What is the clinical evidence from this study?

Study design: Observational. Population: End-stage renal disease (ESRD) on maintenance hemodialysis (n=317). Intervention: Electrocardiographic Left Ventricular Hypertrophy (ECG-LVH) by Cornell voltage-duration product (CP) criteria vs. Absence of ECG-LVH by CP criteria. Primary outcome: Cardiovascular mortality (HR 3.07, 95% CI 1.16-8.11, p=0.024).

April 17, 2012Open Access

Electrocardiographic Left Ventricular Hypertrophy and Outcome in Hemodialysis Patients

Key Result

Electrocardiographic left ventricular hypertrophy defined by Cornell voltage-duration product criteria was significantly associated with increased cardiovascular mortality (HR 3.07) in incident hemodialysis patients.

Study Design

Type

Observational (n=317)

Multicenter

Structured PICO

Do ECG voltage-duration product criteria (SP and CP) better predict cardiovascular mortality and correlate with echocardiographic LVH compared to voltage-only criteria in incident hemodialysis patients?

Population

317 incident hemodialysis patients aged 18-75 years, free of severe systolic dysfunction or valvular heart disease, followed for a mean of 27.4 months.

Exposure

ECG assessment of left ventricular hypertrophy using voltage-duration products (Sokolow-Lyon voltage-duration product [SP] and Cornell voltage-duration product [CP])

Comparator

ECG assessment using traditional voltage-only criteria (Sokolow-Lyon voltage [SV] and Cornell voltage [CV])

Outcome

Cardiovascular mortality at 5 yearshard clinical

In incident hemodialysis patients, ECG criteria using the product of QRS voltage and duration (SP and CP) are superior to voltage-only criteria for identifying LVH and predicting cardiovascular mortality.

Main Result

Hazard Ratio: 3.07 (95% CI 1.16–8.11)

p-value: p=0.024

Limitations

Study subjects were all Korean ESRD patients on hemodialysis, limiting generalizability to other populations.
Exclusion of patients with severe systolic dysfunction and severe valvular heart disease may have introduced selection bias.
A small number of events limited the statistical power of the multivariate analysis.
Only the ECG taken at the time of echocardiography was analyzed, not accounting for intra-individual variability.
Echocardiography was used to determine LV mass index instead of the gold standard MRI.
Follow-up ECG and echocardiography were not included for analysis to assess the impact of changes over time.

Abstract

BACKGROUND AND AIMS: Electrocardiography (ECG) is the most widely used initial screening test for the assessment of left ventricular hypertrophy (LVH), an independent predictor of cardiovascular mortality in patients with end-stage renal disease (ESRD). However, traditional ECG criteria based only on voltage to detect LVH have limited clinical utility for the detection of LVH because of their poor sensitivity. METHODS: This prospective observational study was undertaken to compare the prognostic significance of commonly used ECG criteria for LVH, namely Sokolow-Lyon voltage (SV) or voltage-duration product (SP) and Cornell voltage (CV) or voltage-duration product (CP) criteria, and to investigate the association between echocardiographic LV mass index (LVMI) and ECG-LVH criteria in ESRD patients, who consecutively started maintenance hemodialysis (HD) between January 2006 and December 2008. RESULTS: A total of 317 patients, who underwent both ECG and echocardiography, were included. Compared to SV and CV criteria, SP and CP criteria, respectively, correlated more closely with LVMI. In addition, CP criteria provided the highest positive predictive value for echocardiographic LVH. The 5-year cardiovascular survival rates were significantly lower in patients with ECG-LVH by each criterion. In multivariate analyses, echocardiographic LVH adjusted hazard ratio (HR): 11.71; 95% confidence interval (CI): 1.57-87.18; P = 0.016 and ECG-LVH by SP (HR: 3.43; 95% CI: 1.32-8.92; P = 0.011) and CP (HR: 3.07; 95% CI: 1.16-8.11; P = 0.024) criteria, but not SV and CV criteria, were significantly associated with cardiovascular mortality. CONCLUSIONS: The product of QRS voltage and duration is helpful in identifying the presence of LVH and predicting cardiovascular mortality in incident HD patients.

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