- Email: [email protected]
Geometric patterns of left ventricular hypertrophy and electrocardiography
374
Letters to the Editor
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology (Shewan and Coats 2010;144:1–2). References [1] Kawada T, Otsuka T, Endo T, et al. The metabolic syndrome, smoking, inflammatory markers and obesity. Int J Cardiol 2011;151:367–8. [2] Lin GM, Chu KM, Han CL. The influence of inflammation outweighing the metabolic syndrome on cardiovascular risk and mortality. Int J Cardiol 2011;146:431. [3] Panagiotakos DB, Pitsavos C, Yannakoulia M, et al. The implication of obesity and central fat on markers of chronic inflammation: The ATTICA study. Atherosclerosis 2005;183:308–15.
[4] Brooks GC, Blaha MJ, Blumenthal RS. Relation of C-reactive protein to abdominal adiposity. Am J Cardiol 2010;106:56–61. [5] Wu CK, Yang CY, Lin JW, et al. The relationship among central obesity, systemic inflammation, and left ventricular diastolic dysfunction as determined by structural equation modeling. Obesity (Silver Spring) [Epub ahead of print]; Mar 10 2011, doi:10.1038/oby.2011.30. [6] Glynn RJ, Koenig W, Nordestgaard BG, et al. Rosuvastatin for primary prevention in older persons with elevated C-reactive protein and low to average low-density lipoprotein cholesterol levels: exploratory analysis of a randomized trial. Ann Intern Med 2010;152:488–96. [7] Hastie CE, Haw S, Pell JP. Impact of smoking cessation and lifetime exposure on C-reactive protein. Nicotine Tob Res 2008;10:637–42.
0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.06.102
Geometric patterns of left ventricular hypertrophy and electrocardiography Francisco de Assis Costa a,⁎, Maria Teresa Nogueira Bombig a, Valter Correia de Lima b, Dilma de Souza a, Bráulio Luna Filho a, Francisco Helfenstein Fonseca c, Maria Cristina de Oliveira Izar a, William da Costa a, Andrés Ricardo Perez Riera a, Rui Póvoa d a
Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil Department of Hemodynamics and Interventional Cardiology, Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil c Section of Lipids, Atherosclerosis and Vascular Biology, Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil d Section of Hypertensive Heart Diseases, Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil b
a r t i c l e
i n f o
Article history: Received 18 June 2011 Accepted 21 June 2011 Available online 18 July 2011 Keywords: Arterial hypertension Echocardiography Electrocardiography Left ventricular hypertrophy Patterns of ventricular hypertrophy
Electrocardiography (ECG) is a low-cost, highly reproducible and useful method for the diagnosis of left ventricular hypertrophy (LVH). However, available information on its power to discriminate the geometric patterns of LVH is scarce. The objective of this study was to evaluate the discriminatory power of ECG in the identification of the concentric and eccentric patterns of LVH. ECGs from 763 patients with LVH from the Hypertension Outpatient Clinic of Universidade Federal de São Paulo (UNIFESP) were analyzed from March 2006 to December 2009. All factors that could potentially cause distortion of the LV geometry and of the electrocardiographic analysis were excluded. The UNIFESP's Research Ethics Committee approved the study protocol, according to the Declaration of Helsinki. Resting 12-lead ECG was performed, with a sweep speed of 25 mm/s and calibration set at 1.0 mV/cm (Dixtal EP3, Brazil). The variables required for the study of the eight electrocardiographic criteria assessed were analyzed. 1. [(S + R) X QRS]: LVH is defined when this score is ≥ 2.8 mm s [1]. 2. Sokolow–Lyon voltage criterion: SV1 + RV5 or V6 ≥ 35 mm.
⁎ Corresponding author at: Francisco de Assis Costa, Rua Hamilton de Barros Soutinho, 307, apto 202, CEP 57035 690, Maceió, AL, Brazil. E-mail address: [email protected] (F.A. Costa).
3. Cornell voltage criterion: RaVL + SV3 ≥ 20 mm for women and ≥ 28 mm for men. 4. Cornell duration criterion: (RaVL + SV3) X QRS duration ≥ 2440 mm. ms; for women, add 8 mm. 5. Romhilt–Estes point-score: LVH is diagnosed when the sum is ≥ 5 points. 6. R wave in aVL ≥ 11 mm. 7. Perugia score: one or more of the following findings: Cornell criterion, Romhilt–Estes score, and strain pattern. 8. Presence of strain pattern in V5 or V6. The analysis of reproducibility of the method was carried out by three independent observers who analyzed R and S-wave amplitudes and QRS-complex duration (100 ECG tracings). Echocardiograms were performed using an ATL 1500 (USA) ultrasound system equipped with 2.0–3.5 MHz transducers. Interventricular septal thickness in diastole, left ventricular posterior wall thickness in diastole and end-diastolic diameter were measured; left ventricular mass, in grams, was calculated using the Devereux's modified formula. The echocardiographic diagnosis of LVH was made when LVMI was N 88 g/m2 (women) and N 102 g/m2 (men). Relative wall thickness (RWT) calculation defined two patterns of LVH: concentric (RWT ≥ 0.42) and eccentric (RWT b 0.42) [2]. The discriminatory power of the eight electrocardiographic methods assessed was analyzed in relation to the diagnosis of the two patterns of LVH. Quantitative variables were expressed as mean and standard deviation or median and interquartile intervals. D'Agostino-Pearson and Fisher tests were used. Statistical significance levels were set at 95% confidence intervals and p b 0.05. The Kappa test was used for the analysis of reproducibility. Of the 763 patients with LVH on transthoracic echocardiography included in the study, 326 (42.7%) showed the concentric pattern, and 437 (57.3%), the eccentric pattern. The characteristics of the study population, according to the two patterns of LVH, are summarized in Table 1. Table 2 shows sensitivities and p values of the eight electrocardiographic criteria studied, also according to the geometric patterns.
Letters to the Editor Table 1 Characteristics of the study population according to LVH patterns. Variable
CLVH
ELVH
p
Age* (years) BS** (m2) BMI** LVMI** (g/m2) RWT**
59.2 ± 10.7 1.6 2.6 123.6 0.49
59.7 ± 11.3 1.7 2.7 108.6 0.37
0.58 0.017 0.18 b0.0001 b0.0001
*Mean; **Median; LVH = left ventricular hypertrophy; CLVH = concentric left ventricular hypertrophy; ELVH = eccentric left ventricular hypertrophy; BS = body surface; BMI = body mass index; LVMI = left ventricular mass index; RWT = relative wall thickness.
Table 2 Sensitivity and p values of the electrocardiographic criteria according to LVH patterns. Variable [(S + R) X QRS] Sokolow-Lyon Cornell voltage Cornell duration Romhilt-Estes RaVL Perugia Strain
CLVH (n = 326)
ELVH (n = 437)
Sensitivity% (CI)
Sensitivity% (CI)
40.8 (35.4–46.3) 16.5 (12.7–21.0) 22.0 (17.7–26.9) 11.6 (8.3–15.6) 15.6 (11.8–20.0) 12.5 (9.1–16.6) 34.0 (28.9–39.4) 20.2 (16.0–25.0)
25.8 (21.8–30.2) 11.4 (8.6–14.8) 15.1 (11.8–18.8) 8.7 (6.2–11.7) 10.3 (7.6–13.5) 8.9 (6.4–12.0) 23.8 (19.8–28.0) 13.7 (10.6–17.3)
p b0.0001 0.0433 0.0172 0.1812 0.0356 0.1203 0.0020 0.0181
LVH = left ventricular hypertrophy; CLVH = concentric left ventricular hypertrophy; ELVH = eccentric left ventricular hypertrophy; CI = confidence interval.
The level of agreement between the three observers ranged from 0.82 (QRS) to 0.98 (R and S amplitude). Few studies have explored the power of ECG to discriminate the geometric patterns of LVH, maybe because of its known limitations [3]. Of the eight criteria analyzed, only RaVL and Cornell duration showed no significant differences, and are the two least capable
375
criteria to discriminate the two patterns of LVH. Our findings show that sensitivity was always higher for the diagnosis of concentric LVH, certainly a reflex of more severe disease and myocardial deformation associated with this pattern, which is known to be related to a worse prognosis. Aktoz et al. [4] analyzed 125 hypertensive patients using the Sokolow–Lyon, Cornell voltage, Cornell product, Gubner and RaVL N 11 mm criteria and concluded that the diagnostic value of ECG is acceptable, i.e., it has positive specificity and predictive value to differentiate normal and abnormal ventricular geometry, with modest accuracy in hypertensive patients. Nonetheless, its diagnostic value for the prediction and differentiation of the specific geometric patterns of LVH is poor. The most of the electrocardiographic criteria analyzed showed statistically significant differences in the identification of the concentric and eccentric types of hypertrophic hearts, and this corroborates their usefulness in the diagnosis of the two established patterns of LVH. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology (Shewan and Coats 2010;144:1–2). References [1] Mazzaro CL, Costa FA, Bombig MTN, et al. Massa ventricular e critérios eletrocardiográficos de hipertrofia: avaliação de um novo escore. Arq Bras Cardiol 2008;90(4):249–53. [2] Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American of Echocardiography's guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440–63. [3] Pewsner D, Jüni P, Egger M, Battaglia M, Sundström J, Bachmann LM. Accuracy of electrocardiography in diagnosis of left ventricular hypertrophy in arterial hypertension: systematic review. BMJ 2007;335(7622):711. [4] Aktoz M, Erdogan O, Altun A. Electrocardiographic prediction of left ventricular geometric patterns in patients with essential hypertension. Int J Cardiol 2007;120:344–50.
0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.06.103
Troponin rise in healthy subjects during exercise test S. Tjora a, H. Gjestland b, S. Mordal b, S. Agewall b,⁎ a b
Department of Clinical Chemistry, Oslo University Hospital and Oslo University, 0424 Oslo, Norway Department of Cardiology, Oslo University Hospital and Oslo University, 0424 Oslo, Norway
a r t i c l e
i n f o
Article history: Received 22 June 2011 Accepted 25 June 2011 Available online 20 July 2011 Keywords: Troponin Myocardial infarction Exercise
Cardiomyocyte necrosis is accompanied by a rise and fall of circulating troponin levels. The increased precision in the low analytical ⁎ Corresponding author at: Department of Cardiology, Oslo University Hospital Ullevål, Oslo University, 0424 Oslo, Norway. Tel.: +47 585 817 33; fax: +47 585 867 10. E-mail address: [email protected] (S. Agewall).
end of the hs-cTnT assay contributes to earlier clinical decisions [1]. The universal definition of myocardial infarction in patients presenting with symptoms of cardiac ischemia and/or changes in EKG requires a rise and fall of troponin, where at least one measurement is above the 99th percentile limit [2]. No consensus is obtained how large such a change has to be in order to be classified as significant. Such calculations must consider both biological variation and the analytical variation at the actual level. Participants in extreme sports leak cTn to the circulation at levels high above the accepted 99-percentile limit [3,4]. With the addition of suspect clinical symptoms like chest pain or typical ischemic ECG-signs, they would have fulfilled the international criteria for myocardial infarction. The physiological background of such a leakage is largely unknown. The intention of the present work was primarily to see if physical activity prior to blood sampling might contribute to the biological variation of cTn. Our second aim was to see if the fitness level of the participants might be of relevance.
Letters to the Editor
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology (Shewan and Coats 2010;144:1–2). References [1] Kawada T, Otsuka T, Endo T, et al. The metabolic syndrome, smoking, inflammatory markers and obesity. Int J Cardiol 2011;151:367–8. [2] Lin GM, Chu KM, Han CL. The influence of inflammation outweighing the metabolic syndrome on cardiovascular risk and mortality. Int J Cardiol 2011;146:431. [3] Panagiotakos DB, Pitsavos C, Yannakoulia M, et al. The implication of obesity and central fat on markers of chronic inflammation: The ATTICA study. Atherosclerosis 2005;183:308–15.
[4] Brooks GC, Blaha MJ, Blumenthal RS. Relation of C-reactive protein to abdominal adiposity. Am J Cardiol 2010;106:56–61. [5] Wu CK, Yang CY, Lin JW, et al. The relationship among central obesity, systemic inflammation, and left ventricular diastolic dysfunction as determined by structural equation modeling. Obesity (Silver Spring) [Epub ahead of print]; Mar 10 2011, doi:10.1038/oby.2011.30. [6] Glynn RJ, Koenig W, Nordestgaard BG, et al. Rosuvastatin for primary prevention in older persons with elevated C-reactive protein and low to average low-density lipoprotein cholesterol levels: exploratory analysis of a randomized trial. Ann Intern Med 2010;152:488–96. [7] Hastie CE, Haw S, Pell JP. Impact of smoking cessation and lifetime exposure on C-reactive protein. Nicotine Tob Res 2008;10:637–42.
0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.06.102
Geometric patterns of left ventricular hypertrophy and electrocardiography Francisco de Assis Costa a,⁎, Maria Teresa Nogueira Bombig a, Valter Correia de Lima b, Dilma de Souza a, Bráulio Luna Filho a, Francisco Helfenstein Fonseca c, Maria Cristina de Oliveira Izar a, William da Costa a, Andrés Ricardo Perez Riera a, Rui Póvoa d a
Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil Department of Hemodynamics and Interventional Cardiology, Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil c Section of Lipids, Atherosclerosis and Vascular Biology, Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil d Section of Hypertensive Heart Diseases, Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil b
a r t i c l e
i n f o
Article history: Received 18 June 2011 Accepted 21 June 2011 Available online 18 July 2011 Keywords: Arterial hypertension Echocardiography Electrocardiography Left ventricular hypertrophy Patterns of ventricular hypertrophy
Electrocardiography (ECG) is a low-cost, highly reproducible and useful method for the diagnosis of left ventricular hypertrophy (LVH). However, available information on its power to discriminate the geometric patterns of LVH is scarce. The objective of this study was to evaluate the discriminatory power of ECG in the identification of the concentric and eccentric patterns of LVH. ECGs from 763 patients with LVH from the Hypertension Outpatient Clinic of Universidade Federal de São Paulo (UNIFESP) were analyzed from March 2006 to December 2009. All factors that could potentially cause distortion of the LV geometry and of the electrocardiographic analysis were excluded. The UNIFESP's Research Ethics Committee approved the study protocol, according to the Declaration of Helsinki. Resting 12-lead ECG was performed, with a sweep speed of 25 mm/s and calibration set at 1.0 mV/cm (Dixtal EP3, Brazil). The variables required for the study of the eight electrocardiographic criteria assessed were analyzed. 1. [(S + R) X QRS]: LVH is defined when this score is ≥ 2.8 mm s [1]. 2. Sokolow–Lyon voltage criterion: SV1 + RV5 or V6 ≥ 35 mm.
⁎ Corresponding author at: Francisco de Assis Costa, Rua Hamilton de Barros Soutinho, 307, apto 202, CEP 57035 690, Maceió, AL, Brazil. E-mail address: [email protected] (F.A. Costa).
3. Cornell voltage criterion: RaVL + SV3 ≥ 20 mm for women and ≥ 28 mm for men. 4. Cornell duration criterion: (RaVL + SV3) X QRS duration ≥ 2440 mm. ms; for women, add 8 mm. 5. Romhilt–Estes point-score: LVH is diagnosed when the sum is ≥ 5 points. 6. R wave in aVL ≥ 11 mm. 7. Perugia score: one or more of the following findings: Cornell criterion, Romhilt–Estes score, and strain pattern. 8. Presence of strain pattern in V5 or V6. The analysis of reproducibility of the method was carried out by three independent observers who analyzed R and S-wave amplitudes and QRS-complex duration (100 ECG tracings). Echocardiograms were performed using an ATL 1500 (USA) ultrasound system equipped with 2.0–3.5 MHz transducers. Interventricular septal thickness in diastole, left ventricular posterior wall thickness in diastole and end-diastolic diameter were measured; left ventricular mass, in grams, was calculated using the Devereux's modified formula. The echocardiographic diagnosis of LVH was made when LVMI was N 88 g/m2 (women) and N 102 g/m2 (men). Relative wall thickness (RWT) calculation defined two patterns of LVH: concentric (RWT ≥ 0.42) and eccentric (RWT b 0.42) [2]. The discriminatory power of the eight electrocardiographic methods assessed was analyzed in relation to the diagnosis of the two patterns of LVH. Quantitative variables were expressed as mean and standard deviation or median and interquartile intervals. D'Agostino-Pearson and Fisher tests were used. Statistical significance levels were set at 95% confidence intervals and p b 0.05. The Kappa test was used for the analysis of reproducibility. Of the 763 patients with LVH on transthoracic echocardiography included in the study, 326 (42.7%) showed the concentric pattern, and 437 (57.3%), the eccentric pattern. The characteristics of the study population, according to the two patterns of LVH, are summarized in Table 1. Table 2 shows sensitivities and p values of the eight electrocardiographic criteria studied, also according to the geometric patterns.
Letters to the Editor Table 1 Characteristics of the study population according to LVH patterns. Variable
CLVH
ELVH
p
Age* (years) BS** (m2) BMI** LVMI** (g/m2) RWT**
59.2 ± 10.7 1.6 2.6 123.6 0.49
59.7 ± 11.3 1.7 2.7 108.6 0.37
0.58 0.017 0.18 b0.0001 b0.0001
*Mean; **Median; LVH = left ventricular hypertrophy; CLVH = concentric left ventricular hypertrophy; ELVH = eccentric left ventricular hypertrophy; BS = body surface; BMI = body mass index; LVMI = left ventricular mass index; RWT = relative wall thickness.
Table 2 Sensitivity and p values of the electrocardiographic criteria according to LVH patterns. Variable [(S + R) X QRS] Sokolow-Lyon Cornell voltage Cornell duration Romhilt-Estes RaVL Perugia Strain
CLVH (n = 326)
ELVH (n = 437)
Sensitivity% (CI)
Sensitivity% (CI)
40.8 (35.4–46.3) 16.5 (12.7–21.0) 22.0 (17.7–26.9) 11.6 (8.3–15.6) 15.6 (11.8–20.0) 12.5 (9.1–16.6) 34.0 (28.9–39.4) 20.2 (16.0–25.0)
25.8 (21.8–30.2) 11.4 (8.6–14.8) 15.1 (11.8–18.8) 8.7 (6.2–11.7) 10.3 (7.6–13.5) 8.9 (6.4–12.0) 23.8 (19.8–28.0) 13.7 (10.6–17.3)
p b0.0001 0.0433 0.0172 0.1812 0.0356 0.1203 0.0020 0.0181
LVH = left ventricular hypertrophy; CLVH = concentric left ventricular hypertrophy; ELVH = eccentric left ventricular hypertrophy; CI = confidence interval.
The level of agreement between the three observers ranged from 0.82 (QRS) to 0.98 (R and S amplitude). Few studies have explored the power of ECG to discriminate the geometric patterns of LVH, maybe because of its known limitations [3]. Of the eight criteria analyzed, only RaVL and Cornell duration showed no significant differences, and are the two least capable
375
criteria to discriminate the two patterns of LVH. Our findings show that sensitivity was always higher for the diagnosis of concentric LVH, certainly a reflex of more severe disease and myocardial deformation associated with this pattern, which is known to be related to a worse prognosis. Aktoz et al. [4] analyzed 125 hypertensive patients using the Sokolow–Lyon, Cornell voltage, Cornell product, Gubner and RaVL N 11 mm criteria and concluded that the diagnostic value of ECG is acceptable, i.e., it has positive specificity and predictive value to differentiate normal and abnormal ventricular geometry, with modest accuracy in hypertensive patients. Nonetheless, its diagnostic value for the prediction and differentiation of the specific geometric patterns of LVH is poor. The most of the electrocardiographic criteria analyzed showed statistically significant differences in the identification of the concentric and eccentric types of hypertrophic hearts, and this corroborates their usefulness in the diagnosis of the two established patterns of LVH. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology (Shewan and Coats 2010;144:1–2). References [1] Mazzaro CL, Costa FA, Bombig MTN, et al. Massa ventricular e critérios eletrocardiográficos de hipertrofia: avaliação de um novo escore. Arq Bras Cardiol 2008;90(4):249–53. [2] Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American of Echocardiography's guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440–63. [3] Pewsner D, Jüni P, Egger M, Battaglia M, Sundström J, Bachmann LM. Accuracy of electrocardiography in diagnosis of left ventricular hypertrophy in arterial hypertension: systematic review. BMJ 2007;335(7622):711. [4] Aktoz M, Erdogan O, Altun A. Electrocardiographic prediction of left ventricular geometric patterns in patients with essential hypertension. Int J Cardiol 2007;120:344–50.
0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.06.103
Troponin rise in healthy subjects during exercise test S. Tjora a, H. Gjestland b, S. Mordal b, S. Agewall b,⁎ a b
Department of Clinical Chemistry, Oslo University Hospital and Oslo University, 0424 Oslo, Norway Department of Cardiology, Oslo University Hospital and Oslo University, 0424 Oslo, Norway
a r t i c l e
i n f o
Article history: Received 22 June 2011 Accepted 25 June 2011 Available online 20 July 2011 Keywords: Troponin Myocardial infarction Exercise
Cardiomyocyte necrosis is accompanied by a rise and fall of circulating troponin levels. The increased precision in the low analytical ⁎ Corresponding author at: Department of Cardiology, Oslo University Hospital Ullevål, Oslo University, 0424 Oslo, Norway. Tel.: +47 585 817 33; fax: +47 585 867 10. E-mail address: [email protected] (S. Agewall).
end of the hs-cTnT assay contributes to earlier clinical decisions [1]. The universal definition of myocardial infarction in patients presenting with symptoms of cardiac ischemia and/or changes in EKG requires a rise and fall of troponin, where at least one measurement is above the 99th percentile limit [2]. No consensus is obtained how large such a change has to be in order to be classified as significant. Such calculations must consider both biological variation and the analytical variation at the actual level. Participants in extreme sports leak cTn to the circulation at levels high above the accepted 99-percentile limit [3,4]. With the addition of suspect clinical symptoms like chest pain or typical ischemic ECG-signs, they would have fulfilled the international criteria for myocardial infarction. The physiological background of such a leakage is largely unknown. The intention of the present work was primarily to see if physical activity prior to blood sampling might contribute to the biological variation of cTn. Our second aim was to see if the fitness level of the participants might be of relevance.