Performance of the Electrocardiogram in the Diagnosis of Left Ventricular Hypertrophy in Older and Very Older Hypertensive Patients

Povoa, Fernando Focaccia; Luna Filho, Braulio; Bianco, Henrique Tria; Amodeo, Celso; Povoa, Rui; Bombig, Maria Teresa Nogueira; Miranda, Roberto Dischinger; Fischer, Simone Matheus; Izar, Maria Cristina Oliveira; Fonseca, Francisco A. H.

doi:10.36660/abc.20200600

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Original Article • Arq. Bras. Cardiol. 117 (5) • Nov 2021 • https://doi.org/10.36660/abc.20200600 copy

Performance of the Electrocardiogram in the Diagnosis of Left Ventricular Hypertrophy in Older and Very Older Hypertensive Patients

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Left ventricular hypertrophy (LVH) is an important cardiovascular risk factor, regardless of arterial hypertension. Despite the evolution of imaging tests, the electrocardiogram (ECG) is still the most used in the initial evaluation, however, with low sensitivity.

Objective:

To evaluate the performance of the main electrocardiographic criteria for LVH in elderly and very elderly hypertensive individuals.

Methods:

In a cohort of hypertensive patients, ECGs and doppler echocardiographies (ECHO) were performed and separated into three age groups: <60 years, Group I; 60-79 years Group II; and ≥80 years, Group III. The most used electrocardiographic criteria were applied for the diagnosis of LVH: Perugia; Pegaro-Lo Presti; Gubner-Ungerleider; Narita; (Rm+Sm) x duration; Cornell voltage; Cornell voltage duration; Sokolow-Lyon voltage; R of aVL ≥11 mm; RaVL duration. In evaluating the performance of these criteria, in addition to sensitivity (Sen) and specificity (Esp), the “Diagnostic Odds Ratios” (DOR) were analyzed. We considered p-value <0.05 for the analyses, with two-tailed tests.

Results:

In 2,458 patients, LVH was present by ECHO in 781 (31.7%). In Groups I and II, the best performances were for the criteria of Narita, Perugia, (Rm+Sm) x duration, with no statistical differences between them. In Group III (very elderly) the Perugia criteria and (Rm+Sm) x duration had the best performances: Perugia [44,7/89.3; (Sen/Esp)] and (Rm+Sm) duration [39.4%/91.3%; (Sen/Esp), p<0.05)], with the best PAIN results:6.8. This suggests that in this very elderly population, these criteria have greater discriminatory power to separate patients with LVH.

Conclusion:

In very elderly hypertensive patients, the Perugia electrocardiographic criteria and (Rm+Sm) x duration showed the best diagnostic performance for LVH.

Keywords:
Electrocardiography/methods; Aged; Hypertrophy, Left Ventricular; Hypertension; Heart Failure; Stroke; Myocardial Infarction

Age group		<60 years	60-79 years	≥80 years
N total: (2458)		1270	1103	85
Sex, n (%)
	Male	362 (28.5%)	365 (33.1%)	26 (30.5%)
	Female	908 (71.5%)	738 (66.9%)	59 (69.4%)
Age (years), mean (SD)		50.1 (7.4)	67 (5.2)	84 (3.9)
Weight (kg), mean (SD)		74.4 (16.1)	70.5 (12.9)	64.8 (12.8)
Height (m), mean (SD)		1.61 (0.09)	1.60 (0.07)	1.59 (0.09)
BMI, mean (SD)		28.58 (5.61)	27.53 (4.63)	25.65 (4.51)
BS (m²), mean (SD)		1.75 (0.21)	1.70 (0.18)	1.63 (0.18)
LF cavities (cm), mean (SD)
IV septum		0.98 (0.17)	1.00 (0.17)	1.02 (0.15)
Posterior wall		0.95 (0.16)	0.96 (0.15)	0.96 (0.13)
Diastolic diameter		4.78 (0.52)	4.79 (0.57)	4.80 (0.65)
No LVH on ECO		924	705	47
LVH on ECHO, n (%)		345 (27.1%)	398 (36.0%)	38 (44.7%)
LVMI (g/m²), mean (SD)		93.03 (28.79)	98.33 (27.65)	102.70 (32.74)

Criteria for LVH	GI (< 60 years)		GII (60-79 years)		GIII (≥ 80 years)
	Sensitivity	Specificity	Sensitivity	Specificity	Sensitivity	Specificity
	(95%CI)	(95%CI)	(95%CI)	(95%CI)	(95%CI)	(95%CI)
Perugia	32.2	91.7	35.6	88.5	44.7	89.3
Perugia	(27.3-37.1)	(89.8-93.3)	(31.1-40.5)	(85.9-90.6)	(30.1-60.2)	(77.4-95.3)
(Rmax + Smax) x duration	33.8	88.9	32.4	88.9	39.4	91.3
(Rmax + Smax) x duration	(29.0-38.9)	(86.7-90.8)	(28.0-37.1)	(86.4-91.0)	(25.6-55.2)	(79.6-96.5)
Peguero-Lo Presti	20.2	96.6	17.8	96.7	34.2	89.3
Peguero-Lo Presti	(16.3-24.7)	(95.2-97.6)	(14.3-21.9)	(95.1-97.8)	(21.2-50.1)	(77.4-95.3)
Narita	39.6	89.3	38.1	87.5	26.3	91.4
Narita	(34.5-44.8)	(87.2-91.2)	(33.5-43.0)	(84.8-89.7)	(14.9-42.0)	(80.0-96.6)
Romhilt-Estes	16.1	96.4	14.5	95	21	93.6
Romhilt-Estes	(12.6-20.4)	(95.0-97.4)	(11.4-18.3)	(93.1-96.4)	(11.0-36.3)	(82.8-97.8)
Cornell's voltage [≥ 28 mm (m); ≥ 20mm (f)]	18.2	97.1	17.3	90.6	21	91.4
Cornell's voltage [≥ 28 mm (m); ≥ 20mm (f)]	(14.5-22.6)	(95.9-98.0)	(13.9-21.3)	(88.3-92.5)	(11.0-36.3)	(80.0-96.6)
Sokolow-Lyon voltage (≥ 30 mm)	23.7	92.1	20.8	92.6	21	93.6
Sokolow-Lyon voltage (≥ 30 mm)	(19.5-28.4)	(90.1-93.6)	(17.1-25.1)	(90.4-94.3)	(11.0-36.3)	(82.8-97.8)
Sokolow-Lyon voltage (≥ 35 mm)	14.7	97.1	12	97.1	15.7	97.8
Sokolow-Lyon voltage (≥ 35 mm)	(11.3-18.8)	(95.9-98.0)	(9.2-15.6)	(95.6-98.1)	(7.4-30.4)	(88.8-99.6)
Cornell's voltage duration (≥ 2440 mm.ms)	20.5	96.1	20.1	95.3	21	91.4
Cornell's voltage duration (≥ 2440 mm.ms)	(16.6-25.0)	(94.6-97.1)	(16.4-24.3)	(93.5-96.6)	(11.0-36.3)	(80.0-96.6)
Gubner-Ungerleider (≥ 25 mV)	18.5	97.2	16	97	15.7	93.6
Gubner-Ungerleider (≥ 25 mV)	(14.7-22.9)	(96.0-98.1)	(12.8-20.0)	(95.4-98.0)	(7.4-30.4)	(82.8-97.8)
RaVL (≥ 11 mm)	11.8	96.6	12.3	95.8	15.7	93.6
RaVL (≥ 11 mm)	(8.8-15.6)	(95.2-97.6)	(9.4-15.9)	(94.1-97.1)	(7.4-30.4)	(82.8-97.8)
V₆/V₅(> 1)	15.3	88.1	14	90	13.1	87.2
V₆/V₅(> 1)	(11.9-19.4)	(86.9-90.1)	(11.0-17.8)	(87.6-92.0)	(5.7-27.3)	(74.8-94.0)
RaVL x duration	8.9	98.2	11.8	97.5	7.8	97.8
RaVL x duration	(6.3-12.4)	(97.2-98.9)	(9.0-15.3)	(96.1-98.4)	(2.7-20.8)	(88.8-99.6)

Criteria for LVH	GI (< 60 years)	GII (60-79 years)	GIII (≥ 80 years)
Perugia	5.2 (3.8-7.2)	4.2 (3.1-5.8)	6.8 (2.2-20.9)
(Rmax + Smax) product ≥ 2.8 mm.s	4.1 (3.0-5.5)	3.8 (2.8-5.2)	6.8 ( 2.0-23.0)
Peguero-Lo Presti	7.3 (4.6-11.3)	6.4 (3.9-10.4)	4.3 (1.3-13.7)
Narita	5.5 (4.0-7.4)	4.3 (3.2-5.8)	3.8 (1.09-13.4)
Romhilt-Estes	5.2 (3.3-8.1)	3.2 (2.1-5.0)	3.9 (0.9-15.9)
Cornell's voltage: ≥ 28 mm (h); ≥ 20 mm (m)	7.6 (4.7-12.3)	2.0 (1.4-2.8)	2.8 (0.7-10.3)
Sokolow-Lyon voltage ≥ 30 mm	3.6 (2.5-5.1)	3.3 (2.2-4.7)	3.9 (0.95-15.9)
Sokolow-Lyon voltage ≥ 35 mm	5.9 (3.6-9.7)	4.6 (2.7-8.0)	8.6 (0.99-75.12)
Cornell's voltage duration ≥ 2440 mm.ms	6.3 (4.1-9.7)	5.1 (3.3-7.8)	2.8 (0.7-10.3)
Gubner-Ungerleider ≥ 25 mV	8.1 (5.0-13.2)	6.2 (3.7-10.3)	2.7 (0.6-11.8)
RaVL ≥ 11 mm	3.8 (2.3-6.2)	3.2 (2.0-5.2)	1.9 (0.3-12.1)
V₆/V₅ratio > 1	1.3 (0.9-1.9)	1.4 (1.0-2.1)	1.03 (0.29-3.6)
RaVL.dur QRS > 103 mm.ms	5.5 (3.0-10.3)	5.4 (3.0-9.5)	3.9 (0.39-39.5)

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