Clinical Investigation
Congestive Heart Failure
Diagnostic and prognostic utility of electrocardiography for left ventricular hypertrophy defined by magnetic resonance imaging in relationship to ethnicity: The Multi-Ethnic Study of Atherosclerosis (MESA)

https://doi.org/10.1016/j.ahj.2009.12.035Get rights and content

Background

Left ventricular mass is a strong predictor of cardiovascular disease (CVD), and magnetic resonance imaging (MRI) of the heart is a standard of reference for left ventricular mass measurement. Ethnicity is believed to affect electrocardiographic (ECG) performance. We evaluated the diagnostic and prognostic performance of ECG for left ventricular hypertrophy (LVH) as defined by MRI in relationship to ethnicity.

Methods

Data were analyzed from 4,967 participants (48% men, mean age 62 ± 10 years; 39% white, 13% Chinese, 26% African American, 22% Hispanic) enrolled in the Multi-Ethic Study of Atherosclerosis (MESA) who were followed for a median of 4.8 years for incident CVD.

Results

Thirteen traditional ECG-LVH criteria were assessed, and showed overall and ethnicity-specific low sensitivity (10%-26%) and high specificity (88%-99%) in diagnosing MRI-defined LVH. Ten of 13 ECG-LVH criteria showed superior sensitivity and diagnostic performance in African Americans as compared with whites (P = .02-.001). The sum of amplitudes of S wave in V1, S wave in V2, and R wave in V5 (a MESA-specific ECG-LVH criterion) offered higher sensitivity (40.4%) compared with prior ECG-LVH criteria while maintaining good specificity (90%) and diagnostic performance (receiver operating characteristic area = 0.65). In fully adjusted models, only the MESA-specific ECG-LVH criterion, Romhilt-Estes score, Framingham score, Cornell voltage, Cornell duration product, and Framingham-adjusted Cornell voltage predicted increased CVD risk (P < .05).

Conclusions

Electrocardiography has low sensitivity but high specificity for detecting MRI-defined LVH. The performance of ECG for LVH detection varies by ethnicity, with African Americans showing higher sensitivity and overall performance compared with other ethnic groups.

Section snippets

Study sample and traditional risk factor measurements

MESA is a prospective longitudinal study initiated in July 2000 to explore the prevalence, correlates, and progression of subclinical cardiovascular disease (CVD) in a population-based multiethnic cohort free of clinically recognized CVD at enrollment, and selected from 6 US participating field centers. The study objectives, design, and methods have been previously reported.14Hypertension was defined according to the Joint National Committee VI (1997) criteria as diastolic blood pressure ≥90 mm

Study sample and baseline characteristics

The study sample consisted of 4,967 participants (2,365 men [47.6%], mean age 61.5 ± 10.1 years) (Table I). The ethnicity of the study sample was 38.8% whites, 13.2% Chinese, 25.7% African Americans, and 22.3% Hispanics. Three hundred eighty-four (7.7%) of 4,967 participants had LVH on MRI.

Overall diagnostic performance of ECG-LVH measures against MRI-LVH

Sensitivity, specificity, and area under the curve (AUC) of traditional ECG-LVH measures to detect MRI-LVH ranged from 5.7% to 26.0%, 88.7% to 99.2%, and 0.52 to 0.59, respectively. All criteria showed a

Discussion

In this study, we assessed the diagnostic and prognostic utility of standard ECG measures of LVH in a large multiethnic sample using cardiac MRI to quantify LV mass. We found that commonly used ECG-LVH criteria show a low overall sensitivity that varied by ethnicity, a high specificity, and overall low diagnostic performance in diagnosing LVH as defined by MRI. This finding is consistent with previous studies that have also shown ECG to be typically insensitive and highly specific in detecting

Conclusions

Although ECG has a low sensitivity to diagnose MRI-defined LVH, the standard ECG is the first-line investigation for suspected LVH in view of its simplicity, widespread availability, and low cost. The performance of ECG for LVH detection varies substantially by ethnicity, with the African American subgroup showing higher overall performance compared with other ethnic groups. Our results from a multiethnic study population suggest that alternative ECG criteria may improve detection of LVH. Most

Disclosures

There are no conflicts of interest and financial disclosures for any of the authors.

Acknowledgements

The authors thank other investigators, staff, and participants of the MESA Study for their valuable contributions. A full list of participating MESA investigators and institutions can be found at http://www.mesa-nhlbi.org.

References (27)

Cited by (100)

View all citing articles on Scopus
View full text