A review of the role of electrocardiography in the diagnosis of left ventricular hypertrophy in hypertension☆
Introduction
Left ventricular hypertrophy (LVH) is not only an inevitable adaptation to increased hemodynamic load in hypertension, but also a strong and independent risk factor for premature cardiovascular morbidity and mortality. LVH was first recognized as a complication of hypertension over 150 years ago at autopsy,1 and later by chest X-ray. Over the years, electrocardiography (ECG) has become the first-choice technique for detection of LVH in patients with hypertension due to its wide-scale availability, low cost, repeatability, and established prognostic value. Current guidelines for diagnosis and treatment of hypertension2., 3. strongly recommend ECG as the only examination to be performed in all hypertensive subjects for detection of LVH. However, the use of ECG as a diagnostic tool in hypertensive subjects is limited by the absence of agreement on which of the many proposed criteria is preferable for diagnosis of LVH, and by its poor sensitivity as compared with other more accurate techniques such as echocardiography, computerized tomography, magnetic resonance, and, more recently, three-dimensional echocardiography. The present article reviews the diagnostic and prognostic role of ECG as a tool for detecting LVH in hypertension and as a guide for risk stratification of the hypertensive patient.
Section snippets
Diagnostic criteria of LVH
Several dozens of ECG criteria for LVH have been proposed over the decades; some of them are listed in Table 1. After a phase of general passive acceptance, the wide-scale spread of echocardiography allowed to verify the diagnostic accuracy of ECG. As shown in Table 2, the sensitivity of ECG in detecting LVH defined as a LV mass above a given threshold is generally low. Since the prevalence of LVH in unselected subjects with essential hypertension is quite low, a high specificity (i.e.,
Prognostic value of LVH
For any given level of concomitant risk factors, the risk of cardiovascular complications is greater in the subjects with LVH at ECG than in the subjects with normal ECG.51., 52. Moreover, the benefit of antihypertensive treatment is larger in subjects with LVH.53 On the basis of these data, LVH has been accepted as an important risk factor for cardiovascular morbidity and mortality.
However, the practical usefulness of ECG as a tool for prognostic stratification is conditioned by the very low
Prognostic significance of LVH regression
It is well known that long-term antihypertensive treatment may influence the time course of LVH. In MRFIT study, the subjects with a more aggressive treatment and a better blood pressure control (special intervention) had a lower incidence of LVH at follow-up, and a more frequent regression of LVH than the subjects with a less intensive treatment (usual care).54 In the setting of the Framingham study,55 the subjects with serial increase or decrease of Cornell voltage during follow-up had a
Conclusions
ECG remains the first line method for detection of LVH in patients with hypertension. ECG diagnosis of LVH predicts a several-fold increase in age- and risk factor-adjusted cardiovascular morbidity and mortality in asymptomatic patients with essential hypertension. When compared with traditional ECG methods, Cornell voltage product and multifactorial criteria such as the Perugia criterion allow detection of LVH in a higher proportion of subjects while carrying a high attributable risk for
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The manuscript is original, and no part of it has been or will be submitted elsewhere for publication. Each author has contributed to, read and approved the manuscript.