol 2001; 6: 343–368.
European Society of Hypertension-European Society of Cardiology Guidelines Committee. European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003; 21: 1011–1053.
Okin PM, Devereux RB, Nieminen MS, Jern S, Oikarinen L, Viitasalo M et al. Electrocardiographic strain pattern and prediction of new-onset congestive heart failure in hypertensive patients: the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) study. Circulation 2006; 113: 67–73.
Lonn E, Mathew J, Pogue J, Johnstone D, Danisa K, Bosch J et al. Relationship of electrocardiographic left ventricular hypertrophy to mortality and cardiovascular morbidity in high-risk patients. Eur J Cardiovasc Prev Rehabil 2003; 10: 420–428.
Larsen CT, Dahlin J, Blackburn H, Scharling H, Appleyard M, Sigurd B et al. Prevalence and prognosis of electrocardiographic left ventricular hypertrophy, ST segment depression and negative T-wave; the Copenhagen City Heart Study. Eur Heart J 2002; 23: 315–324.
Okin PM, Roman MJ, Devereux RB, Kligfield P . Electrocardiographic identification of increased left ventricular mass by simple voltage-duration products. J Am Coll Cardiol 1995; 25: 417–423.
Verdecchia P, Angeli F, Reboldi G, Carluccio E, Benemio G, Gattobigio R et al. Improved cardiovascular risk stratification by a simple ECG index in hypertension. Am J Hypertens 2003; 16: 646–652.
Kannel WB, Gordon T, Offutt D . Left ventricular hypertrophy by electrocardiogram. Prevalence, incidence, and mortality in the Framingham study. Ann Intern Med 1969; 71: 89–105.
Kannel WB, Gordon T, Castelli WP, Margolis JR . Electrocardiographic left ventricular hypertrophy and risk of coronary heart disease. The Framingham study. Ann Intern Med 1970; 72: 813–822.
Okin PM, Devereux RB, Jern S, Kjeldsen SE, Julius S, Nieminen MS et al. Regression of electrocardiographic left ventricular hypertrophy during antihypertensive treatment and the prediction of major cardiovascular events. JAMA 2004; 292: 2343–2349.
Levy D, Salomon M, D'Agostino RB, Belanger AJ, Kannel WB . Prognostic implications of baseline electrocardiographic features and their serial changes in subjects with left ventricular hypertrophy. Circulation 1994; 90: 1786–1793.
Hsieh BP, Pham MX, Froelicher VF . Prognostic value of electrocardiographic criteria for left ventricular hypertrophy. Am Heart J 2005; 150: 161–167.
Kannel WB . Prevalence and natural history of electrocardiographic left ventricular hypertrophy. Am J Med 1983; 75: 4–11.
Okin PM, Devereux RB, Nieminen MS, Jern S, Oikarinen L, Viitasalo M et al. Electrocardiographic strain pattern and prediction of cardiovascular morbidity and mortality in hypertensive patients. Hypertension 2004; 44: 48–54.
Houghton JL, Frank MJ, Carr AA, von Dohlen TW, Prisant LM . Relations among impaired coronary flow reserve, left ventricular hypertrophy and thallium perfusion defects in hypertensive patients without obstructive coronary artery disease. J Am Coll Cardiol 1990; 15: 43–51.
Pringle SD, Macfarlane PW, McKillop JH, Lorimer AR, Dunn FG . Pathophysiologic assessment of left ventricular hypertrophy and strain in asymptomatic patients with essential hypertension. J Am Coll Cardiol 1989; 13: 1377–1381.
de Simone G, Devereux RB, Roman MJ, Ganau A, Saba PS, Alderman MH et al. Assessment of left ventricular function by the midwall fractional shortening/end-systolic stress relation in human hypertension. J Am Coll Cardiol 1994; 23: 1444–1451.
Palmieri V, Okin PM, Bella JN, Wachtell K, Oikarinen L, Gerdts E et al. Electrocardiographic strain pattern and left ventricular diastolic function in hypertensive patients with left ventricular hypertrophy: the LIFE study. J Hypertens 2006; 24: 2079–2084.
Schillaci G, Pirro M, Ronti T, Gemelli F, Pucci G, Innocente S et al. Prognostic impact of prolonged ventricular repolarization in hypertension. Arch Intern Med 2006; 166: 909–913.
Oikarinen L, Nieminen MS, Viitasalo M, Toivonen L, Jern S, Dahlof B et al. QRS duration and QT interval predict mortality in hypertensive patients with left ventricular hypertrophy: the Losartan Intervention for Endpoint Reduction in Hypertension Study. Hypertension 2004; 43: 1029–1034.
Alfakih K, Walters K, Jones T, Ridgway J, Hall AS, Sivananthan M . New gender-specific partition values for ECG criteria of left ventricular hypertrophy: recalibration against cardiac MRI. Hypertension 2004; 44: 175–179.
Liao Y, Cooper RS, McGee DL, Mensah GA, Ghali JK . The relative effects of left ventricular hypertrophy, coronary artery disease, and ventricular dysfunction on survival among black adults. JAMA 1995; 273: 1592–1597.
Dunn FG, McLenachan J, Isles CG, Brown I, Dargie HJ, Lever AF et al. Left ventricular hypertrophy and mortality in hypertension: an analysis of data from the Glasgow blood pressure clinic. J Hypertens 1990; 8: 775–782.
Kannel WB . Left ventricular hypertrophy as a risk factor: the Framingham experience. J Hypertens Suppl 1991; 9: S3–S8; discussion S8–9.
Antikainen RL, Grodzicki T, Palmer AJ, Beevers DG, Webster J, Bulpitt CJ . Left ventricular hypertrophy determined by Sokolow–Lyon criteria: a different predictor in women than in men? J Hum Hypertens 2006; 20: 451–459.
Lang C, Lip G . Complications of hypertension. Cardiology. (Mosby: London) 2001: 489–500.
Okin PM, Roman MJ, Lee ET, Galloway JM, Howard BV, Devereux RB . Combined echocardiographic left ventricular hypertrophy and electrocardiographic ST depression improve prediction of mortality in American Indians: the Strong Heart Study. Hypertension 2004; 43: 769–774.
Sundstrom J, Lind L, Arnlov J, Zethelius B, Andren B, Lithell HO . Echocardiographic and electrocardiographic diagnoses of left ventricular hypertrophy predict mortality independently of each other in a population of elderly men. Circulation 2001; 103: 2346–2351.
Kohsaka S, Sciacca RR, Sugioka K, Sacco RL, Homma S, Di Tullio MR . Additional impact of electrocardiographic over echocardiographic diagnosis of left ventricular hypertrophy for predicting the risk of ischemic stroke. Am Heart J 2005; 149: 181–186.
Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Gattobigio R, Zampi I et al. Prognostic significance of serial changes in left ventricular mass in essential hypertension. Circulation 1998; 97: 48–54.
Mathew J, Sleight P, Lonn E, Johnstone D, Pogue J, Yi Q et al. Reduction of cardiovascular risk by regression of electrocardiographic markers of left ventricular hypertrophy by the angiotensin-converting enzyme inhibitor ramipril. Circulation 2001; 104: 1615–1621.
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Ang, D., Lang, C. The prognostic value of the ECG in hypertension: where are we now?. J Hum Hypertens 22, 460–467 (2008). https://doi.org/10.1038/jhh.2008.24
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DOI: https://doi.org/10.1038/jhh.2008.24
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