Sensitivity and specificity of frequently used electrocardiographic criteria for left ventricular hypertrophy in patients with anterior wall myocardial infarction Elias B. Hanna, MD, D. Luke Glancy, MD, and Evrim Oral, PhD
Electrocardiographic left ventricular hypertrophy (LVH) strongly predicts mortality in patients with myocardial infarction (MI). However, the validity of LVH voltage criteria in this context has not been assessed. Reviewing the coded database of echocardiographic studies performed at one institution, we performed a retrospective analysis of 49 patients who had anterior akinesis on the echocardiogram and anterior wall MI on the electrocardiogram. Results showed that, compared with the sensitivities and specificities of the electrocardiographic voltage criteria in historical cohorts, Cornell criteria were less sensitive and specific for the diagnosis of LVH in patients with anterior wall MI. The sensitivity was reduced in the presence of an associated lateral wall MI, and the specificity was reduced in the absence of a lateral wall MI (overall sensitivity in case of anterior wall MI, with or without an associated lateral wall MI, 21% vs 41%, P = 0.049; overall specificity 84% vs 98%, P = 0.003). All criteria, except for S in V1 + R in V5 or V6 >3.5 mV, had a significantly reduced specificity in the case of anterior wall MI not associated with lateral wall MI, and all criteria, except for R in V6 > R in V5, had reduced sensitivity in the presence of a lateral wall MI. In conclusion, anterior wall MI reduces the sensitivity and the specificity of the most commonly used LVH voltage criteria.
A
lthough many voltage criteria for left ventricular hypertrophy (LVH) have been reported (1–6), the sensitivity and specificity of the most commonly used criteria in patients with an anterior wall myocardial infarction (MI) have not been described. LVH determined by the echocardiographic calculation of left ventricular mass strongly predicts short- and long-term mortality in patients with ST-elevation MI (7, 8). However, no study has assessed how well the electrocardiographic LVH voltage criteria identify echocardiographic LVH in the context of anteroseptal MI. Thus, the assessment of the sensitivity and specificity of the electrocardiographic LVH voltage criteria in the context of an anteroseptal MI is clinically relevant. Methods Study population and design We reviewed the coded database of echocardiographic studies performed at one institution between July 2007 and March 2009. Patients with anteroseptal akinesis, with or without apical Proc (Bayl Univ Med Cent) 2010;23(1):15–18
dyskinesis, were initially selected. Patients had to have an electrocardiogram (ECG) and an echocardiogram performed within 1 month of each other, both showing evidence of anterior wall MI. If multiple ECGs were available, the one performed closest to the timing of the echocardiogram was evaluated. Since akinesis may be due to hibernation rather than infarction, patients were included only if Q waves were present in at least two anterior leads or if there was poor or reverse R-wave progression in the anterior precordial leads. Poor or reverse Rwave progression was considered a sign of anterior wall MI if one of three features defined by Zema et al was present: 1) R wave in lead I ≤4 mm without deep S wave (S ≤1 mm); 2) R wave in lead V3 ≤1.5 mm; or 3) T-wave inversion or ST-segment elevation in leads V2 or V3 (9). Patients may have an old or an acute or an indeterminate age anterior wall MI. Patients were excluded if they had complete left bundle branch block or a ventricular-paced rhythm. Definition of study parameters LVH was defined as an increased LV mass on echocardiography. We used the formula recommended by the American Society of Echocardiography for estimation of LV mass from LV linear dimensions (10, 11). LV linear dimensions are determined from the parasternal long-axis view, as described in the guidelines (10). This LV mass formula correlates strongly with LV mass obtained at necropsy (r = 0.90, P < 0.001) (11). We determined the presence of one or more of the following LVH voltage criteria in each patient: Cornell criteria (R in aVL + S in V3 >2.0 mV in women and >2.8 mV in men) (2); R in lead I ≥1.5 mV; two Sokolow-Lyon criteria (R in lead aVL >1.1 mV in the absence of left anterior fascicular block or >1.3 mV in the presence of left anterior fascicular block; and S in V1 + R in V5 or V6 >3.5 mV); and R in V6 > R in V5 (6). The presence of a high lateral wall MI in addition to the anterior wall MI From the Department of Cardiology, Louisiana State University, New Orleans (Hanna, Glancy), and the Biostatistics Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans (Oral). Dr. Hanna is now at the University of Oklahoma Health Science Center. Corresponding author: Elias B. Hanna, MD, 301 North Walker Avenue, Apartment 5301, Oklahoma City, Oklahoma 73102 (e-mail: elias-hanna@ouhsc. edu,
[email protected]). 15
was noted: high lateral wall MI was defined as the presence of abnormal Q wave(s) (≥0.04 sec) or ST elevation in leads I or aVL. End points The sensitivity and specificity of each one of the previous LVH voltage criteria in patients with anterior wall MI were compared with a historical cohort of patients without anterior wall MI. Subsequently, the sensitivity and specificity were determined in the subgroups of patients with and without an electrocardiographic diagnosis of high lateral wall MI, and results were compared with the historical cohort.
Table 1. Sensitivities and specificities of various LVH electrocardiographic criteria in 49 patients with anterior wall MI compared with historical values Sensitivity (95% CI) Criteria
Our study
Historical cohort
Cornell criteria
21% (7, 42)
41% (36, 46)
R in aVL >1.1 mV
12.5% (3, 32)
R in I ≥1.5 mV
Specificity (95% CI) P value
Our study Historical cohort
P value
0.049*
84% (64, 95)
98% (96, 99)
0.003*
10.6% (6, 16.5)
0.729
88% (69, 97)
100% (98, 100)
0.001*
8% (1, 27)
7.5% (4, 13)
1.000
92% (74, 99)
100% (98, 100)
0.012*
S in V1 + R in V5 or V6 >3.5 mV
9% (1, 29)
42.5% (35, 50.5)
0.002*
100% (85, 100)
95% (91, 98)
0.604
R in V6 > R in V5
79% (58, 93)
22.5% (16, 30)
1.1 mV and R in I ≥1.5 mV were reduced in the case of anconfidence intervals, were as follows: terior wall MI (88% vs 100%, P = 0.001, and 92% vs 100%, • Cornell criteria: sensitivity 41% (36%, 46%), specificity P = 0.012, respectively) (Table 1). 98% (96%, 99%) (1) Of the 49 patients, 17 had evidence of high lateral wall • R in lead aVL >1.1 mV: sensitivity 10.6% (6%, 16.5%), infarction and 32 did not. Sensitivities and specificities of varispecificity 100% (98%, 100%) (1) ous criteria were determined for these two subgroups (Tables 2 • R in lead I ≥1.5 mV: sensitivity 7.5% (4%, 13%), specificity and 3). The Cornell criteria were less sensitive and specific for 100% (98%, 100%) (3) the diagnosis of LVH in the presence of anterior wall MI. The • S in lead V1 + R in lead V5 or V6 >3.5 mV: sensitivity 42.5% sensitivity was significantly reduced in patients with an associ(35%, 50.5%), specificity 95% (91%, 98%) (3) ated high lateral wall MI, and the specificity was significantly • R in V6 > R in V5: sensitivity 22.5% (16%, 30%), specificity reduced in the absence of a high lateral wall MI. All criteria, 89.5% (84%, 93%) (3) except for S in V1 + R in V5 or V6 >3.5 mV, had significantly reduced specificities in the case of anterior wall MI not associResults ated with a high lateral wall MI. All criteria, except R in V6 > Seventy-three patients had an echocardiographic diagR in V5, had reduced sensitivities with an anterior wall MI in nosis of anterior wall MI; of that group, 24 were excluded: the presence of a high lateral wall MI (though not statistically 3 because no ECG was found; 4 because of complete left significant for R in aVL >1.1 mV and R in I ≥1.5 mV). bundle branch block; 1 because of right ventricular-paced rhythm; and 16 because of the absence of anterior Q waves Discussion and the predefined poor R-wave progression. Forty-nine To our knowledge, this is the first report assessing the sensipatients were included in the study. The mean age was 57 tivity and specificity of various electrocardiographic criteria for ± 9 years; 29 out of the 49 patients (59%) were male. Eight LVH in patients with anterior wall MI. The results are consistent out of the 49 patients had an acute anterior wall MI. All with the vector of ventricular depolarization in anterior wall 16
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in lead I, thus reducing the sensitivity without affecting the specificity of these criteria. The sensitivity of the S in V1 + R Sensitivity (95% CI) Specificity (95% CI) in V 5 or V6 >3.5 mV criterion was Criteria Our study Historical cohort P value Our study Historical cohort P value reduced in all cases of anterior wall 33% 41% 76.5% 98% MI, because of the reduced size of Cornell criteria 0.605 0.001* (12, 62) (36, 46) (50, 93) (96, 99) the R wave in V5 and V6. Delayed R20% 10.6% 82% 100% R in aVL >1.1 wave precordial progression explains 0.385 0.006* mV (4, 48) (6, 16.5) (56.5, 96) (98, 100) why the R in V6 tends to be greater 13% 7.5% 88% 100% than the R in V5 in most cases of R in I ≥1.5 mV 0.342 0.006* (2, 40) (4, 13) (64, 99) (98, 100) anterior wall MI, regardless of the presence of LVH; hence, the criteS in V1 + R in 13% 42.5% 100% 95% V5 or V6 >3.5 0.029* 1.000 rion of R in V6 > R in V5 should not (2, 40) (30, 50.5) (80, 100) (91, 98) mV be used to diagnose LVH in patients with anterior wall MI. 93% 22.5% 24% 89.5% R in V6 > R 3.5 0.012* 1.000 ria were identical whether LV mass (0, 34) (30, 50.5) (63, 100) (91, 98) mV was obtained by echocardiography 56% 22.5% 62.5% 89.5% or necropsy (1, 2). R in V6 > R 0.039† 0.051† in V5 In conclusion, in the case of ante(21, 86) (16, 30) (24, 91) (84, 93) rior wall MI, Cornell criteria are less LVH indicates left ventricular hypertrophy; MI, myocardial infarction; CI, confidence interval. sensitive and specific for LVH defi*Statistically significant. †As opposed to other criteria, sensitivity of this criterion is statistically significantly improved in case of anterior wall MI, but nition, the sensitivity being mostly the specificity is significantly reduced. reduced in cases of an associated high lateral wall MI, and the specificity being reduced in the absence of an MI, i.e., depolarization is directed posteriorly and away from associated high lateral wall MI. All criteria, except S in V1 + R the anterior wall, which leads to a large S wave in lead V3. In in V5 or V6 >3.5 mV, have reduced specificity in the presence the absence of a high lateral wall MI, depolarization is also of an anterior wall MI, especially in the absence of an associated directed laterally. This explains why the R wave in aVL and the high lateral wall MI, and all criteria, except for R in V6 > R in summation of the S wave in V3 and the R wave in aVL may be V5, have reduced sensitivity in the presence of an anterior wall large and falsely suggestive of LVH (i.e., reduced specificity of MI with an associated high lateral wall MI. these criteria). In the presence of an associated high lateral wall MI, R-wave size in lead aVL is apparently reduced to a larger extent than S- or QS-wave size is increased in lead V3, which 1. Casale PN, Devereux RB, Kligfield P, Eisenberg RR, Miller DH, Chaudhary BS, Phillips MC. Electrocardiographic detection of left ventricular reduces the Cornell voltage and the R voltage in lead aVL and Table 2. Sensitivities and specificities of various LVH electrocardiographic criteria in 32 patients with anterior wall MI without lateral wall MI compared with historical values
January 2010
Sensitivity and specificity of frequently used electrocardiographic criteria for left ventricular hypertrophy
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