open access

Vol 27, No 4 (2023)
Original paper
Published online: 2023-09-11
Get Citation

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

Szymon Salamaga1, Iwona Juszczyk1, Franciszek Dydowicz1, Mateusz Matyjasek1, Agnieszka Turowska1, Dawid Lipski1, Regina Pawlak-Chomicka1, Andrzej Tykarski1, Paweł Uruski1
·
Arterial Hypertension 2023;27(4):223-231.
Affiliations
  1. Department of Hypertensiology, Angiology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland

open access

Vol 27, No 4 (2023)
ORIGINAL PAPERS
Published online: 2023-09-11

Abstract

Background: Left ventricular hypertrophy (LVH) is a well-known risk factor for cardiovascular events. Even though, there are many electrocardiographic (ECG) criteria for LVH, they still provide poor performance, especially among obese patients. The aim of this study was to examine the sensitivity and specificity in obese and nonobese patients, with obesity defined using body mass index (BMI), visceral fat level (VFATL) and waist hip ratio (WHR).

Material and methods: Overall, 1722 patients were included in the study. All patients underwent complete physical examination, office blood pressure measurement, analysis of body composition, 12-lead ECG, M-mode two-dimensional echocardiography. Six standard ECG criteria for LVH were analyzed, including: Cornell voltage criteria, Cornell duration criteria, Sokolow- Lyon voltage criteria, Sokolow-Lyon product criteria, R I + S III and R wave of aVL. Sensitivity and specificity of those criteria was evaluated for patients with and without obesity. Transthoracic echocardiography was used as a reference method to detect LVH.

Results: In obese patients, Cornell duration criteria showed the best performance and should be used in detecting LVH. Increased amount of adipose tissue and presence of obesity, defined by different indicators, decreased sensitivity and specificity values of ECG criteria; however, only several criteria showed statistical significance. Sokolov-Lyon voltage and Cornel voltage were evaluated to have good sensitivity in nonobese women patients, but their performance was insufficient in obese women.

Conclusion: LVH should not be diagnosed using ECG criteria without assessment of patients obesity. Preferred parameter, from discussed in this study, to assess patients obesity is VFATL.

Abstract

Background: Left ventricular hypertrophy (LVH) is a well-known risk factor for cardiovascular events. Even though, there are many electrocardiographic (ECG) criteria for LVH, they still provide poor performance, especially among obese patients. The aim of this study was to examine the sensitivity and specificity in obese and nonobese patients, with obesity defined using body mass index (BMI), visceral fat level (VFATL) and waist hip ratio (WHR).

Material and methods: Overall, 1722 patients were included in the study. All patients underwent complete physical examination, office blood pressure measurement, analysis of body composition, 12-lead ECG, M-mode two-dimensional echocardiography. Six standard ECG criteria for LVH were analyzed, including: Cornell voltage criteria, Cornell duration criteria, Sokolow- Lyon voltage criteria, Sokolow-Lyon product criteria, R I + S III and R wave of aVL. Sensitivity and specificity of those criteria was evaluated for patients with and without obesity. Transthoracic echocardiography was used as a reference method to detect LVH.

Results: In obese patients, Cornell duration criteria showed the best performance and should be used in detecting LVH. Increased amount of adipose tissue and presence of obesity, defined by different indicators, decreased sensitivity and specificity values of ECG criteria; however, only several criteria showed statistical significance. Sokolov-Lyon voltage and Cornel voltage were evaluated to have good sensitivity in nonobese women patients, but their performance was insufficient in obese women.

Conclusion: LVH should not be diagnosed using ECG criteria without assessment of patients obesity. Preferred parameter, from discussed in this study, to assess patients obesity is VFATL.

Get Citation

Keywords

obesity; left ventricular hypertrophy; electrocardiography; hypertension

About this article
Title

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

Journal

Arterial Hypertension

Issue

Vol 27, No 4 (2023)

Article type

Original paper

Pages

223-231

Published online

2023-09-11

Page views

577

Article views/downloads

201

DOI

10.5603/ah.96273

Bibliographic record

Arterial Hypertension 2023;27(4):223-231.

Keywords

obesity
left ventricular hypertrophy
electrocardiography
hypertension

Authors

Szymon Salamaga
Iwona Juszczyk
Franciszek Dydowicz
Mateusz Matyjasek
Agnieszka Turowska
Dawid Lipski
Regina Pawlak-Chomicka
Andrzej Tykarski
Paweł Uruski

References (37)
  1. Kopelman PG. Obesity as a medical problem. Nature. 2000; 404(6778): 635–643.
  2. Vaamonde JG, Álvarez-Món MA. Obesity and overweight . Medicine. 2020; 13(14): 767–777.
  3. Zhao Y, Qie R, Han M, et al. Association of BMI with cardiovascular disease incidence and mortality in patients with type 2 diabetes mellitus: A systematic review and dose-response meta-analysis of cohort studies. Nutr Metab Cardiovasc Dis. 2021; 31(7): 1976–1984.
  4. Cuspidi C, Rescaldani M, Sala C, et al. Left-ventricular hypertrophy and obesity: a systematic review and meta-analysis of echocardiographic studies. J Hypertens. 2014; 32(1): 16–25.
  5. Cuspidi C, Sala C, Grassi G. Detection of left ventricular hypertrophy in obesity: mission impossible? J Hypertens. 2013; 31(2): 256–258.
  6. Rodrigues JCL, McIntyre B, Dastidar AG, et al. The effect of obesity on electrocardiographic detection of hypertensive left ventricular hypertrophy: recalibration against cardiac magnetic resonance. J Hum Hypertens. 2016; 30(3): 197–203.
  7. Nomsawadi V, Krittayaphong R. Diagnostic performance of electrocardiographic criteria for left ventricular hypertrophy among various body mass index groups compared to diagnosis by cardiac magnetic resonance imaging. Ann Noninvasive Electrocardiol. 2019; 24(4): e12635.
  8. Salamaga S, Dydowicz F, Turowska A, et al. Visceral fat level correction of the left ventricular hypertrophy electrocardiographic criteria. Ann Noninvasive Electrocardiol. 2021; 26(6): e12863.
  9. Bottini PB, Carr AA, Prisant LM, et al. Magnetic resonance imaging compared to echocardiography to assess left ventricular mass in the hypertensive patient. Am J Hypertens. 1995; 8(3): 221–228.
  10. Marwick TH, Gillebert TC, Aurigemma G, et al. Recommendations on the use of echocardiography in adult hypertension: a report from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE)†. Eur Heart J Cardiovasc Imaging. 2015; 16(6): 577–605.
  11. Cuspidi C, Sala C, Tadic M, et al. Left-ventricular hypertrophy and obesity: a systematic review and meta-analysis of echocardiographic studies. J Hypertens. 2014; 32(1): 16–25.
  12. Cuspidi C, Meani S, Negri F, et al. Indexation of left ventricular mass to body surface area and height to allometric power of 2.7: is the difference limited to obese hypertensives? J Hum Hypertens. 2009; 23(11): 728–734.
  13. Fraley MA, Birchem JA, Senkottaiyan N, et al. Obesity and the electrocardiogram. Obes Rev. 2005; 6(4): 275–281.
  14. Bakkum MJ, Danad I, Romijn MAJ, et al. The impact of obesity on the relationship between epicardial adipose tissue, left ventricular mass and coronary microvascular function. Eur J Nucl Med Mol Imaging. 2015; 42(10): 1562–1573.
  15. Hancock EW, Deal BJ, Mirvis DM, et al. American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology, American College of Cardiology Foundation, Heart Rhythm Society. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2009; 53(11): 992–1002.
  16. Madias JE. Apparent electrocardiogram left ventricular hypertrophy during tachycardia. J Electrocardiol. 2021; 65: 3–7.
  17. Jimenez E, El-Bokl A, Cortez D. Vectorcardiography as a prognostic tool in hypertrophic cardiomyopathy. J Electrocardiol. 2021; 68: 80–84.
  18. Kim DH, Verdino RJ. Electrocardiogram voltage discordance: Interpretation of low QRS voltage only in the precordial leads. J Electrocardiol. 2017; 50(5): 551–554.
  19. Rider OJ, Ntusi N, Bull SC, et al. Improvements in ECG accuracy for diagnosis of left ventricular hypertrophy in obesity. Heart. 2016; 102(19): 1566–1572.
  20. Bacharova L, Szathmary V, Potse M, et al. Computer simulation of ECG manifestations of left ventricular electrical remodeling. J Electrocardiol. 2012; 45(6): 630–634.
  21. Lu N, Zhu JX, Yang PX, et al. Models for improved diagnosis of left ventricular hypertrophy based on conventional electrocardiographic criteria. BMC Cardiovasc Disord. 2017; 17(1): 217.
  22. Mincholé A, Zacur E, Ariga R, et al. MRI-Based Computational Torso/Biventricular Multiscale Models to Investigate the Impact of Anatomical Variability on the ECG QRS Complex. Front Physiol. 2019; 10: 1103.
  23. You Z, He T, Ding Y, et al. Predictive value of electrocardiographic left ventricular hypertrophy in the general population: A meta-analysis. J Electrocardiol. 2020; 62: 14–19.
  24. Domain G, Chouquet C, Réant P, et al. Relationships between left ventricular mass and QRS duration in diverse types of left ventricular hypertrophy. Eur Heart J Cardiovasc Imaging. 2022; 23(4): 560–568.
  25. Cuspidi C, Sala C, Grassi G. Detection of left ventricular hypertrophy in obesity: mission impossible? J Hypertens. 2013; 31(2): 256–258.
  26. Domienik-Karłowicz J, Lichodziejewska B, Lisik W, et al. Electrocardiographic criteria of left ventricular hypertrophy in patients with morbid obesity. Ann Noninvasive Electrocardiol. 2011; 16(3): 258–262.
  27. Rodrigues JCL, McIntyre B, Dastidar AG, et al. The effect of obesity on electrocardiographic detection of hypertensive left ventricular hypertrophy: recalibration against cardiac magnetic resonance. J Hum Hypertens. 2016; 30(3): 197–203.
  28. Horton JD, Sherber HS, Lakatta EG. Distance correction for precordial electrocardiographic voltage in estimating left ventricular mass: an echocardiographic study. Circulation. 1977; 55(3): 509–512.
  29. Okin PM, Roman MJ, Devereux RB, et al. Electrocardiographic identification of left ventricular hypertrophy: test performance in relation to definition of hypertrophy and presence of obesity. J Am Coll Cardiol. 1996; 27(1): 124–131.
  30. Nevill AM, Duncan MJ, Myers T. BMI is dead; long live waist-circumference indices: But which index should we choose to predict cardio-metabolic risk? Nutr Metab Cardiovasc Dis. 2022; 32(7): 1642–1650.
  31. Cuspidi C, Facchetti R, Bombelli M, et al. Does QRS Voltage Correction by Body Mass Index Improve the Accuracy of Electrocardiography in Detecting Left Ventricular Hypertrophy and Predicting Cardiovascular Events in a General Population? J Clin Hypertens (Greenwich). 2016; 18(5): 415–421.
  32. Elffers TW, Trompet S, de Mutsert R, et al. Electrocardiographic Detection of Left Ventricular Hypertrophy; Adding Body Mass Index and Spatial QRS-T Angle: A Cross-Sectional Study. Cardiol Ther. 2019; 8(2): 345–356.
  33. Zheng X, Han L, Shen S, et al. Association between visceral adiposity index and chronic kidney disease: Evidence from the China Health and Retirement Longitudinal Study. Nutr Metab Cardiovasc Dis. 2022; 32(6): 1437–1444.
  34. Fu L, Cheng H, Zhao X, et al. Distinct causal effects of body fat distribution on cardiometabolic traits among children: Findings from the BCAMS study. Nutr Metab Cardiovasc Dis. 2022; 32(7): 1753–1765.
  35. Molloy TJ, Okin PM, Devereux RB, et al. Electrocardiographic detection of left ventricular hypertrophy by the simple QRS voltage-duration product. J Am Coll Cardiol. 1992; 20(5): 1180–1186.
  36. Okin PM, Jern S, Devereux RB, et al. LIFE Study Group. Effect of obesity on electrocardiographic left ventricular hypertrophy in hypertensive patients : the losartan intervention for endpoint (LIFE) reduction in hypertension study. Hypertension. 2000; 35(1 Pt 1): 13–18.
  37. Courand PY, Grandjean A, Charles P, et al. R Wave in aVL Lead is a Robust Index of Left Ventricular Hypertrophy: A Cardiac MRI Study. Am J Hypertens. 2015; 28(8): 1038–1048.

Regulations

Important: This website uses cookies. More >>

The cookies allow us to identify your computer and find out details about your last visit. They remembering whether you've visited the site before, so that you remain logged in - or to help us work out how many new website visitors we get each month. Most internet browsers accept cookies automatically, but you can change the settings of your browser to erase cookies or prevent automatic acceptance if you prefer.

By VM Media Group sp. z o.o., Grupa Via Medica, ul. Świętokrzyska 73, 80–180 Gdańsk

tel.:+48 58 320 94 94, faks:+48 58 320 94 60, e-mail: viamedica@viamedica.pl