Combining ECG Criteria for Left Ventricular Hypertrophy Improves Risk Prediction in Patients With Hypertension

Peter M Okin, Darcy A Hille, Sverre E Kjeldsen, Richard B Devereux, Peter M Okin, Darcy A Hille, Sverre E Kjeldsen, Richard B Devereux

Abstract

Background: Patients with hypertension with ECG left ventricular hypertrophy (LVH) have higher cardiovascular morbidity and mortality, but single ECG criteria may underestimate risk. Whether continued presence or new development of ECG LVH by 2 criteria can further concentrate risk during blood pressure lowering is unclear.

Methods and results: Incident stroke, myocardial infarction, cardiovascular death, the composite of these outcomes, and all-cause mortality were examined in relation to the presence of on-treatment ECG LVH by Cornell product and/or Sokolow-Lyon voltage during a mean of 4.8±0.9 years follow-up in 9193 patients with hypertension randomized to losartan- or atenolol-based regimens. Patients were categorized into 4 groups according to the presence or absence of ECG LVH by each criterion at baseline and yearly during the study. At baseline, LVH by both criteria was present in 960 patients (10.4%). Compared with the absence of ECG LVH by both criteria, persistence or development of ECG LVH by both criteria entered as a time-varying covariate was associated with >3-fold increased risks of events in multivariable Cox analyses adjusting for randomized treatment, baseline risk factors, and on-treatment heart rate and systolic and diastolic blood pressures. Patients with ECG LVH by either Cornell product or Sokolow-Lyon voltage had 45% to 140% higher risks of all end points.

Conclusions: Persistence or development of ECG LVH by both Cornell product and Sokolow-Lyon voltage criteria during antihypertensive therapy is associated with markedly increased risks of cardiovascular end points and all-cause mortality. Further study is indicated to determine whether additional therapy in these patients can reduce their risk.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00338260.

Keywords: ECG; ECG criteria; hypertension; hypertrophy; prognosis.

© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
Rates of myocardial infarction (MI, Panel A), stroke (Panel B), cardiovascular death (Panel C), the composite end point (Panel D), and all‐cause mortality (Panel E) in relation to the presence or absence of ECG left ventricular hypertrophy by both Cornell product (CP) and Sokolow‐Lyon voltage (SL) at study baseline. CI indicates confidence interval; CV, cardiovascular.
Figure 2
Figure 2
Risk of myocardial infarction (Panel A), stroke (Panel B), cardiovascular death (Panel C), the composite end point (Panel D), and all‐cause mortality (Panel E) in relation to the on‐treatment presence or absence of ECG left ventricular hypertrophy by both Cornell product (CP) and Sokolow‐Lyon voltage (SL) treated as time‐varying covariates in Cox analyses. *Adjusted for randomized treatment, age, sex, prevalent diabetes mellitus, history of stroke, myocardial infarction, ischemic heart disease, heart failure, peripheral vascular disease or prior antihypertensive treatment, baseline serum cholesterol, high‐density lipoprotein cholesterol, glucose and creatinine, and urine albumin/creatinine ratio treated as standard covariates, and on‐treatment heart rate and diastolic and systolic blood pressure treated as time‐varying covariates. CI indicates confidence interval.

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