DÄ internationalArchive40/2007Accuracy of Electrocardiography in Diagnosis of Left Ventricular Hypertrophy in Arterial Hypertension

Review article

Accuracy of Electrocardiography in Diagnosis of Left Ventricular Hypertrophy in Arterial Hypertension

Systematic Review

Dtsch Arztebl 2007; 104(40): A-2732

Pewsner, D; Jüni, P; Egger, M; Battaglia, M; Sundström, J; Bachmann, L M

Objective: To review the accuracy of electrocardiography in screening for left ventricular hypertrophy in patients with hypertension. Design Systematic review of studies of test accuracy of six electrocardiographic indexes: the Soko-low-Lyon index, Cornell voltage index, Cornell product index, Gubner index, and Romhilt-Estes scores with thresholds for a positive test of 4 points or 5 points.
Data sources: Electronic databases ((Pre-)Medline, Embase), reference lists of relevant studies and previous reviews, and experts.
Study selection: Two reviewers scrutinised abstracts and examined potentially eligible studies. Studies comparing the electrocardiographic index with echocardiography in hypertensive patients and reporting sufficient data were included. Data extraction Data on study populations, echocardiographic criteria, and methodological quality of studies were extracted.
Data synthesis: Negative likelihood ratios, which indicate to what extent the posterior odds of left ventricular hypertrophy is reduced by a negative test, were calculated.
Results: 21 studies and data on 5608 patients were analysed. The median prevalence of left ventricular hypertrophy was 33% (interquartile range 23–41%) in primary care settings (10 studies) and 65% (37–81%) in secondary care settings (11 studies). The median negative likelihood ratio was similar across electrocardiographic indexes, ranging from 0.85 (range 0.34–1.03) for the Romhilt-Estes score (with threshold 4 points) to 0.91 (0.70–1.01) for the Gubner index. Using the Romhilt-Estes score in primary care, a negative electrocardiogram result would reduce the typical pre-test probability from 33% to 31%. In secondary care the typical pretest probability of 65% would be reduced to 63%.
Conclusion: Electrocardiographic criteria should not be used to rule out left ventricular hypertrophy in patients with hypertension.
LNSLNS The original English version of this article has been published in the British Medical Journal and can be accessed at

http://bmj.com/cgi/reprint_abr/335/7622/711
1.
Kannel WB, Gordon T, Offutt D: Left ventricular hypertrophy by electrocardiogram: prevalence, incidence, and mortality in the Framingham study. Ann Intern Med 1969; 71: 89–105. MEDLINE
2.
Kannel WB, Gordon T, Castelli WP, Margolis JR: Electrocardiographic left ventricular hypertrophy and risk of coronary heart disease: the Framingham study. Ann Intern Med 1970; 72: 813–22. MEDLINE
3.
Haider AW, Larson MG, Benjamin EJ, Levy D: Increased left ventricular mass and hypertrophy are associated with increased risk for sudden death. J Am Coll Cardiol 1998; 32: 1454–9. MEDLINE
4.
Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Gattobigio R, Zampi I et al.: Prognostic value of a new electrocardiographic method for diagnosis of left ventricular hypertrophy in essential hypertension. J Am Coll Cardiol 1998; 31: 383–90. MEDLINE
5.
Sundström J, Lind L, Amlöv J, Zethelius B, Andrén B, Lithell HO: Echocardiographic and electrocardiographic diagnoses of left ventricular hypertrophy predict mortality independently of each other in a population of elderly men. Circulation 2001; 103: 2346–51. MEDLINE
6.
Sokolov M, Lyon TP: The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads. American Heart Journal 1949; 37: 161–86. MEDLINE
7.
Casale PN, Devereux RB, Kligfield P, Eisenberg RR, Miller DH, Chaudhary BS et al.: Electrocardiographic detection of left ventricular hypertrophy: development and prospective validation of improved criteria. J Am Coll Cardiol 1985; 6: 572–80. MEDLINE
8.
Norman JE Jr, Levy D: Adjustment of ECG left ventricular hypertrophy criteria for body mass index and age improves classification accuracy: the effects of hypertension and obesity. J Electrocardiol 1996; 29: 241–7. MEDLINE
9.
Gubner R, Ungerleider HE: Electrocardiographic criteria of left ventricular hypertrophy. Factors determining the evaluation of the electrocardiographic patterns in hypertrophy and bundle branch block. Arch Intern Med 1943; 72: 196–206.
10.
Romhilt DW, Estes EH Jr: A point-score system for the ECG diagnosis of left ventricular hypertrophy. Am Heart J 1968; 75: 752–8. MEDLINE
11.
Schillaci G, Verdecchia P, Pede S, Porcellati C: Electrocardiography for left ventricular hypertrophy in hypertension: time for re-evaluation? G Ital Cardiol 1998; 28: 706–13. MEDLINE
12.
Verdecchia P, Dovellini EV, Gorini M, Gozzelino G, Lucci D, Milletich A et al.: Comparison of electrocardiographic criteria for diagnosis of left ventricular hypertrophy in hypertension: the MAVI study. Ital Heart J 2000; 1: 207–15. MEDLINE
13.
Conway D, Lip GY: The ECG and left ventricular hypertrophy in primary care hypertensives. J Hum Hypertens 2001; 15: 215–7. MEDLINE
14.
Lijmer JG, Mol BW, Heisterkamp S, Bonsel GJ, Prins MH, vander Meulen JH et al.: Empirical evidence of design-related bias in studies of diagnostic tests. JAMA 1999; 282: 1061–6. MEDLINE
15.
Whiting P, Rutjes AW, Reitsma JB, Glas AS, Bossuyt PM, Kleijnen J: Sources of variation and bias in studies of diagnostic accuracy: a systematic review. Ann Intern Med 2004; 140: 189–202. MEDLINE
16.
Jaeschke R, Guyatt G, Sackett DL: Users’ guides to the medical literature III: how to use an article about a diagnostic test A: are the results of the study valid? Evidence-Based Medicine Working Group. JAMA 1994; 271: 389–91. MEDLINE
17.
Pewsner D, Battaglia M, Minder C, Marx A, Bucher HC, Egger M: Ruling a diagnosis in or out with "SpPIn" and "SnNOut": a note of caution. BMJ 2004; 329: 209–13. MEDLINE
18.
Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ et al.: Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003; 289: 2083–93. MEDLINE
19.
Svetkey LP, Erlinger TP, Vollmer WM, Feldstein A, Cooper LS, Appel LJ et al.: Effect of lifestyle modifications on blood pressure by race, sex, hypertension status, and age. J Hum Hypertens 2005; 19: 21–31. MEDLINE
20.
Jackson R, Lawes CM, Bennett DA, Milne RJ, Rodgers A: Treatment with drugs to lower blood pressure and blood cholesterol based on an individual’s absolute cardiovascular risk. Lancet 2005; 365: 434–41. MEDLINE
1. Kannel WB, Gordon T, Offutt D: Left ventricular hypertrophy by electrocardiogram: prevalence, incidence, and mortality in the Framingham study. Ann Intern Med 1969; 71: 89–105. MEDLINE
2. Kannel WB, Gordon T, Castelli WP, Margolis JR: Electrocardiographic left ventricular hypertrophy and risk of coronary heart disease: the Framingham study. Ann Intern Med 1970; 72: 813–22. MEDLINE
3. Haider AW, Larson MG, Benjamin EJ, Levy D: Increased left ventricular mass and hypertrophy are associated with increased risk for sudden death. J Am Coll Cardiol 1998; 32: 1454–9. MEDLINE
4. Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Gattobigio R, Zampi I et al.: Prognostic value of a new electrocardiographic method for diagnosis of left ventricular hypertrophy in essential hypertension. J Am Coll Cardiol 1998; 31: 383–90. MEDLINE
5. Sundström J, Lind L, Amlöv J, Zethelius B, Andrén B, Lithell HO: Echocardiographic and electrocardiographic diagnoses of left ventricular hypertrophy predict mortality independently of each other in a population of elderly men. Circulation 2001; 103: 2346–51. MEDLINE
6. Sokolov M, Lyon TP: The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads. American Heart Journal 1949; 37: 161–86. MEDLINE
7. Casale PN, Devereux RB, Kligfield P, Eisenberg RR, Miller DH, Chaudhary BS et al.: Electrocardiographic detection of left ventricular hypertrophy: development and prospective validation of improved criteria. J Am Coll Cardiol 1985; 6: 572–80. MEDLINE
8. Norman JE Jr, Levy D: Adjustment of ECG left ventricular hypertrophy criteria for body mass index and age improves classification accuracy: the effects of hypertension and obesity. J Electrocardiol 1996; 29: 241–7. MEDLINE
9. Gubner R, Ungerleider HE: Electrocardiographic criteria of left ventricular hypertrophy. Factors determining the evaluation of the electrocardiographic patterns in hypertrophy and bundle branch block. Arch Intern Med 1943; 72: 196–206.
10. Romhilt DW, Estes EH Jr: A point-score system for the ECG diagnosis of left ventricular hypertrophy. Am Heart J 1968; 75: 752–8. MEDLINE
11. Schillaci G, Verdecchia P, Pede S, Porcellati C: Electrocardiography for left ventricular hypertrophy in hypertension: time for re-evaluation? G Ital Cardiol 1998; 28: 706–13. MEDLINE
12. Verdecchia P, Dovellini EV, Gorini M, Gozzelino G, Lucci D, Milletich A et al.: Comparison of electrocardiographic criteria for diagnosis of left ventricular hypertrophy in hypertension: the MAVI study. Ital Heart J 2000; 1: 207–15. MEDLINE
13. Conway D, Lip GY: The ECG and left ventricular hypertrophy in primary care hypertensives. J Hum Hypertens 2001; 15: 215–7. MEDLINE
14. Lijmer JG, Mol BW, Heisterkamp S, Bonsel GJ, Prins MH, vander Meulen JH et al.: Empirical evidence of design-related bias in studies of diagnostic tests. JAMA 1999; 282: 1061–6. MEDLINE
15. Whiting P, Rutjes AW, Reitsma JB, Glas AS, Bossuyt PM, Kleijnen J: Sources of variation and bias in studies of diagnostic accuracy: a systematic review. Ann Intern Med 2004; 140: 189–202. MEDLINE
16. Jaeschke R, Guyatt G, Sackett DL: Users’ guides to the medical literature III: how to use an article about a diagnostic test A: are the results of the study valid? Evidence-Based Medicine Working Group. JAMA 1994; 271: 389–91. MEDLINE
17. Pewsner D, Battaglia M, Minder C, Marx A, Bucher HC, Egger M: Ruling a diagnosis in or out with "SpPIn" and "SnNOut": a note of caution. BMJ 2004; 329: 209–13. MEDLINE
18. Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ et al.: Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003; 289: 2083–93. MEDLINE
19. Svetkey LP, Erlinger TP, Vollmer WM, Feldstein A, Cooper LS, Appel LJ et al.: Effect of lifestyle modifications on blood pressure by race, sex, hypertension status, and age. J Hum Hypertens 2005; 19: 21–31. MEDLINE
20. Jackson R, Lawes CM, Bennett DA, Milne RJ, Rodgers A: Treatment with drugs to lower blood pressure and blood cholesterol based on an individual’s absolute cardiovascular risk. Lancet 2005; 365: 434–41. MEDLINE

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