jksh Journal of the Korean Society of Hypertension J Korean Soc Hypertens 2233-8136 2233-8454 The Korean Society of Hypertension 10.5646/jksh.2013.19.4.112 jksh-19-112 Original Article The Accuracy of Electrocardiogram Criteria for Left Ventricular Hypertrophy in Korean Cohort (Atherosclerosis Risk of a Rural Area Korean General Population) AhnMin-SooMD1 YooByung-SuMD1 LeeJi HyunMD1 LeeJun-WonMD1 YounYoung JinMD1 AhnSung GyunMD1 KimJang-YoungMD1 LeeSeung-HwanMD1 YoonJung hanMD1 ChoeKyung-HoonMD1 KohSang-BeakMD2 AhnSong VogueMD2 ParkJong-kuMD2 Division of Cardiology, Institute of Genomic Cohort, Yonsei University Wonju College of Medicine, Wonju, Korea Department of Preventive Medicine, Institute of Genomic Cohort, Yonsei University Wonju College of Medicine, Wonju, Korea Tel: 033) 741-0920, Fax: 033) 741-1219 E-mail: yubs@yonsei.ac.kr 12 2013 10 12 2013 19 4 112 122 28102013 31102013 09122013 Copyright © 2013 The Korean Society of Hypertension 2013 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background:

Left ventricular hypertrophy (LVH) offers prognostic information beyond that provided by the evaluation of traditional cardiovascular risk factors. However, the validation of electrocardiogram (ECG) criteria for the diagnosis of LVH is limited in Korea general population. The purpose of this study is to investigate the diagnostic accuracy of ECG criteria for the detection of LVH in general population.

 Methods:

In the present study, we investigated a total of 1,946 adults from the community-based cohort. The left ventricular mass index (LVMI) was estimated with echocardiographic measurement and adjusted with body surface area. LVH was defined as a value greater than or equal to the sex-specific 90th percentile value of LVMI. ECG criteria for the diagnosis of LVH were Sokolow-Lyon criteria and Cornell criteria.

 Results:

The LVMI was significantly higher in male subjects (91.1 ± 23.9 g/m2 vs. 83.9 ± 21.7 g/m2, p < 0.001). The cutoff values were 120.8 g/m2 in male subjects and 112.2 g/m2 in female subjects. The sensitivity and specificity of Sokolow-Lyon criteria were 5.6% and 93.6% in male, 4.1% and 97.8% in female. Those of Cornell criteria were 2.8% and 98.7% in male, 14.3% and 95.8% in female. In male, the area under the receiver operating characteristic curves of Sokolow-Lyon voltage and Cornell voltage were 0.55 and 0.52. And those in female were 0.59 and 0.60.

 Conclusions:

In our community-based sample, ECG criteria showed low sensitivity and high specificity. The performance of ECG criteria for detection of LVH was suboptimal, suggesting limited usefulness of ECG as mass screening tools.

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The correlation of electrocardiogram criteria and left ventricular (LV) mass index (g/m2). (A) The correlation between Sokolow-Lyon criteria and left ventricular mass index in male. (B) The correlation between Cornell voltage criteria and left ventricular mass index in male. (C) The correlation between Sokolow-Lyon criteria and left ventricular mass index in female. (D) The correlation between Cornell voltage criteria and left ventricular mass index in female.

Receiver operating characteristic curves for electrocardiogram criteria for detecting left ventricular hypertrophy in (A) male and (B) female. AUC, area under the curve.

Demographic and clinical characteristics of male subjects

Characteristic Without LVH (n = 659) With LVH (n = 73) p-value
Age (yr) 55.4 ± 8.5 59.6 ± 7.6 0.001 ＜
Height (cm) 167.5 ± 5.4 164.8 ± 5.8. 0.001 ＜
Weight (kg) 68.2 ± 9.0 69.6 ± 9.1 0.21
Waist circumference (cm) 88.3 ± 7.2 90.2 ± 12.2 0.26
Hip circumference (cm) 97.2 ± 5.2 98.5 ± 6.0 0.09
Body mass index (kg/m2) 24.3 ± 2.7 25.6 ± 3.1 0.001 ＜
History of hypertension (%) 172 (28.7) 28 (42.4) 0.02
History of diabetes mellitus (%) 74 (12.4) 9 (13.6) 0.77
History of hyperlipidemia (%) 73 (12.2) 4 (6.1) 0.14
Systolic blood pressure (mm Hg) 137.1 ± 18.7 141.4 ± 23.4 0.13
Diastolic blood pressure (mm Hg) 83.8 ± 11.9 84.6 ± 13.4 0.60
Glucose (mg/dL) 103.7 ± 25.7 104.8 ± 28.4 0.75
Total cholesterol (mg/dL) 197.7 ± 37.8 196.5 ± 30.5 0.79
High density lipoprotein cholesterol (mg/dL) 41.1 ± 9.3 43.5 ± 10.0 0.04
Low density lipoprotein cholesterol (mg/dL) 114.3 ± 32.3 113.0 ± 29.9 0.75
Triglyceride (mg/dL) 175.1 ± 156.7 160.9 ± 105.8 0.45
Creatinine (mg/dL) 1.1 ± 0.2 1.1 ± 0.2 0.10

Values are presented as mean ± standard deviation or frequency (%).

LVH, left ventricular hypertrophy.

Demographic and clinical characteristics of female subjects

Characteristic Without LVH (n = 1102) With LVH (n = 122) p-value
Age (yr) 53.4 ± 7.8 60.7 ± 11.4 0.001 ＜
Height (cm) 154.9 ± 5.3 151.7 ± 5.7 0.001 ＜
Weight (kg) 57.5 ± 8.3 62.5 ± 10.3 0.001 ＜
Waist circumference (cm) 82.8 ± 8.0 90.5 ± 8.3 0.001 ＜
Hip circumference (cm) 95.2 ± 5.6 99.5 ± 7.5 0.001 ＜
Body mass index (kg/m2) 23.9 ± 3.1 27.1 ± 4.0 0.001 ＜
History of hypertension (%) 224 (23.4) 48 (44.0) 0.001 ＜
History of diabetes mellitus (%) 67 (7.0) 19 (17.4) 0.001 ＜
History of hyperlipidemia (%) 131 (13.7) 16 (14.7) 0.78
Systolic blood pressure (mm Hg) 130.2 ± 18.5 139.7 ± 18.5 0.001 ＜
Diastolic blood pressure (mm Hg) 79.0 ± 11.1 83.5 ± 10.3 0.001 ＜
Glucose (mg/dL) 94.5 ± 14.6 97.3 ± 15.1 0.06
Total cholesterol (mg/dL) 199.5 ± 37.3 200.3 ± 39.6 0.81
High density lipoprotein cholesterol (mg/dL) 46.5 ± 11.0 44.3 ± 10.4 0.04
Low density lipoprotein cholesterol (mg/dL) 117.5 ± 32.7 117.2 ± 36.8 0.92
Triglyceride (mg/dL) 123.8 ± 65.8 153.1 ± 107.7 0.01 ＜
Creatinine (mg/dL) 0.8 ± 0.1 0.9 ± 0.6 0.03

Values are presented as mean ± standard deviation or frequency (%).

LVH, left ventricular hypertrophy.

Echocardiographic parameter in male subjects

Variable Without LVH (n = 659) With LVH (n = 73) p-value
IVSd (cm) 0.8 ± 0.1 1.0 ± 0.2 <0.001
LVPWd (cm) 0.9 ± 0.2 1.0 ± 0.2 <0.001
LVDd (cm) 5.1 ± 0.5 5.8 ± 0.6 <0.001
Relative wall thickness 0.35 ± 0.42 0.36 ± 0.08 0.93
Ejection fraction (%) 64.6 ± 7.7 63.8 ± 8.3 0.37
LV mass/BSA (g/m2) 85.9 ± 17.3 137.6 ± 24.6 <0.001
LV mass/height2 (g/m2) 54.2 ± 11.3 89.0 ± 14.6 <0.001
E (m/sec) 0.63 ± 0.15 0.61 ± 0.15 0.35
A (m/sec) 0.68 ± 0.16 0.72 ± 0.17 0.06
Deceleration time (msec) 234.8 ± 64.4 234.2 ± 63.4 0.94
E/A 0.97 ± 0.31 0.89 ± 0.28 0.05
E’ (cm/sec) 0.07 ± 0.02 0.06 ± 0.02 <0.001
A’ (cm/sec) 0.10 ± 0.02 0.09 ± 0.02 0.01
E/E’ 9.8 ± 2.7 11.5 ± 3.4 <0.001

Values are presented as mean ± standard deviation.

LVH, left ventricular hypertrophy; IVSd, end-diastolic interventricular septal thickness; LVPWd, end-diastolic left ventricular posterior wall thickness; LVDd, end-diastolic left ventricular dimension; BSA, body surface area.

Echocardiographic parameter in female subjects

Variable Without LVH (n = 659) With LVH (n = 73) p-value
IVSd (cm) 0.8 ± 0.1 1.0 ± 0.2 <0.001
LVPWd (cm) 0.8 ± 0.1 1.0 ± 0.1 <0.001
LVDd (cm) 4.8 ± 0.5 5.4 ± 0.5 <0.001
Relative wall thickness 0.33 ± 0.07 0.37 ± 0.08 <0.001
Ejection fraction (%) 66.4 ± 7.2 65.1 ± 7.8 0.06
LV mass/BSA (g/m2) 79.1 ± 15.8 127.2 ± 19.5 <0.001
LV mass/height2 (g/m2) 51.3 ± 11.0 87.5 ± 14.5 <0.001
E (m/sec) 0.73 ± 0.16 0.68 ± 0.18 0.01
A (m/sec) 0.73 ± 0.15 0.82 ± 0.17 <0.001
Deceleration time (msec) 216.0 ± 52.5 231.9 ± 61.9 0.01
E/A 1.03 ± 0.32 0.86 ± 0.29 <0.001
E’ (cm/sec) 0.07 ± 0.03 0.05 ± 0.01 <0.001
A’ (cm/sec) 0.09 ± 0.02 0.09 ± 0.02 0.04
E/E’ 10.9 ± 3.2 13.4 ± 3.8 <0.001

Values are presented as mean ± standard deviation.

LVH, left ventricular hypertrophy; IVSd, end-diastolic interventricular septal thickness; LVPWd, end-diastolic left ventricular posterior wall thickness; LVDd, end-diastolic left ventricular dimension; BSA, body surface area.

Electrocardiographic characteristics of male subject

Characteristic Without LVH (n = 659) With LVH (n = 73) p-value
PR interval (ms) 166.1 ± 22.8 167.8 ± 27.2 0.67
QRS duration (ms) 95.3 ± 12.8 99.3 ± 16.3 0.08
QTc (ms) 415.2 ± 23.4 420.7 ± 21.0 0.17
SV1 (mm) 5.7 ± 4.3 6.2 ± 4.8 0.49
RV5 (mm) 12.1 ± 7.3 10.8 ± 7.4 0.30
RV6 (mm) 14.7 ± 6.4 14.4 ± 6.3 0.80
SV3 (mm) 2.8 ± 2.8 3.1 ± 2.7 0.59
SV1 + RV5 (mm) 12.0 ± 7.0 23.1 ± 6.7 0.93
SV1 + RV6 (mm) 20.5 ± 6.8 20.7 ± 6.6 0.84
Sokolow-Lyon voltage (mm) 23.4 ± 7.0 23.6 ± 6.7 0.90
Cornell voltage (mm) 13.6 ± 5.6 14.7 ± 6.0 0.28
Sokow-Lyon criteria LVH (%) 19 (6.5) 2 (5.1) 0.75
Cornell criteria LVH (%) 4 (1.4) 1 (2.6) 0.56

Values are presented as mean ± standard deviation.

LVH, left ventricular hypertrophy; QTc, corrected QT interval; SV1, S wave amplitude in V1 lead; RV5, R wave amplitude in V5 lead; RV6, R wave amplitude in V6 lead; SV3, S wave amplitude in V3 lead.

Electrocardiographic characteristics of female subject

Without LVH (n = 659) With LVH (n = 73) p-value
PR interval (ms) 158.5 ± 21.8 165.6 ± 26.7 0.07
QRS duration (ms) 85.3 ± 9.6 85.7 ± 9.0 0.72
QTc (ms) 430.6 ± 26.3 436.5 ± 22.2 0.11
SV1 (mm) 5.7 ± 3.9 5.7 ± 4.5 0.11
RV5 (mm) 10.8 ± 5.9 11.7 ± 7.8 0.42
RV6 (mm) 13.0 ± 4.7 14.6 ± 5.5 0.02
SV3 (mm) 3.7 ± 3.1 3.1 ± 3.1 0.19
SV1 + RV5 (mm) 20.1 ± 6.0 22.3 ± 7.0 0.01
SV1 + RV6 (mm) 18.7 ± 5.3 20.3 ± 5.9 0.03
Sokolow-Lyon voltage (mm) 20.4 ± 5.9 20.4 ± 7.0 0.02
Cornell voltage (mm) 11.2 ± 4.7 13.7 ± 5.7 0.001 ＜
Sokow-Lyon criteria LVH (%) 13 (2.4) 1 (1.9) 0.80
Cornell criteria LVH (%) 23 (4.2) 7 (13.0) 0.01

Values are presented as mean ± standard deviation.

LVH, left ventricular hypertrophy; QTc, corrected QT interval; SV1, S wave amplitude in V1 lead; RV5, R wave amplitude in V5 lead; RV6, R wave amplitude in V6 lead; SV3, S wave amplitude in V3 lead.

Diagnostic performance of electrocardiographic left ventricular hypertrophy criteria

Sokolow-Lyon criteria Cornell Voltage criteria
Male Female Male Female
Sensitivity (%) 5.1 1.9 2.6 13.0
Specificity (%) 93.5 97.6 98.6 95.8
Positive predictive value (%) 9.5 7.1 20.0 23.3
Negative predictable value (%) 88.1 90.9 88.4 91.7
Accuracy (%) 83.2 91.7 87.4 88.3