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Electrocardiographic detection of left atrial enlargement in arterial hypertension: re-calibration against cardiac magnetic resonance
© Rodrigues et al. 2016
- Published: 27 January 2016
- Cardiac Magnetic Resonance
- Receiver Operator Curve Analysis
- Left Atrial Enlargement
- Short Axis Cine
- Operator Curve Analysis
Both American and European guidelines on the management of arterial hypertension advise that an electrocardiogram (ECG) be routinely performed in all patients with arterial hypertension. The ECG may demonstrate evidence of left atrial enlargement (LAE), which has adverse prognostic implications in hypertension. We sought to determine the accuracy of 5 ECG criteria of LAE in a hypertensive cohort relative to cardiac magnetic resonance (CMR) gold-standard. We also sought to investigate the confounding effect of obesity.
Consecutive referrals for CMR (1.5T) from a tertiary hypertension clinic were reviewed. Patients with any concomitant cardiac pathology other than hypertension were excluded. ECGs were assessed, blinded to the CMR data, for:
1) P wave >110 ms
2) P mitrale (notched P wave with inter-peak duration >40 ms)
3) P wave axis <30°
4) Area of negative P terminal force in lead V1 (NPTF-V1) > 40 ms·mm
5) Positive P terminal force in aVL (PPTF-aVL) >0.5 mm
LA volume (LAV), excluding LA appendage and pulmonary vein confluence, was measured at maximum atrial diastole using the biplane area-length method, which has previously been validated against LA short axis cine stack measurements. LAV were indexed to body surface area. LAE was defined as ≥55 ml/m2 (>2 standard deviations above the mean published references value for normal, healthy volunteers). CMR analysis was performed blinded to ECG data. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated. Area under the receiver operator curve analysis was performed.
130 patients were included (age: 51.4 ± 15.1 years, 47% male, 51% obese, systolic blood pressure: 171 ± 29 mmHg, diastolic blood pressure: 97 ± 15 mmHg).
Individual ECG criteria of LAE in hypertension are specific, but not sensitive, for identifying anatomical LAE, relative to CMR. LAE in hypertension should not be excluded on the basis of the ECG, particularly in obese subjects.
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