By Michael H. Crawford, MD
Professor of Medicine, Chief of Clinical Cardiology, University of California, San Francisco
Dr. Crawford reports no financial relationships relevant to this field of study.
SYNOPSIS: In comparison to other popular criteria for the ECG diagnosis of left ventricular hypertrophy, the newly proposed Peguero-Lo Presti criteria, when tested in patients with proximate ECGs and echocardiograms, showed superior sensitivity and accuracy.
SOURCES: Peguero JG, Lo Presti S, Perez J, et al. Electrocardiographic criteria for the diagnosis of left ventricular hypertrophy. J Am Coll Cardiol 2017;69:1694-1703.
Boyle NG, Vohra JK. The enduring role of the electrocardiogram as a diagnostic tool in cardiology. J Am Coll Cardiol 2017;69:1704-1706.
The current popular ECG criteria for diagnosing left ventricular hypertrophy (LVH) are highly specific, but lack sensitivity. Thus, investigators from Columbia University tested a new, more sensitive criteria compared to other current criteria to see if the accuracy of LVH determination could be improved. To do so, they selected 50 patients admitted to the Mount Sinai Medical Center in Miami for hypertensive crisis and 50 additional patients with normal blood pressure and no major cardiac disease who also received ECGs during the same admission. Six patients were excluded because of poor echoes. These 94 patients were the test cohort. A validation cohort comprised the first 150 patients referred for an echocardiogram who also received a concomitant ECG. Because of poor echoes, 28 of these patients were excluded. Notably, patients with ECGs showing complete right or left bundle branch block or a paced rhythm were never considered for the study. Left ventricular mass index by echo was the standard for diagnosing LVH. The closest ECG to the time of the echo was chosen for the analysis. Four ECG criteria (Cornell, Sokolow-Lyon, R aVL, R lead 1) were compared to the new Peguero-Lo Presti (PLP) criteria. The PLP criterion was the deepest S wave in any lead plus the S wave amplitude in V4. If these were the same, the amplitude of the S wave in V4 was doubled. Values ≥ 2.3 mV in women and ≥ 2.8 mV in men were used to diagnose LVH by ECG. The PLP criteria performed well in the test cohort, which exhibited an LVH prevalence of 32% (area under the curve [AUC], 0.85). The validation cohort demonstrated a higher prevalence of LVH (42%) and was older. The PLP performed well (AUC, 0.80) and demonstrated the best sensitivity for LVH (57%), followed by Cornell (31%) and Sokolow-Lyon and the single-lead measurements (all at 14%). Specificities were ≥ 90% for all criteria and were not significantly different. The authors concluded that the proposed PLP criteria improved the sensitivity and accuracy of ECG LVH diagnosis significantly.
COMMENTARY
According to the American College of Cardiology/American Heart Association/Heart Rhythm Society ECG guidelines, there are at least three dozen ECG criteria for LVH. All of them have low sensitivity and high specificity, and none are considered superior to the others. Most computer analysis software uses some of these criteria with potential tweaks based on their beta testing. Drs. Peguero and Lo Presti believed that the problem with most of the existing criteria is that they focused on R waves and other events early in the QRS complex, such as the intrinsicoid deflection. Since the vectors of the depolarization of the LV myocardium are later in the QRS and directed posterolaterally, they hypothesized that the S wave may be more sensitive for detecting milder degrees of LVH. Their studies showed that the amplitude of the deepest S wave plus the S wave in V4, if ≥ 2.3 mV (23 mm) in women or ≥ 2.8 mV (28 mm) in men, indicated LVH. If the deepest S wave is in V4, then double the value. This study confirmed the value of the PLP criteria compared to the most popular current criteria. Not only is it much more sensitive than other criteria, but it is simple to use.
There are limitations to this study. It is small, and the authors didn’t consider race or ethnicity. Also, one could argue that cardiac MRI would be a better gold standard for LVH determination, but it is expensive and less available than echo. Additionally, the authors did not provide data on the type of LVH. It is well known that the current criteria are even worse at detecting eccentric vs. concentric LVH. Although a larger study with more of this information would be desirable, this study is so sufficiently robust that I am going to start using these new criteria immediately.
In comparison to other popular criteria for the ECG diagnosis of left ventricular hypertrophy, the newly proposed Peguero-Lo Presti criteria, when tested in patients with proximate ECGs and echocardiograms, showed superior sensitivity and accuracy.
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