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. 2016 Oct 1;102(19):1566-72.
doi: 10.1136/heartjnl-2015-309201. Epub 2016 Aug 2.

Improvements in ECG accuracy for diagnosis of left ventricular hypertrophy in obesity

Oliver J Rider  1 , Ntobeko Ntusi  2 , Sacha C Bull  1 , Richard Nethononda  3 , Vanessa Ferreira  1 , Cameron J Holloway  4 , David Holdsworth  1 , Masliza Mahmod  1 , Jennifer J Rayner  1 , Rajarshi Banerjee  1 , Saul Myerson  1 , Hugh Watkins  1 , Stefan Neubauer  1
Affiliations

Improvements in ECG accuracy for diagnosis of left ventricular hypertrophy in obesity

Oliver J Rider et al. Heart. .

Abstract

Objectives: The electrocardiogram (ECG) is the most commonly used tool to screen for left ventricular hypertrophy (LVH), and yet current diagnostic criteria are insensitive in modern increasingly overweight society. We propose a simple adjustment to improve diagnostic accuracy in different body weights and improve the sensitivity of this universally available technique.

Methods: Overall, 1295 participants were included-821 with a wide range of body mass index (BMI 17.1-53.3 kg/m(2)) initially underwent cardiac magnetic resonance evaluation of anatomical left ventricular (LV) axis, LV mass and 12-lead surface ECG in order to generate an adjustment factor applied to the Sokolow-Lyon criteria. This factor was then validated in a second cohort (n=520, BMI 15.9-63.2 kg/m(2)).

Results: When matched for LV mass, the combination of leftward anatomical axis deviation and increased BMI resulted in a reduction of the Sokolow-Lyon index, by 4 mm in overweight and 8 mm in obesity. After adjusting for this in the initial cohort, the sensitivity of the Sokolow-Lyon index increased (overweight: 12.8% to 30.8%, obese: 3.1% to 27.2%) approaching that seen in normal weight (37.8%). Similar results were achieved in the validation cohort (specificity increased in overweight: 8.3% to 39.1%, obese: 9.4% to 25.0%) again approaching normal weight (39.0%). Importantly, specificity remained excellent (>93.1%).

Conclusions: Adjusting the Sokolow-Lyon index for BMI (overweight +4 mm, obesity +8 mm) improves the diagnostic accuracy for detecting LVH. As the ECG, worldwide, remains the most widely used screening tool for LVH, implementing these findings should translate into significant clinical benefit.

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Figures

Figure 1
Figure 1
Flow chart of subjects through the study. ECG, electrocardiogram; LVH, left ventricular hypertrophy.
Figure 2
Figure 2
Defining the coronal anatomical left ventricular axis using multiplanar reconstruction. Images show the coronal axis in the (A) short axis, (B) vertical long axis and (C) horizontal axis views.
Figure 3
Figure 3
The effect of obesity and leftward axis deviation on electrocardiogram (ECG) voltage criteria. (A) Clear left ventricular hypertrophy (LVH) in obesity with leftward axis and negative Sokolow–Lyon criteria for LVH, which becomes positive only when adjusted for body mass index (BMI) (by +8 mm) and (B) clear LVH in a normal weight participant with normal left ventricular (LV) anatomical axis and positive Sokolow–Lyon criteria for LVH. IVSd, Intraventricular Septum in Diastole.
See this image and copyright information in PMC

References

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