Electrocardiogram Performance in the Diagnosis of Left Ventricular Hypertrophy in Hypertensive Patients With Left Bundle Branch Block / Desempenho do Eletrocardiograma no Diagnóstico da Hipertrofia Ventricular Esquerda em Pacientes Hipertensos na Presença de Bloqueio de Ramo Esquerdo

Abstract Background: Left ventricular hypertrophy (LVH) is an important risk factor for cardiovascular events, and its detection usually begins with an electrocardiogram (ECG). Objective: To evaluate the impact of complete left bundle branch block (CLBBB) in hypertensive patients in the diagnostic performance of LVH by ECG. Methods: A total of 2,240 hypertensive patients were studied. All of them were submitted to an ECG and an echocardiogram (ECHO). We evaluated the most frequently used electrocardiographic criteria for LVH diagnosis: Cornell voltage, Cornell voltage product, Sokolow-Lyon voltage, Sokolow-Lyon product, RaVL, RaVL+SV3, RV6/RV5 ratio, strain pattern, left atrial enlargement, and QT interval. LVH identification pattern was the left ventricular mass index (LVMI) obtained by ECHO in all participants. Results: Mean age was 11.3 years ± 58.7 years, 684 (30.5%) were male and 1,556 (69.5%) were female. In patients without CLBBB, ECG sensitivity to the presence of LVH varied between 7.6 and 40.9%, and specificity varied between 70.2% and 99.2%. In participants with CLBBB, sensitivity to LVH varied between 11.9 and 95.2%, and specificity between 6.6 and 96.6%. Among the criteria with the best performance for LVH with CLBBB, Sokolow-Lyon, for a voltage of ≥ 3,0mV, stood out with a sensitivity of 22.2% (CI 95% 15.8 - 30.8) and specificity of 88.3% (CI 95% 77.8 - 94.2). Conclusion: In hypertensive patients with CLBBB, the most often used criteria for the detection of LVH with ECG showed significant decrease in performance with regards to sensitivity and specificity. In this scenario, Sokolow-Lyon criteria with voltage ≥3,0mV presented the best performance.

Resumo Fundamento: A hipertrofia ventricular esquerda (HVE) é importante fator de risco para eventos cardiovasculares, e sua identificação se inicia, geralmente, pela realização do eletrocardiograma (ECG). Objetivo: Avaliar, em hipertensos, o impacto do bloqueio completo do ramo esquerdo (BCRE) no desempenho diagnóstico da HVE pelo ECG. Métodos: Foram estudados 2.240 pacientes hipertensos. Todos realizaram ECG e ecocardiograma (ECO). Foram avaliados os critérios eletrocardiográficos mais utilizados para o diagnóstico de HVE: Cornell voltagem, Cornell voltagem produto, Sokolow-Lyon voltagem, Sokolow-Lyon produto, RaVL, RaVL produto, RaVL+SV3, Relação RV6/RV5, padrão strain, aumento atrial esquerdo e o intervalo QT. O padrão de identificação da HVE foi o índice de massa do ventrículo esquerdo (IMVE) obtido pelo ECO em todos participantes. Resultados: A média de idade foi de 11,3 anos ± 58,7 anos, 684 (30,5%) homens e 1.556 (69,5%) mulheres. Nos participantes sem BCRE, a sensibilidade do ECG para a presença de HVE variou de 7,6 a 40,9%, e a especificidade de 70,2 a 99,2%. Nos participantes com BCRE, a sensibilidade para a HVE variou de 11,9 a 95,2%, e a especificidade de 6,6 a 96,6%. Dentre os critérios com melhor desempenho para HVE com BCRE, destacou-se o de Sokolow-Lyon para voltagem ≥ 3,0mV com sensibilidade de 22,2% (IC 95% 15,8 - 30,8) e especificidade de 88,3% (IC 95% 77,8 - 94,2). Conclusão: Nos hipertensos com BCRE, os critérios mais utilizados para detecção da HVE pelo ECG apresentaram diminuição significativa de desempenho da sensibilidade e especificidade. Nesse cenário, o critério de Sokolow-Lyon com voltagem ≥3,0mV apresentou melhor comportamento.

Electrocardiogram Performance in the Diagnosis of Left Ventricular Hypertrophy in Hypertensive Patients With Left Bundle Branch Block.

BACKGROUND: Left ventricular hypertrophy (LVH) is an important risk factor for cardiovascular events, and its detection usually begins with an electrocardiogram (ECG). OBJECTIVE: To evaluate the impact of complete left bundle branch block (CLBBB) in hypertensive patients in the diagnostic performance of LVH by ECG. METHODS: A total of 2,240 hypertensive patients were studied. All of them were submitted to an ECG and an echocardiogram (ECHO). We evaluated the most frequently used electrocardiographic criteria for LVH diagnosis: Cornell voltage, Cornell voltage product, Sokolow-Lyon voltage, Sokolow-Lyon product, RaVL, RaVL+SV3, RV6/RV5 ratio, strain pattern, left atrial enlargement, and QT interval. LVH identification pattern was the left ventricular mass index (LVMI) obtained by ECHO in all participants. RESULTS: Mean age was 11.3 years ± 58.7 years, 684 (30.5%) were male and 1,556 (69.5%) were female. In patients without CLBBB, ECG sensitivity to the presence of LVH varied between 7.6 and 40.9%, and specificity varied between 70.2% and 99.2%. In participants with CLBBB, sensitivity to LVH varied between 11.9 and 95.2%, and specificity between 6.6 and 96.6%. Among the criteria with the best performance for LVH with CLBBB, Sokolow-Lyon, for a voltage of ≥ 3,0mV, stood out with a sensitivity of 22.2% (CI 95% 15.8 - 30.8) and specificity of 88.3% (CI 95% 77.8 - 94.2). CONCLUSION: In hypertensive patients with CLBBB, the most often used criteria for the detection of LVH with ECG showed significant decrease in performance with regards to sensitivity and specificity. In this scenario, Sokolow-Lyon criteria with voltage ≥3,0mV presented the best performance.

Hipertensão arterial secundária a coarctação atípicada aorta abdominal infrarrenal: relato de caso / Secondary arterial hypertension due to atypical coarctation of the aorta below-renal: case report

Relata-se um caso de uma paciente de 50 anos, dislipidêmica, tabagista e hipertensa, que se queixava de claudicação intermitente progressiva há seis anos (durante primeira consulta ao deambular 100 metros). Ao exame clínico inicial, apresentava-se hipertensa (PA: 150 x 70 mmHg) e baixa amplitude de pulso nas artérias femorais, já em uso de quatro classes diferentes de anti-hipertensivos. Durante investigação diagnóstica, detectou-se, na angioressonância, estenose de 75% do lumen da aorta, 5 cm abaixo das artérias renais. Foi submetida à aortoplastia com stent, com satisfatória evolução clínica e normalização dos níveis pressóricos. Dessa forma, com as características clínicas descritas e com o tratamento utilizado para esta paciente, ilustramos um caso de coarctação atípica da aorta abdominal infrarrenal, patologia rara e com mecanismo fisiopatológico pouco compreendido. Destaca-se a importância do diagnóstico precoce e do tratamento adequado dessa síndrome.

We report a case of a 50 years-old patient, with dyslipidemia, that smokes and has hypertension, who complained of progressive intermittent claudication six years ago (during the first visit when walking 100 meters). The initial clinical examination revealed hypertension (BP: 150 x 70 mmHg) and low pulse width in femoral arteries, already in use in four different classes of antihypertensive drugs. During diagnostic investigation was detected in magnetic resonance angiography, 75% stenosis of the aorta lumen 5 cm below the renal arteries. She underwent angioplasty with a stent, a good outcome and normal blood pressure. Thus, with the clinical characteristics and the treatment used for this patient, we illustrate a case of atypical coarctation of the aorta abdominal below-renal, rare disease with poorly understood pathophysiological mechanism. We emphasize the importance of early diagnosis and appropriate treatment of this syndrome.

A obesidade como fator de risco para a hipertensão / Obesity as a risk factor for hypertension

A epidemia mundial de obesidade e o reconhecimento da hipertensão como um dos maiores fatores de morbidade e mortalidade cardiovascular nos levam a realizar esta revisão, que visa entender o envolvimento do tecido adiposo e seu impacto no sistema metabólico. O tecido adiposo funciona como um órgão endócrino produtor de múltiplos moduladores imunes conhecidos como adipocitocinas. A obesidade leva ao aumento da expressão dessas adipocitocinas pró-inflamatórias no organismo, gerando um estado inflamatório crônico. O desequilíbrio dessas adipocitocinas parece ser a chave, a resposta moduladora do sistema inflamatório que contribui para as doenças cardiovasculares e, concomitantemente, com a hipertensão arterial.

The global obesity epidemic and the recognition of hypertension as a major factor of cardiovascular morbidity and mortality lead us to carry out this review, which seeks to understand the involvement of adipose tissue and its impact on metabolic system. Adipose tissue works as an endocrine organ that produces multiple immune modulators known as adipocytokines. Obesity leads to increased expression of these pro-inflammatory adipocytokines in the body, creating achronic inflammatory state. Thisimbalance of these adipocytokines seems to be the key in modulating the inflammatory system that contributes to cardiovascular diseases and concomitantly to hypertension.