Prevalence and prognostic implications of electrocardiographic left ventricular hypertrophy in heart failure: evidence from the CHARM programme

Nathaniel M Hawkins ^1*, Duolao Wang ², John JV McMurray ³, Marc A Pfeffer ⁴, Karl Swedberg ⁵, Christopher B Granger ⁶, Salim Yusuf ⁷, Stuart J Pocock ², Jan Östergren ⁸, Eric L Michelson ⁹ and Francis G Dunn ¹

¹ Stobhill Hospital, United Kingdom
² London School of Hygiene and Tropical Medicine, United Kingdom
³ University of Glasgow, United Kingdom
⁴ Brigham and Women's Hospital, Harvard Medical School, United States
⁵ Goteborg University, Sweden
⁶ Duke University, United States
⁷ McMaster University, Canada
⁸ Karolinska Hospital, Sweden
⁹ AstraZeneca, United States

^* To whom correspondence should be addressed. E-mail: nathawkins{at}hotmail.com.

Accepted 15 August 2006

Abstract

Background Electrocardiographic left ventricular hypertrophy (ECG LVH) is a powerful independent predictor of cardiovascular morbidity and mortality in hypertension. The contemporary prevalence and prognostic implications of ECG LVH in a broad spectrum of patients with heart failure (HF) with and without reduced left ventricular ejection fraction (LVEF) are unknown.

Methods The Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme randomised 7599 patients with symptomatic HF to receive candesartan or placebo. The primary outcome comprised cardiovascular death or hospital admission for worsening HF. The relative risk conveyed by ECG LVH compared to a normal ECG was examined in a Cox model, adjusting for up to 31 co-variates of prognostic importance.

Results The prevalence of ECG LVH was similar in all 3 CHARM trials (Alternative 15.4%, Added 17.1%, Preserved 14.7%, Overall 15.7%), despite a more frequent history of hypertension in CHARM-Preserved. ECG LVH was an independent predictor of worse prognosis in CHARM-Overall. The relative risk for the primary outcome was 1.27 (95% confidence interval 1.04-1.55), p=0.0175. Risk of secondary endpoints was also increased: cardiovascular death 1.50 (1.13-1.99), p=0.0054; HF hospitalisation 1.19 (0.94-1.50), p=0.1482; composite major cardiovascular events 1.35 (1.12-1.62), p=0.0017.

Conclusion ECG LVH is similarly prevalent in patients with symptomatic heart failure regardless of LVEF. The simple clinical finding of ECG LVH was an independent predictor of a worse clinical outcome in a broad spectrum of patients with HF receiving extensive contemporary treatment. Candesartan had similar benefits in patients with and without ECG LVH.

Keywords: candesartan, electrocardiogram, heart failure, left ventricular hypertrophy, left ventricular systolic dysfunction

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