Determinants of Discrepancies in Detection and Comparison of the Prognostic Significance of Left Ventricular Hypertrophy by Electrocardiogram and Cardiac Magnetic Resonance Imaging

doi:10.1016/j.amjcard.2014.11.037

The American Journal of Cardiology

Volume 115, Issue 4, 15 February 2015, Pages 515-522

https://doi.org/10.1016/j.amjcard.2014.11.037 Get rights and content

Despite the low sensitivity of the electrocardiogram (ECG) in detecting left ventricular hypertrophy (LVH), ECG-LVH is known to be a strong predictor of cardiovascular risk. Understanding reasons for the discrepancies in detection of LVH by ECG versus imaging could help improve the diagnostic ability of ECG. We examined factors associated with false-positive and false-negative ECG-LVH, using cardiac magnetic resonance imaging (MRI) as the gold standard. We also compared the prognostic significance of ECG-LVH and MRI-LVH as predictors of cardiovascular events. This analysis included 4,748 participants (mean age 61.9 years, 53.5% females, 61.7% nonwhites). Logistic regression with stepwise selection was used to identify factors associated with false-positive (n = 208) and false-negative (n = 387), compared with true-positive (n = 208) and true-negative (n = 4,041) ECG-LVH, respectively. A false-negative ECG-LVH status was associated with increased odds of Hispanic race/ethnicity, current smoking, hypertension, increased systolic blood pressure, prolongation of QRS duration, and higher body mass index and with lower odds of increased ejection fraction (model-generalized R² = 0.20). A false-positive ECG-LVH status was associated with lower odds of black race, Hispanic race/ethnicity, minor ST-T abnormalities, increased systolic blood pressure, and presence of any major electrocardiographic abnormalities (model-generalized R² = 0.29). Both ECG-LVH and MRI-LVH were associated with an increased risk of cardiovascular disease events (hazard ratio 1.51, 95% confidence interval 1.03 to 2.20 and hazard ratio 1.81, 95% confidence interval 1.33 to 2.46, respectively). In conclusion, discrepancy in LVH detection by ECG and MRI can be relatively improved by considering certain participant characteristics. Discrepancy in diagnostic performance, yet agreement on predictive ability, suggests that LVH by ECG and LVH by imaging are likely to be two distinct but somehow related phenotypes.

Section snippets

Methods

MESA is a prospective longitudinal study aimed to explore the prevalence, correlates, and progression of subclinical cardiovascular disease (CVD) in a population-based multiethnic cohort. The description of the MESA study is provided elsewhere.⁹ Briefly, from July 2000 to August 2002, a total of 6,814 men and women aged 45 to 84 years and free of clinically apparent CVD were recruited from 6 US communities: Baltimore City and Baltimore County, Maryland; Chicago, Illinois; Forsyth County, North

Results

These analyses included 4,748 participants (age 61.9 ± 10.1 years, 53.5% women, 38.3% whites, 13.4% American Chinese, 25.8% African-American, 22.5% Hispanic). MRI- and ECG-LVH were present in 10.5% (n = 499) and 6.7% (n = 320) of the participants, respectively. About 2.4% (n = 112) of the participants had LVH by both MRI and ECG (i.e., true-positive ECG-LVH), and 85.1% (n = 4041) did not have LVH by either method (i.e., true-negative ECG-LVH). The remaining 12.5% (n = 595) of the participants

Discussion

In these analyses from the MESA study, we sought to identify factors associated with false-positive and false-negative ECG-LVH, aiming to find an explanation for the discrepancies between LVH by ECG and MRI. We also examined the association between ECG-LVH (stratified by its diagnostic accuracy) and risk of CVD events. The key findings from our study are as follows: (1) we have identified a number of factors associated with false-positive and false-negative ECG-LVH. However, these factors

Acknowledgment

This research was supported by contracts N01-HC-95159 through N01-HC-95169 from the National Heart, Lung, and Blood Institute. The authors thank the other investigators, the staff, and the participants of the MESA study for their valuable contributions. A full list of participating MESA investigators and institutions can be found at http://www.mesa-nhlbi.org.

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Cited by (58)

ISE/ISHNE Expert Consensus Statement on ECG Diagnosis of Left Ventricular Hypertrophy: The Change of the Paradigm. The joint paper of the International Society of Electrocardiology and the International Society for Holter Monitoring and Noninvasive Electrocardiology
2023, Journal of Electrocardiology
The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria, i.e. the increased QRS complex amplitude in defined leads. The classical ECG diagnostic paradigm postulates that the increased left ventricular mass generates a stronger electrical field, increasing the leftward and posterior QRS forces. These increased forces are reflected in the augmented QRS amplitude in the corresponding leads. However, the clinical observations document increased QRS amplitude only in the minority of patients with LVH. The low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm.
ECG in left ventricular hypertrophy: A change in paradigm from assessing left ventricular mass to its electrophysiological properties
2022, Journal of Electrocardiology
Left ventricular hypertrophy (LVH) detected electrocardiographically is documented as an independent cardiovascular risk factor. However, the reasoning for using electrocardiography (ECG) for LVH detection is frequently referring to its low cost and availability, which should compensate for the main problem of the ECG criteria for LVH detection (ECG-LVH) - the high number of ECG false negative results and the resulting low sensitivity. This opinion paper is focused on the scientific evidence for advocating the usefulness of ECG in LVH assessment.
The classical paradigm assumes that the increased left ventricular mass generates a stronger electrical field that has to be reflected in the increased QRS amplitude. However, the solid angle theorem postulates that the recorded ECG voltage depends not only on the extent of the activation front that is increased in LVH, but also on the electrical characteristics of myocardium. There is an accumulated evidence from animal and clinical studies documenting significant alterations of structural and functional properties of hypertrophied myocardium, both of cardiomyocytes as well as of interstitium. These alterations are associated with significant changes of active and passive electrical properties of myocardium modifying the resultant QRS amplitudes.
The new paradigm should consider the altered electrical properties of hypertrophied myocardium in interpreting the whole spectrum of QRS patterns seen in LVH patients: the increased QRS voltage, the QRS voltage within normal limits, occurrence of left axis deviation and left bundle branch block. Thus further research is necessary for utilizing the unique diagnostic information provided by ECG: to link the agreements as well as the disagreements between ECG and imaging methods findings to pathophysiological processes and patho-anatomical backgrounds, to the risk assessment and the clinical status of patients with LVH.
Cardiac functional imaging
2022, Presse Medicale
Citation Excerpt :
This highly reproducible technique involves acquiring a set of contiguous short-axis cine images of the entire LV. Myocardial mass is measured as the area between endocardial and epicardial borders, multiplied by the interslice distance and the specific gravity of the myocardium (1.05 g/ml) [3]. Ventricular contractility may be regionally impaired in different diseases.
During the last 20 years, cardiac imaging has drastically evolved. Positron emission tomography (PET), fast three-dimensional (3D) imaging with the latest generations of echocardiography & multi-detector computed tomography (CT), stress perfusion assessed by magnetic resonance imaging (MRI), blood flow analysis using four-dimensional (4D) flow MRI, all these techniques offer new trends for optimal noninvasive functional cardiac imaging. Dynamic functional imaging is obtained by acquiring images of the heart at different phases of the cardiac cycle, allowing assessment of cardiac motion, function, and perfusion. Between CT and Cardiac MRI (CMR), CMR has the best temporal resolution, which is suitable for functional imaging while cardiac CT provides higher spatial resolution with isotropic data that have an identical resolution in the three dimensions of the space. The latest generations of CT scanners enable whole heart assessment in one beat, offering also an acceptable temporal resolution with the possibility to display the images in a dynamic mode. Another rapidly growing technique using functional and molecular imaging for the assessment of biological and metabolic pathways is the PET using radio-labeled tracers. Meanwhile, the oldest cardiac imaging tool with doppler ultrasound technology has never stopped evolving. Echocardiography today performs 3D imaging, stress perfusion, and myocardial strain assessment, with high temporal resolution. It still is the first line and more accessible exam for the patient. These different modalities are complementary and may be even combined into PET-CT or PET-MRI. The ability to combine the functional/molecular data with anatomical images may implement a new dimension to our diagnostic tools.
Absence of electrocardiographic left ventricular hypertrophy in patients undergoing Transcatheter aortic valve replacement is associated with increased mortality
2020, Journal of Electrocardiology
We examined the association between the absence ECG LVH and all-cause mortality in patients with severe AS undergoing TAVR.
We conducted a retrospective single center study on 399 TAVR patients from 2012 to 2016. ECGs were reviewed for LVH diagnosed by Sokolow-Lyon's voltage criteria. All patients met echocardiographic criteria for LVH. Logistic regression was used to examine the association between ECG LVH and covariates. Survival analysis was performed using Cox regression analysis and Kaplan Meier curves.
Patients without ECG LVH were younger (81.0 ± 8.4 vs. 84.0 ± 7.7 years, p = 0.001) with a higher BMI (29.3 ± 7.0 vs. 27.1 ± 5.6 kg/m², p = 0.006) and lower FEV1 (65.6 ± 22.8 vs. 74.1 ± 21.6%, p = 0.002). In multivariable analysis, increased BMI and decreased FEV1 remained predictive of the absence of ECG LVH. Over a mean follow-up time of 32 (± 17.0) months, the 5-year cumulative survival was 79% in the ECG LVH group and 58% in the group without ECG LVH (p = 0.039). Absence of ECG LVH remained predictive of all-cause mortality (HR 1.56, 95% CI 1.01–2.59, p = 0.045) in multivariable Cox regression analysis. When patients were grouped by comorbidities, patients with the highest mortality were those with increased BMI or decreased FEV1.
Absence of LVH by ECG criteria in patients with severe AS undergoing TAVR was associated with increased all-cause mortality. Routinely performed, noninvasive and inexpensive ECG may aid in identification of high-risk patients that may not benefit from TAVR and warrant further evaluation of underlying comorbidities.
CMR in the Evaluation of Diastolic Dysfunction and Phenotyping of HFpEF: Current Role and Future Perspectives
2020, JACC: Cardiovascular Imaging
Citation Excerpt :
Currently, as recommended by the American Society of Echocardiography, myocardial mass is estimated on echocardiography from linear measurements of the wall made on parasternal long-axis view (either by 2-dimensional [2D] or M-mode), based on the assumption of the LV as a prolate ellipsoid (5). CMR, on the other hand, has the advantage of accurately measuring LV mass with a highly reproducible technique, without geometric assumption, with absolute values that are typically of lower cutoff than those derived by echocardiography (6). This usually involves acquiring a set of contiguous short-axis cine images covering the entire left ventricle, and then the myocardial volume is measured as the area between endocardial and epicardial borders, multiplied by the interslice distance (4) (Figure 1).
Heart failure with preserved ejection fraction presents a challenging diagnosis given a heterogeneous patient population and limited therapeutic options. Diastolic function assessment using echocardiography has been a cornerstone in the work-up and is as important as systolic functional assessment. There has been increased awareness to the potential utility of cardiac magnetic resonance (CMR) imaging over the past decade as a promising, radiation-free, robust imaging modality providing an unrestricted field of view and high-resolution images for global and regional functional assessment. CMR provides early markers for detecting myocardial disease using tissue characterization imaging, which might prove useful to improve diagnosis and management. Over the years, several studies have examined CMR-derived diastolic functional indices, including transmitral and pulmonary venous velocities, left ventricular and left atrial strain using myocardial tagging, and, more recently, feature tracking. The relevance of imaging-based diastolic function indices and their clinical application across different modalities is increasingly recognized.
Interrelation Between Electrocardiographic Left Atrial Abnormality, Left Ventricular Hypertrophy, and Mortality in Participants With Hypertension
2019, American Journal of Cardiology
Citation Excerpt :
LA enlargement is commonly found independent of the presence of other echocardiographic signs of hypertensive heart disease like concentric LVH or LVH remodeling,25 so, coexistence of ECG-LAA and ECG-LVH likely represents advanced structural and electrical remodeling.12,13 Despite the low sensitivity of ECG for detecting LVH and LA dilatation,26,27 each is independently predictive of mortality. The highest risk of mortality associated with their concomitant presence suggests that additional prognostic information can be obtained from ECG to identify high-risk populations.
Left ventricular hypertrophy (LVH) and left atrial abnormality (LAA) are common correlated complications of hypertension. It is unclear how common for electrocardiographic markers of LAA (ECG-LAA) to coexist with ECG-LVH and how their coexistence impacts their prognostic significance. This analysis included 4,077 participants (61.2 ± 13.0 years, 51.2% women, 48.6% whites) with hypertension from the Third National Health and Nutrition Examination Survey. ECG-LVH was defined by Cornell voltage criteria. ECG-LAA was defined as deep terminal negativity of P wave in V1 >100 µV. Cox proportional hazard analysis was used to examine the associations between various combinations of ECG-LAA and ECG-LVH with all-cause mortality over a median follow-up of 14 years. The baseline prevalence of ECG-LVH, ECG-LAA, and the concomitant presence of both was 3.6%, 2.7%, and 0.34%, respectively. In a multivariable-adjusted model, mortality risk was highest in the group with concomitant ECG-LAA and ECG-LVH (hazard ratio [HR; 95% confidence interval {CI}] 2.69 [1.51, 4.80]), followed by isolated ECG-LAA (HR [95% CI] 1.63 [1.26, 2.12]), and then isolated ECG-LVH (HR [95% CI] 1.40 [1.08, 1.81]), compared with the group without ECG-LAA or ECG-LVH. Effect modification of these results by age and diabetes but not by gender or race was observed. In models with similar adjustment where ECG-LVH and ECG-LAA were entered as 2 separate variables and subsequently additionally adjusted for each other, the mortality risk was essentially unchanged for both variables. In conclusion, in participants with hypertension, ECG-LAA and ECG-LVH are independent markers of poor outcomes, and their concomitant presence carries a higher risk than either marker alone.

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MiscellaneousDeterminants of Discrepancies in Detection and Comparison of the Prognostic Significance of Left Ventricular Hypertrophy by Electrocardiogram and Cardiac Magnetic Resonance Imaging

Section snippets

Methods

Results

Discussion

Acknowledgment

J Am Coll Cardiol

Am Heart J

Am J Cardiol

J Am Coll Cardiol

Am J Med

J Electrocardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Electrocardiol

J Am Coll Cardiol

J Electrocardiol

Am J Hypertens

Accuracy of electrocardiography in diagnosis of left ventricular hypertrophy in arterial hypertension: systematic review

BMJ

Electrocardiographic left ventricular hypertrophy and risk of coronary heart disease: the Framingham Study

Ann Intern Med

Miscellaneous
Determinants of Discrepancies in Detection and Comparison of the Prognostic Significance of Left Ventricular Hypertrophy by Electrocardiogram and Cardiac Magnetic Resonance Imaging