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Serial Assessment of the Electrocardiographic Strain Pattern for Prediction of Newonset Heart Failure During Antihypertensive Tr European Journal of Heart Failure (2011) 13, 384–391 doi:10.1093/eurjhf/hfq224 Serial assessment of the electrocardiographic strain pattern for prediction of new-onset heart failure during antihypertensive treatment: the LIFE study Peter M. Okin 1*, Lasse Oikarinen 2, Matti Viitasalo 2, Lauri Toivonen 2, Sverre E. Kjeldsen 3,4, Markku S. Nieminen 2, Jonathan M. Edelman 5, Bjo¨ rn Dahlo¨ f 6, and Richard B. Devereux 1 for the LIFE study Investigators 1Greenberg Division of Cardiology, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA; 2Division of Cardiology, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland; 3University of Oslo, Ulleva˚l Hospital, Oslo, Norway; 4University of Michigan Medical Center, Ann Arbor, MI, USA; 5Merck & Co., Inc., North Wales, PA, USA; and 6Department of Medicine, Sahlgrenska University Hospital/O¨ stra, Gothenburg, Sweden Received 16 September 2010; revised 11 October 2010; accepted 14 October 2010; online publish-ahead-of-print 14 January 2011 Aims Although the presence of the electrocardiographic (ECG) strain pattern has been associated with an increased risk of developing heart failure (HF), the relationship of regression vs. persistence vs. development of new ECG strain to subsequent HF is unclear. ..................................................................................................................................................................................... Methods Electrocardiographic strain was evaluated at baseline and at year-1 in 7265 hypertensive patients without HF treated and results with atenolol- or losartan-based regimens. During 3.9 + 0.7 years of follow-up after the year-1 ECG, 154 patients (2.1%) were hospitalized for HF. Five-year HF incidence was lowest in patients with no ECG strain (1.6%), intermedi- ate in patients with regression of strain (5.4%), and highest in patients with persistent (7.1%) or new strain (7.0%; P , 0.0001 across groups). In the Cox multivariable analyses adjusting for the known predictive value of in-treatment ECG left ventricular hypertrophy by the Cornell product and Sokolow–Lyon voltage, in-treatment QRS duration, systolic and diastolic pressure, incident myocardial infarction and atrial fibrillation, randomized treatment and other risk factors for HF, regression of strain [hazards ratio (HR) 2.4, 95% confidence interval (CI) 1.2–5.0], persist- ence of strain (HR 1.9, 95% CI 1.2–3.2), and development of new ECG strain (HR 2.3, 95% CI 1.2–4.4) were all independently associated with an increased risk of new HF compared with the absence of ECG strain on both base- line and year-1 ECGs. ..................................................................................................................................................................................... Conclusion The development of new ECG strain or persistence of ECG strain between baseline and year-1 is associated with an increased risk of HF. The regression of ECG strain between baseline and year-1 does not convey a decreased risk of HF. Clinical trials registration: http://clinicaltrials.gov/ct/show/NCT00338260. ----------------------------------------------------------------------------------------------------------------------------------------------------------- Keywords Electrocardiogram † Hypertension † Hypertrophy Introduction hypertrophy (LVH).1– 7 Electrocardiographic strain is associated with depressed LV function5 and improves ECG detection of struc- The classic strain pattern of lateral ST depression and T-wave tural hypertrophy when incorporated into scores that include stan- inversion on the electrocardiogram (ECG) is a well-recognized dard voltage criteria.2,4 Electrocardiographic strain has been marker of the presence and severity of anatomical left ventricular associated with adverse prognosis in a variety of populations,8– 14 * Corresponding author. Tel: +1 212 746 4688, Fax: +1 212 746 8473, Email: [email protected] Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2011. For permissions please email: [email protected]. ECG strain and new heart failure 385 including hypertensive patients,8,9,12 –14 and has often been the considered consistent with the presence of typical strain when there primary marker of untoward outcomes when ECG LVH criteria was a down-sloping convex ST-segment with an inverted asymmetrical 5,9 have been utilized for risk stratification.8,12,13 Indeed, strain on T-wave with polarity opposite to the main QRS deflection. the baseline ECG was an independent predictor of cardiovascular (CV) morbidity and mortality9 and new-onset heart failure (HF)14 among hypertensive patients with ECG LVH in the LIFE study. Endpoint determination The serial assessment of ECG voltage and voltage–duration Hospitalization for HF was a pre-specified secondary endpoint in the product criteria for LVH has demonstrated that the regression of LIFE study.18,22 The diagnosis of HF was based on clinical and diagnos- ECG LVH appears to confer a decreased risk of CV mortality and tic findings modified from Framingham criteria24 that are outlined in morbidity, including the development of new HF.11 – 13,15 –18 Table 1. Each case was reviewed and verified by the Endpoint Among LIFE study patients,18 a greater than median decrease in Committee, which was blinded to study ECG strain and LVH results 21,22 the Cornell product LVH was associated with a 36% lower adjusted when classifying possible morbid events. risk of HF hospitalization, independent of treatment modality, blood pressure lowering, and other HF risk factors. The persistence or development of new ECG strain were strongly associated with an Statistical methods increased risk of CV morbidity and mortality in the LIFE study19 Data management and analysis were performed with SPSS version 12.0 and with an increased risk of a composite CV endpoint that included software. Data are presented as mean + SD for continuous variables new-onset HF in patients with essential hypertension.12 However, and proportions for categorical variables. Patients were classified whether changes in the ECG strain pattern provide additional prog- into four groups according to the presence or absence of strain at nostic information for HF onset beyond that provided by changes in baseline and year-1 as follows: no strain on either ECG (absence of strain); strain at baseline but not at year-1 (regression of strain); ECG LVH18 and QRS duration20 in the LIFE study population has not strain on both ECGs (persistence of strain); or no strain at baseline been examined. Therefore, the present study examined the relation- and strain at year-1 (development of new strain). Differences in preva- ship of the strain pattern on the baseline and year-1 ECGs in the LIFE lences between groups were compared using x2 analyses and mean study to the risk of HF hospitalization, independent of other HF risk values of continuous variables were compared using one-way factors, treatment effects, blood pressure reduction, and of the ANOVA, with P-values given for the statistical significance of the 20 known effects of in-treatment QRS duration and regression of linear trend across groups. ECG LVH on HF incidence.18 Event rates were calculated and plotted according to the Kaplan– Meier product limit method and statistical significance tested for the linear trend across groups using the log-rank statistic. The relation of Methods strain at baseline and year-1 to the risk of developing new HF was assessed using Cox’s proportional hazards models. Partial residuals Subjects were plotted against survival times and visually examined to check The LIFE study21,22 enrolled hypertensive patients with ECG LVH by the proportional hazards assumption. To test the independence of the Cornell product23 and/or Sokolow–Lyon voltage criteria1 on a serial assessment of ECG strain for incident HF, the presence or screening ECG in a prospective, double-blind study large enough absence of ECG strain at baseline and year-1 was entered into a multi- (n ¼ 9193) to demonstrate an appreciable reduction in mortality and variable Cox model that also included as covariates age, gender, treat- morbid events with the use of losartan as opposed to atenolol.21 Eli- ment group, race, diabetes, history of ischaemic heart disease, gible patients were men and women aged 55–80 years with previously myocardial infarction, stroke, peripheral vascular disease, atrial fibrilla- untreated or treated essential hypertension with mean blood pressure tion and smoking, baseline urinary albumin/creatinine ratio, total and in the range 160–200/95–115 mmHg after 1 and 2 weeks on placebo. HDL cholesterol, glucose, creatinine, uric acid, and body mass index A total of 7265 patients with no history of HF by patient self-report as standard covariates, and baseline and in-treatment values of systolic prior to enrolment or during the first year of treatment in LIFE had and diastolic pressure, QRS duration, the Cornell product, the baseline and year-1 ECGs on which the strain pattern could be deter- Sokolow–Lyon voltage, and incident myocardial infarction and atrial mined (3906 women and 3359 men, mean age 67 + 7 years). fibrillation as time-varying covariates. Analyses were repeated stratifying the population by sex, age, race, Electrocardiography treatment group, history of ischaemic heart disease, prevalent diabetes, and by the presence or absence of LVH by the Cornell product and Hard-copy ECGs were interpreted at
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