Electrocardiographic observations in severe aortic valve stenosis: Correlative necropsy study to clinical, hemodynamic, and ECG variables demonstrating relation of 12-lead QRS amplitude to peak systolic transaortic pressure gradient

doi:10.1016/0002-8703(82)90494-X

American Heart Journal

Volume 103, Issue 2, February 1982, Pages 210-221

https://doi.org/10.1016/0002-8703(82)90494-X Get rights and content

Abstract

Most ECG studies in patients with aortic valve stenosis (AS) have involved living patients in whom the status of the left ventricular (LV) myocardium, epicardial coronary arteries, and mitral valve was not precisely known. We examined the 12-lead ECG recorded within 2 months of death in 50 patients aged 16 to 65 years (mean 48) with peak systolic pressure gradients (PSPG) across the aortic valve ranging from 52 to 180 mm Hg (mean 98) and anatomically normal mitral valves. Excluding four patients with complete left bundle branch block (LBBB), 44 (96%) of the other 46 patients had the usual voltage criteria for LV hypertrophy (LVH). Measurement of the total 12-lead QRS amplitude, which ranged from 144 to 417 mm (10 mm = 1 mV), (mean 257) proved useful for it correlated directly with PSPG across the aortic valve and, when the four LBBB patients were excluded, with the peak LV systolic pressure. The total 12-lead QRS amplitude (mm) was similar in most patients to the LV systolic pressure (mm Hg). Thus, subtraction of the indirect systemic arterial systolic pressure (mm Hg) from the total 12-lead QRS amplitude (mm) provides a reasonable noninvasive prediction of the PSPG across the aortic valve in patients with moderate to severe AS. Additionally, the mean of the total 12-lead QRS amplitude was significantly (p < 0.05) greater in the 11 younger (≤ 40 years) than in the 39 older patients (278 mm vs 257 mm), in the 14 women than in the 36 men (277 mm vs 249 mm), in the 22 patients with heavier (> 600 gm) hearts (274 mm vs 244 mm), in the 34 patients without compared to the 16 with significant coronary arterial narrowing (270 mm vs 238 mm), and in the 22 patients without compared to the 24 with ECG myocardial damage patterns (269 mm vs 236 mm).

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Although several electrocardiographic features of arrhythmogenic right ventricular cardiomyopathy (ARVC) (also called dysplasia) have been described, total 12-lead QRS voltage is not one of them. This report describes total 12-lead QRS voltage in 11 patients with ARVC who underwent orthotopic heart transplantation (OHT) because of progressively severe heart failure. Additionally, it illustrates the varied morphologic features of ARVC. The total 12-lead nonpaced QRS voltages before OHT ranged from 28 to 118 mm (mean 74 ± 32), and those in the paced tracings, from 33 to 129 mm (62 ± 32). The voltages are the lowest we have encountered among 12 previously reported cardiovascular conditions. The heart weights among the 11 ARVC patients ranged from 285 to 670 g (mean 448 ± 125). Very low 12-lead QRS voltage is characteristic of patients with ARVC with heart failure severe enough to warrant OHT, and thus may serve as a clue to its diagnosis.
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Citation Excerpt :
There were 14 voltage-only criteria and 3 composite criteria (2 point-score systems and 1 regression equation criteria) (Table 1). These included Minnesota code 3.1,4 Sokolow-Lyon,5 unadjusted Cornell voltages,6 Framingham-adjusted Cornell voltages,7 Lewis index,8 Gubner-Ungerleider,9 sum of 12 leads,10 Peguero,1 Cornell products,11 12-lead products,10 Perugia score,12 Romhilt-Estes score,13 and the Rautaharju left ventricular mass index equation.14 The California Department of Health Care Services and Social Security Death Index were used to ascertain the vital status of each patient as of April 2013.
Numerous methods have been proposed for diagnosing left ventricular hypertrophy using the electrocardiogram. They have limited sensitivity for recognizing pathological hypertrophy, at least in part due to their inability to distinguish pathological from physiological hypertrophy. Our objective is to compare the major electrocardiogram–left ventricular hypertrophy criteria using cardiovascular mortality as a surrogate for pathological hypertrophy.
This study was a retrospective analysis of 16,253 veterans < 56 years of age seen at a large Veterans Affairs Medical Center from 1987 to 1999 and followed a median of 17.8 years for cardiovascular mortality. Receiver operating characteristics and Cox hazard survival techniques were applied.
Of the 16,253 veterans included in our target population, the mean age was 43 years, 8.6% were female, 33.5% met criteria for electrocardiogram–left ventricular hypertrophy, and there were 744 cardiovascular deaths (annual cardiovascular mortality 0.25%). Receiver operating characteristic analysis demonstrated that the greatest area under the curve (AUC) for classification of cardiovascular death was obtained using the Romhilt-Estes score (0.63; 95% confidence interval, 0.61-0.65). Most of the voltage-only criteria had nondiagnostic area under the curves, with the Cornell being the best at 0.59 (95% confidence interval, 0.57-0.62). When the components of the Romhilt-Estes score were examined using step-wise Wald analysis, the voltage criteria dropped from the model. The Romhilt-Estes score ≥ 4, the Cornell, and the Peguero had the highest association with cardiovascular mortality (adjusted hazard ratios 2.2, 2.0, and 2.1, consecutively).
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Electrocardiographic voltage has been used to determine the presence of left ventricular hypertrophy for about 70 years. Varying electrocardiographic criteria have been applied. We have found total 12-lead QRS voltage to be most useful in this regard. We measured total 12-lead QRS voltage in 24 patients in whom an ascending aortic aneurysm was resected and histologic study of its wall was classic of syphilitic aortitis. In these 24 patients total 12-lead QRS voltage ranged from 57 to 161 mm, averaging 120 ± 32 in the 11 men and 106 ± 24 mm in the 13 women. If normal 12-lead QRS voltage in adults is considered to be >175 mm not a single one of the 24 patients had normal voltage. Indeed, most were in the low normal area. Thus, this study provides some evidence via this indirect means that the heart itself is infrequently involved by syphilitic aortitis which produces an ascending aortic aneurysm of sufficient size to warrant resection.
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Although total 12-lead voltage proved to have a greater AUC, this difference is not significant. Additionally, using the commonly reported cutoff of 175 mV,9 the specificity of the total voltage criterion would lead to a large number of false-positive results and unnecessary additional testing. Because HC is an unpredictable progressive disease, the need to diagnose as early as possible is imperative.
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Electrocardiographic observations in severe aortic valve stenosis: Correlative necropsy study to clinical, hemodynamic, and ECG variables demonstrating relation of 12-lead QRS amplitude to peak systolic transaortic pressure gradient

Abstract

Am Heart J

Am Heart J

Am Heart J

Am Heart J

Am Heart J

Am J Cardiol

Am Heart J

Dis Chest

Am Heart J

Am J Cardiol

Am J Cardiol

Am Heart J

Am Heart J

Am J Cardiol

Am Heart J

Correlation between electrocardiographic changes and systemic hemodynamics in human arterial hypertension

Am J Cardiol

Electrocardiographic differentiation between left ventricular hypertrophy and anterior myocardial infarction

Circulation

Aortic stenosis—clinical manifestations and course of the disease. Review of one hundred proved cases

Arch Intern Med