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The Prognostic Value of the ECG in Hypertension: Where Are We Now?

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The Prognostic Value of the ECG in Hypertension: Where Are We Now? Journal of Human Hypertension (2008) 22, 460–467 & 2008 Nature Publishing Group All rights reserved 0950-9240/08 $30.00 www.nature.com/jhh REVIEW The prognostic value of the ECG in hypertension: where are we now? DSC Ang and CC Lang Division of Medicine and Therapeutics, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK In hypertension, the presence of left ventricular hyper- review article, we discuss the individual strength and trophy (LVH) is associated with increased risk of both weaknesses of the commonly used ECG criteria in cardiovascular morbidity and mortality. To date, the diagnosing LVH. In addition, we present the latest data electrocardiogram (ECG) remains the cornerstone of on the prognostic significance of ECG LVH and the LVH diagnosis in clinical practice because it is uni- survival differences conferred in different genders. In versally available, technically easy to perform and view of the recent Losartan Intervention for Endpoint highly specific. In the most recent European Society of Reduction in Hypertension trial, the prognostic benefit Hypertension/European Society of Cardiology guide- of LVH regression will also be addressed. Finally, with lines for the treatment of arterial hypertension, the the wider availability of echocardiography, the role of Sokolow–Lyon voltage criterion was recommended as combining both modalities to improve risk stratification part of all routine assessment of subjects with hyperten- in hypertension is reviewed. sion. However, the use of the ECG in the diagnosis of Journal of Human Hypertension (2008) 22, 460–467; LVH is somewhat limited by its poor sensitivity. In this doi:10.1038/jhh.2008.24; published online 24 April 2008 Keywords: electrocardiography; echocardiography; left ventricular hypertrophy; prevalence; prognosis and regression Introduction How good is the ECG in detecting true anatomic LVH? Left ventricular hypertrophy (LVH) diagnosed on electrocardiography (ECG) is an ominous prognostic One major limitation of the ECG is its low sensitivity sign that predicts a high rate of cardiovascular (CV) for detection of LVH.1 For example, the prevalence events. In hypertension, this condition is of parti- of ECG-LVH detected by the Framingham method cular importance because it helps guide risk strati- in the general population was only 2%, which fication. Various ECG criteria for diagnosing LVH compared with a prevalence of 20% when echocar- exist (Table 1). They range from the more widely diography was used.2,3 The sensitivity of the ECG is employed fixed voltage criteria like the Sokolow– also dependant on the population in which it is Lyon criterion (sum of SV1 þ RV5X3.5 mV or max applied. Although the sensitivity of several ECG RV5/6X2.6 mV), the McPhie criterion (the sum of criteria for LVH may be acceptable, albeit low (from the tallest R and deepest S in the precordial 58% for the Romhilt–Estes score4 to 41% for the leadsX4.5 mV) and the gender-specific Cornell Cornell voltage5), among patients with disparate voltage (sum of leads RaVL þ SV3X2.8 mV in men cardiac conditions, the sensitivity of the ECG andX2.0 mV in women) to the more complicated consistently decreases in the general population. Romhilt–Estes score of five points or more, which For example, the sensitivity of the Cornell voltage combines QRS voltage and voltage-independent criterion was only 10% in men and 22% in women signs (QRS duration, intrinsicoid deflection in V5 in the Framingham Heart Study2 and only 12% in or V6, left atrial enlargement, left-axis deviation and men and 19% in women in the Progetto Ipertensione left ventricular (LV) strain). Figure 1 illustrates an Umbria Monitoraggio Ambulatoriale (PIUMA) example of how these commonly used ECG criteria study.6 In a longitudinal study involving 923 are calculated. untreated hypertensive participants, Schillaci et al.7 showed that the performance of the Cornell voltage was superior to the Sokolow–Lyon voltage Correspondence: Dr DSC Ang, Division of Medicine and Thera- criterion in predicting echo LVH. In addition, a peutics, Ninewells Hospital and Medical School, University of modified sex-specific partition value of the Cornell Dundee, Dundee DD1 9SY, UK. E-mail: [email protected] voltage (2.4 mV in men and 2.0 mV in women) Received 23 August 2007; revised 16 March 2008; accepted 21 further improved its predictive value. Subsequent March 2008; published online 24 April 2008 studies evaluated the inclusion of conduction Prognostic value of the ECG in hypertension: where are we now? DSC Ang and CC Lang 461 Table 1 Various ECG LVH criteria employed Name Criteria Cut-point for LVH Sokolow–Lyon voltage SV1+RV5X3.5 mV or max RV5/6 X2.6 mV Cornell voltage RaVL+SV3 X2.8 mV (men) X2.0 mV (women) Modified Cornell voltage RaVL+SV3 X2.4 mV (men) X2.0 mV (women) Framingham adjusted Men: RaVL+SV3+0.0174  (age, 49)+0.191  (BMI, 26.5) X2.8 mV (men) Cornell voltage Women: RaVL+SV3+0.0387  (age, 50)+0.212  (BMI, 24.9) X2.0 mV (women) Minnesota code 3.1 RV5/V642.6 mV, RI/II/III/aVF 42.0 mV or RaVL 41.2 mV Lewis index (RI+SIII)À(RIII+SI) 41.7 mV Gubner and Ungerleider RI+SIII X 2.2 mV Sum of 12 leads Sum of max (R+S) amplitude in each of the 12 leads 417.9 mV McPhie criterion The sum of the tallest R and deepest S in the precordial leads 44.5 mV 12-lead product 12-lead sum voltage  QRS duration 17472 mm  ms Cornell product (RaVL+SV3)  QRS duration 2436 mm  ms Framingham score RI+SIII 42.5 mV, SV1/2+RV5/643.5 mV, SV1/2/342.5 mV+RV4/5/642.5 mV plus left ventricular strain pattern Perugia score Positivity of at least one of the following: (1) SV3+RaVL 4 2.4 mV (2) Left ventricular strain pattern (3) Romhilt–Estes point scoreX5 Romhilt–Estes point score (1) Any limb lead R or S X2.0 mV or X 5 points–definite LVH SV1/2X3.0 mV or RV5/6X3.0 mV (3 points) X 4 points–probable LVH (2) Left ventricular strain pattern (1 point) (3) Left atrial enlargement (3 points) (4) Left axis deviation (5) QRS duration X 90 ms (1 point) (6) Intrinsicoid QRS deflection of X50 ms in V5/6 (1 point) Abbreviations: BMI, body mass index; LVH, left ventricular hypertrophy. abnormalities with voltage criteria to improve the cohorts that have assessed the risk associated with sensitivity of the ECG. The Cornell voltage duration ECG-LVH and these have reinforced in general, the product (Cornell voltage  QRS duration) further prognostic value of ECG-LVH. The prevalence of enhances sensitivity of the ECG while maintaining ECG-LVH and the estimates of risk associated with high specificity, with a sensitivity of 51 versus 31% ECG-LVH vary however, quite considerably in these for Sokolow–Lyon voltage criterion when examined studies and the variability of these estimates is at a matched specificity of 95%.8 Despite this, the related to the different populations studied and the original Sokolow–Lyon voltage criterion9 is the still differences in the diagnostic criteria used to define the most commonly used ECG criterion because ECG-LVH and to define the clinical end points of more complex criteria and scoring systems are interest. Furthermore, in most of these studies, the difficult to apply in clinical practice. The Soko- number of individuals with ECG-LVH and the low–Lyon voltage criterion was successfully used number of outcome events were relatively small, together with the Cornell voltage duration product accounting for difficulties in obtaining precise in detecting patients with LVH in the Losartan estimates of risk, in spite of the large number of Intervention for Endpoint Reduction in Hyperten- subjects studied and the prolonged periods of sion (LIFE) study. On the basis of the LIFE study, the follow-up. It should be noted that there have only European Society of Hypertension guidelines re- been a few published reports on the risk associated commend the use of the Sokolow–Lyon voltage with ECG-LVH based solely on the Sokolow–Lyon criterion and the Cornell voltage duration product voltage criterion. The seminal data for the prognos- for the assessment of LVH.10 A summary of the tic value of the ECG (Sokolow–Lyon voltage criter- epidemiology studies employing various ECG LVH ion) came from the Framingham Heart Study more methods in identifying anatomic LVH is shown in than 35 years ago.16,17 In this longitudinal popula- Table 2. tion-based study, the risk of fatal and nonfatal CV morbid events increased from threefold to eightfold higher in middle-aged persons with ECG-LVH Voltage ECG LVH criteria as a prognostic compared to normal adults of similar age, and this indicator finding remained significant after adjustment for co- existent risk factors. It should be noted that these There have been a number of large population-based findings relate to ST-T abnormalities (LV strain epidemiological studies and studies in hypertensive defined as ST-J point depressionX0.1 mV þinverted Journal of Human Hypertension Prognostic value of the ECG in hypertension: where are we now? DSC Ang and CC Lang 462 Sokolow-Lyon voltage SV1 + RV5 1.5mV + 2.4mV = 3.9mV Cornell voltage RAVL + SV3 1.2mV + 1.0mV = 2.2mV Cornell product (RAVL + SV3) QRS duration 22mm × 130ms = 2860m m ms 12 lead sum 12 lead sum 15.2 mV 12 lead product 12 lead sum of QRS amplitude 152mm × 130ms =19760m m ms McPhie criterion RV4 + SV1 2.7mV + 1.5mV = 4.2mV Gubner-U voltage RI + SIII 1.3mV + 1.1mV = 2.4mV Lewis voltage (RI + SIII) – (RIII + SI) (1.3mV + 1.1mV) – 0mV = 2.4 mV Figure 1 An example of calculating various electrocardiogram (ECG) left ventricular hypertrophy (LVH) criteria of a 67-year-old man with a long-standing history of hypertension.
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