Electrocardiographic identification of increased left ventricular mass by simple voltage-duration products

Department of Medicine, New York Hospital-Cornell Medical Center, New York 10021.

OBJECTIVES. This study was conducted to validate the hypothesis that the product of QRS voltage and duration, as an approximation of the time-voltage area of the QRS complex, can improve the electrocardiographic (ECG) detection of echocardiographically determined left ventricular hypertrophy and to further assess the relative contribution of QRS duration to the ECG detection of hypertrophy. BACKGROUND. The ECG identification of left ventricular hypertrophy has been limited by the poor sensitivity of standard voltage criteria alone. However, increases in left ventricular mass can be more accurately related to increases in the time-voltage area of the QRS complex than to changes in QRS voltage or duration alone. METHODS. Standard 12-lead ECGs and echocardiograms were obtained for 389 patients, including 116 patients with left ventricular hypertrophy. Simple voltage-duration products were calculated by multiplying Cornell voltage by QRS duration (Cornell product) and the 12-lead sum of voltage by QRS duration (12-lead product). RESULTS. In a stepwise logistic regression model that also included Cornell voltage, Sokolow-Lyon voltage, age and gender, QRS duration remained a highly significant predictor of the presence of left ventricular hypertrophy (chi-square 26.9, p < 0.0001). At a matched specificity of 96%, each voltage-duration product significantly improved sensitivity for the detection of left ventricular hypertrophy compared with simple voltage criteria alone (Cornell product 37% vs. Cornell voltage 28%, p < 0.02, and 12-lead product 50% vs. 12-lead voltage 43%, p < 0.005). Sensitivities of both the Cornell product and the 12-lead product were significantly greater than the 27% sensitivity of QRS duration alone (p < 0.01 vs. p < 0.001), the 20% sensitivity of a Romhilt-Estes point score > 4 (p < 0.001) and the 33% sensitivity of the best-fit logistic regression model in this cohort (p < 0.05 vs. p < 0.001). CONCLUSIONS. QRS duration is an independent ECG predictor of the presence of left ventricular hypertrophy, and the simple product of either Cornell voltage or 12-lead voltage and QRS duration significantly improves identification of left ventricular hypertrophy relative to other ECG criteria that use QRS duration and voltages in linear combinations.

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				K. Wachtell, J. N. Bella, P. R. Liebson, E. Gerdts, B. Dahlof, T. Aalto, M. J. Roman, V. Papademetriou, H. Ibsen, J. Rokkedal, et al. Impact of Different Partition Values on Prevalences of Left Ventricular Hypertrophy and Concentric Geometry in a Large Hypertensive Population : The LIFE Study Hypertension, January 1, 2000; 35(1): 6 - 12. [Abstract] [Full Text] [PDF]

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				P. M. Okin, M. J. Roman, R. B. Devereux, T. G. Pickering, J. S. Borer, and P. Kligfield Time-Voltage QRS Area of the 12-Lead Electrocardiogram : Detection of Left Ventricular Hypertrophy Hypertension, April 1, 1998; 31(4): 937 - 942. [Abstract] [Full Text] [PDF]

				R. B. Devereux Do Antihypertensive Drugs Differ in Their Ability to Regress Left Ventricular Hypertrophy? Circulation, April 15, 1997; 95(8): 1983 - 1985. [Full Text]

				P. M. Okin, M. J. Roman, R. B. Devereux, and P. Kligfield Association of Carotid Atherosclerosis With Electrocardiographic Myocardial Ischemia and Left Ventricular Hypertrophy Hypertension, July 1, 1996; 28(1): 3 - 7. [Abstract] [Full Text]

				P. M. Okin, M. J. Roman, R. B. Devereux, and P. Kligfield Time-Voltage Area of the QRS for the Identification of Left Ventricular Hypertrophy Hypertension, February 1, 1996; 27(2): 251 - 258. [Abstract] [Full Text]