DÄ internationalArchive15/2008Accuracy of Electrocardiography in Diagnosis of Left Ventricular Hypertrophy in Arterial Hypertension - Systematic Review: In Reply

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Accuracy of Electrocardiography in Diagnosis of Left Ventricular Hypertrophy in Arterial Hypertension - Systematic Review: In Reply

Dtsch Arztebl Int 2008; 105(15): 292. DOI: 10.3238/arztebl.2008.0292b

Pewsner, D

LNSLNS Dr. Doepp's comments prompted us to perform a PubMed literature search on this subject. We retrieved six articles evaluating heart-rate variability (HRV) in the diagnosis of left ventricular hypertrophy (LVH) (1–6). Indeed, as Dr. Doepp states, all six studies demonstrated an inverse correlation between HRV and the degree of left ventricular hypertrophy in echocardiography. Diminished HRV is thus a sign of stiffening of the heart in LVH, the severity of which is also positively correlated with the age of the patient and with the severity of arterial hypertension.

The informational value of these papers is limited by the fact that all of them are diagnostic case-control studies. In all six studies, hypertensive individuals with echocardiographically demonstrated LVH were compared to healthy control individuals. Artificial study populations of this type, in which persons in an advanced stage of disease are set against healthy persons without comorbidity, are but a poor substitute for the group of patients for whom the diagnostic technique under investigation is actually intended. We know from empirical research that such studies tend to overestimate the value of diagnostic tests to a marked extent (7). Moreover, the six studies were small (22 to 92 cases), which limits their value still further.

Even if the postulated correlation between low HRV and LVH were to be confirmed in larger studies involving representative populations of hypertensive patients, we are not sure whether this test would then become an established part in the diagnosis of LVH. The reason is that HRV measurement requires a long-term electrocardiogram and complex electronic analysis. The effort and expense needed for HRV measurement are thus comparable to those of echocardiography, rather than the cheap and easily obtainable ECG. Echocardiography, which is considered the gold standard for the diagnosis of LVH, is in all likelihood of greater diagnostic value than HRV measurement even in the best case.

We therefore stick by our statement that, in the primary and secondary medical care of hypertensive patients at risk for, or already suspected of having, left ventricular hypertrophy, echocardiography should be performed as the diagnostic method of choice – even if the ECG findings are negative. DOI: 10.3238/arztebl.2008.0292b


Dr. med. Daniel Pewsner
Institute of Social and Preventive Medicine (ISPM)
University of Bern
Finkenhubelweg 11
3012 Bern, Switzerland

Conflict of interest statement
The authors of the above letter and the reply to it state that they have no conflict of interest as defined by the guidelines of the International Committee of Medical Journal Editors.
1.
Alter P, Grimm W, Vollrath A, Czerny F, Maisch B: Heart rate variability in patients with cardiac hypertrophy – relation to left ventricular mass and etiology. Am Heart J 2006;151: 829–36. MEDLINE
2.
Chakko S, Mulingtapang RF, Huikuri HV, Kessler KM, Materson BJ, Myerburg RJ: Alterations in heart rate variability and its circadian rhythm in hypertensive patients with left ventricular hypertrophy free of coronary artery disease. Am Heart J 1993;126: 1364–72. MEDLINE
3.
Mandawat MK, Wallbridge DR, Pringle SD, Riyami AA, Latif S, Macfarlane PW et al.: Heart rate variability in left ventricular hypertrophy. Br Heart J 1995; 73: 139–44. MEDLINE
4.
Martini G, Rabbia F, Gastaldi L, Riva P, Sibona MP, Morra di Cella S et al.: Heart rate variability and left ventricular diastolic function in patients with borderline hypertension with and without left ventricular hypertrophy. Clin Exp Hypertens 2001; 23: 77–87. MEDLINE
5.
Piccirillo G, Bucca C, Tarantini S, Santagada E, Viola E, Durante M et al.: Left ventricular mass and heart rate variability in middle-aged and elderly salt-sensitive hypertensive subjects. Arch Gerontol Geriatr 1999; 28: 159–77. MEDLINE
6.
Ryabykina GV, Sobolev AV, Pushina EA, Lutikova LN, Aleeva MK, Sergakova LM et al.: Influence of left ventricular hypertrophy on heart rate variability in hypertensive patients. Bratisl Lek Listy 1996; 97: 526–30. MEDLINE
7.
Lijmer JG, Mol BW, Heisterkamp S, Bonsel GJ, Prins MH, van der Meulen JH et al.: Empirical evidence of design-related bias in studies of diagnostic tests. Jama 1999; 282: 1061–6. MEDLINE
1. Alter P, Grimm W, Vollrath A, Czerny F, Maisch B: Heart rate variability in patients with cardiac hypertrophy – relation to left ventricular mass and etiology. Am Heart J 2006;151: 829–36. MEDLINE
2. Chakko S, Mulingtapang RF, Huikuri HV, Kessler KM, Materson BJ, Myerburg RJ: Alterations in heart rate variability and its circadian rhythm in hypertensive patients with left ventricular hypertrophy free of coronary artery disease. Am Heart J 1993;126: 1364–72. MEDLINE
3. Mandawat MK, Wallbridge DR, Pringle SD, Riyami AA, Latif S, Macfarlane PW et al.: Heart rate variability in left ventricular hypertrophy. Br Heart J 1995; 73: 139–44. MEDLINE
4. Martini G, Rabbia F, Gastaldi L, Riva P, Sibona MP, Morra di Cella S et al.: Heart rate variability and left ventricular diastolic function in patients with borderline hypertension with and without left ventricular hypertrophy. Clin Exp Hypertens 2001; 23: 77–87. MEDLINE
5. Piccirillo G, Bucca C, Tarantini S, Santagada E, Viola E, Durante M et al.: Left ventricular mass and heart rate variability in middle-aged and elderly salt-sensitive hypertensive subjects. Arch Gerontol Geriatr 1999; 28: 159–77. MEDLINE
6. Ryabykina GV, Sobolev AV, Pushina EA, Lutikova LN, Aleeva MK, Sergakova LM et al.: Influence of left ventricular hypertrophy on heart rate variability in hypertensive patients. Bratisl Lek Listy 1996; 97: 526–30. MEDLINE
7. Lijmer JG, Mol BW, Heisterkamp S, Bonsel GJ, Prins MH, van der Meulen JH et al.: Empirical evidence of design-related bias in studies of diagnostic tests. Jama 1999; 282: 1061–6. MEDLINE

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