Are Electrocardiographic Criteria Reliable for Left Ventricular Hypertrophy Detection in Indian Adults?

BACKGROUND: Left ventricular hypertrophy (LVH) detection is vital to the risk stratification of adults at risk of adverse cardiovascular events such as coronary heart disease, cerebrovascular disease, and aortic aneurysms. Electrocardiogram (ECG), a non-invasive, cost-effective instrument has been widely used as a screening tool for LVH. The objective of this study was to determine the diagnostic accuracy of seven frequently used ECG criteria in high-risk Indian adults in comparison with echocardiography. METHODS: ECG and transthoracic echocardiography were performed in adults older than 18 years with at least one cardiac risk factor (chronic hypertension, obesity, ischemic heart disease, and type 2 diabetes mellitus). Precision and accuracy were calculated for the various ECG criteria against LVH based on left ventricular mass index (LVMI) and cardiac remodeling by echocardiography. RESULTS: A total of 220 participants were enrolled. Of these, 96 had LVH by echocardiography. There was marked variability in LVH detection by the different ECG criteria: 28 by Sokolow-Lyon criteria, 26 by Cornell criteria, 24 by Lewis criteria, 46 by Scott criteria, eight by Romhilt-Estes criteria, six by Modified Cornell criteria, and only two by Roberts criteria. Agreement statistics between ECG criteria and LVMI showed that none of them had a good agreement for LVH detection. CONCLUSION: None of the ECG criteria were sensitive enough to rule out ventricular hypertrophy. In the context of cardiac remodeling, the ECG criteria had high sensitivity but low specificity and, hence, limited clinical relevance.

Evaluation of the Reliability of Electrocardiographic Criteria for Cardiac Hypertrophy Based on Echocardiographic Data.

Background: Left ventricular hypertrophy (LVH) regardless of other risk factors may be associated with an increased risk of mortality from cardiovascular diseases. Therefore, timely diagnosis for LVH is important in order to avoid possible complications. One of the simplest and cheapest methods to diagnose LVH is electrocardiography (ECG). Although a number of ECG criteria for LVH is known, their reliability varies in many studies. Aim: To evaluate the reliability of ECG criteria for LVH based on transthoracic echocardiography (TTE) data. Methods: The study included all consecutive patients in Kaunas Clinical Hospital Department of Cardiology from December 2019 until March 2020 and from September until October 2020, after applying the inclusion and exclusion criteria. The sensitivity and specificity of the ECG criteria for LVH were assessed based on TTE measurements performed during the same inpatient setting. The reliability of the ECG criteria for LVH was assessed using ROC curves. Reliability differences in gender, age and nutritional status groups were assessed using ANOVA statistical method. Results: Data from 95 patients were analyzed (63.2% were women and 36.8% were men). The sensitivity, specificity and AUC of Sokolow-Lyon criterion were 9.38%, 85.71% and 0.44 (p = 0.034), R in aVL - 6.25%, 90.48% and 0.51 (p = 0.038), Cornell - 21.88%, 100 % and0.69 (p = 0.084), Cornell product - 31.25%, 95.24% and 0.72 (p = 0.070), Peguero-Lo Presti - 31.25%, 85.71% and 0.68 (p = 0.053), respectively. No statistically significant differences were observed among the individual gender, age and nutritional status groups. Conclusions: Sokolow-Lyon and RaVL criteria were not statistically significantly reliable in LVH diagnosis compared to TTE, unlike the Cornell, Cornell product, and Peguero-Lo Presti criteria.

Assessment of electrocardiogram abnormality and associated factors among apparently healthy adult type 2 diabetic patients on follow-up at Jimma Medical Center, Southwest Ethiopia: Cross-sectional study.

BACKGROUND: Diabetes mellitus is a group of metabolic disorders causing long-term damage to the cardiovascular system which remains asymptomatic among diabetic patients. An electrocardiograph is a simple and first-line tool in the screening of cardiovascular diseases. OBJECTIVE: To assess electrocardiogram abnormality and associated factors among apparently healthy adult type 2 diabetes patients on follow-up at Jimma Medical Center, 2019. MATERIALS AND METHODS: Institutional based cross-sectional study was conducted from April 1 to May 30, 2019, at Jimma Medical Center among selected type 2 diabetes patients. Systematic random sampling was employed to select the study participants. The World Health Organization stepwise approach and interviewer-administered semi-structured questionnaires were employed to collect basic data. Resting Electrocardiography was done using a standard 12-lead electrocardiograph machine. The collected data were checked for completeness, coded, entered into the Epi-data Version 4.0.2. and exported to SPSS Version 21. Descriptive statistics like frequencies, percentages, mean and standard deviations were carried out. Binary and multiple logistic regression was done and a p value of less than 0.05 was used as a level of significance. RESULTS: A total of 344 type 2 diabetes patients were interviewed and underwent electrocardiography making a 100% response rate. Electrocardiographic abnormality was identified among 209 (61%) of the respondents. Not attending formal education [AOR = 3.07, 95%, CI = 1.37-6.87], solid oil use, [AOR = 1.79, 95%, CI = 1.07-2.98], body mass index ≥ 25 kg/m2 [AOR = 2.74, 95%, CI = 1.67-4.50] and long duration of diabetes ≥ 10 years [AOR = 3.36, 95%, CI = 1.46-7.71] were associated with electrocardiogram abnormality. CONCLUSIONS: and recommendation In this study, the majority (3/5th) of the participant had electrocardiogram abnormality. Not attending formal education, longer duration of diabetes ≥ 10 years, solid oil use, and increased body mass index ≥ 25 kg/m2 were independent predictors of electrocardiographic abnormality. Integrating electrocardiogram screening in routine diabetic management can pick cardiac complications of diabetes.

Pediatric athletes' ECG and diagnostic performance of contemporary ECG interpretation criteria.

BACKGROUND: Electrocardiographic (ECG) pre-participation screening(PPS) can prevent sudden cardiac death(SCD) but the Interpretation of the athlete's ECG is based on specific criteria addressed for adult athletes while few data exist about the pediatric athlete's ECG. We aimed to assess the features of pediatric athletes' ECG and compared the diagnostic performance of 2017 International ECG recommendation, 2010 European Society of Cardiology recommendation and 2013-Seattle criteria in detecting clinical conditions at risk of SCD. METHODS: 886 consecutive pediatric athletes (mean age 11.7 ± 2.5 years; 7-16-years) were enrolled and prospectively evaluated with medical history, physical examination, resting and exercise ECG and transthoracic echocardiography during their PPS. RESULTS: The most common physiological ECG patterns in pediatric athletes were isolated left ventricular hypertrophy criteria (26.9%), juvenile T-wave pattern (22%) and early repolarization pattern (13.2%). The most frequent borderline abnormalities were left axis deviation (1.8%) and right axis deviation (0.9%) while T-wave inversion (0.8%) especially located in inferior leads (0.7%) was the most prevalent abnormal findings. Seven athletes (0.79%) were diagnosed with a condition related to SCD. Compared to Seattle and ESC, the International improved ECG specificity (International = 98% ESC = 64% Seattle = 95%) with lower sensitivity (ESC and Seattle 86%vs International 57%). The false-positive rate decreases from 36% of ESC to 2.2% of International but the latter showed a higher false-negative rate(0.34%). CONCLUSION: Pediatric athletes like the adult counterpart exhibit a high prevalence of ECG abnormalities mostly representing training-related ECG adaptation. The International criteria showed a lower false-positive rate but at the cost of loss of sensitivity.

Optimal measuring point for ST deviation in chest pain patients with possible acute coronary syndrome.

INTRODUCTION: In the ECG, significant ST elevation or depression according to specific amplitude criteria can be indicative of acute coronary syndrome (ACS). Guidelines state that the ST amplitude should be measured at the J point, but data to support that this is the optimal measuring point for ACS detection is lacking. We evaluated the impact of different measuring points for ST deviation on the diagnostic accuracy for ACS in unselected emergency department (ED) chest pain patients. MATERIAL AND METHODS: We included 14,148 adult patients with acute chest pain and an ECG recorded at a Swedish ED between 2010 and 2014. ST deviation was measured at the J point (STJ) and at 20, 40, 60 and 80 ms after the J point. A discharge diagnosis of ACS or not at the index visit was noted in all patients. RESULTS: In total, 1489 (10.5%) patients had ACS. ST amplitude criteria at STJ had a sensitivity of 28% and a specificity of 92% for ACS. With these criteria, the highest positive and negative predictive values for ACS were obtained near the J point, but the optimal point varied with ST deviation, age group and sex. The overall best measuring points were STJ and ST20. CONCLUSIONS: This study indicates that the diagnostic accuracy of the ECG criteria for ACS is very low in ED chest pain patients, and that the optimal measuring point for the ST amplitude in the detection of ACS differs between ST elevation and depression, and between patient subgroups.

Accuracy of the 2017 international recommendations for clinicians who interpret adolescent athletes' ECGs: a cohort study of 11 168 British white and black soccer players.

AIM: To investigate the accuracy of the recently published international recommendations for ECG interpretation in young athletes in a large cohort of white and black adolescent soccer players. METHODS: 11 168 soccer players (mean age 16.4±1.2 years) were evaluated with a health questionnaire, ECG and echocardiogram; 10 581 (95%) of the players were male and 10 163 (91%) were white. ECGs were retrospectively analysed according to (1) the 2010 European Society of Cardiology (ESC) recommendations, (2) Seattle criteria, (3) refined criteria and (4) the international recommendations for ECG interpretation in young athletes. RESULTS: The ESC recommendations resulted in a higher number of abnormal ECGs compared with the Seattle, refined and international criteria (13.2%, 4.3%, 2.9% and 1.8%, respectively). All four criteria were associated with a higher prevalence of abnormal ECGs in black athletes compared with white athletes (ESC: 16.2% vs 12.9%; Seattle: 5.9% vs 4.2%; refined: 3.8% vs 2.8%; international 3.6% vs 1.6%; p<0.001 each). Compared with ESC recommendations, the Seattle, refined and international criteria identified a lower number of abnormal ECGs-by 67%, 78% and 86%, respectively. All four criteria identified 36 (86%) of 42 athletes with serious cardiac pathology. Compared with ESC recommendations, the Seattle criteria improved specificity from 87% to 96% in white athletes and 84% to 94% in black athletes. The international recommendations demonstrated the highest specificity for white (99%) and black (97%) athletes and a sensitivity of 86%. CONCLUSIONS: The 2017 international recommendations for ECG interpretation in young athletes can be applied to adolescent athletes to detect serious cardiac disease. These recommendations perform more effectively than previous ECG criteria in both white and black adolescent soccer players.

Assessment of Left Ventricular Hypertrophy (LVH) Criteria by Surface Electrocardiography in a Sample of Iraqi Patients with Systemic Arterial Hypertension.

BACKGROUND: Left ventricular hypertrophy (LVH) in hypertensive patients indicates an ongoing disease process involving the heart. Different electrocardiography (ECG) criteria were investigated; however, the results were conflicting. OBJECTIVE: To evaluate different ECG criteria in diagnosis of LVH in hypertensive patients using echocardiography as a gold standard. METHODS: A hospital based cross sectional observational study which included 140 adult patients with a history of hypertension. Patients were assessed for LVH using five ECG criteria: Romhilt-Estes, SokoloweLyon, Cornell voltage, Gubnere Ungerleider and Peguero-Lo Presti. Echocardiography was used to determine the left ventricular mass index for the patients. The sensitivity and specificity of each ECG criterion was determined considering echocardiography as a gold standard. RESULTS: According to the echocardiographic results, 83 patients (59.29%) were found to have LVH. Age over 40 years, overweight and obesity, high systolic blood pressure (>170 mmHg) and using of antihypertensive drugs were significantly associated with the increased risk of LVH. All included ECG criteria showed low sensitivity and high specificity in detection of LVH in hypertensive patients. There were no significant differences in the efficiency of different ECG criteria in discrimination between mild, moderate and severe cases of LVH. CONCLUSION: LVH is very common among hypertensive patients, and the sensitivity of ECG criteria is low for these criteria to be clinically used for detection of LVH with high specificity, in which Cornell criterion is the best in detection.

The Accuracy of Combined Electrocardiogram Criteria to Diagnose Right Atrial Enlargement in Adults With Uncorrected Secundum Atrial Septal Defect.

BACKGROUND: Right atrium (RA) enlargement in uncorrected atrial septal defect (ASD) is due to chronic volume overload. Several electrocardiogram (ECG) criteria had been proposed for screening RA enlargement. This study aimed to compare the accuracy of ECG criteria in detecting RA enlargement in adults with uncorrected ASD. METHODS: This was a cross-sectional study involving 120 adults with uncorrected secundum ASD. The subjects underwent ECG examination, transthoracic echocardiography, and right heart catheterization. An RA enlargement was determined with RA volume index by transthoracic echocardiography. Various ECG and combined ECG criteria were evaluated. Statistical analysis was performed to analyze the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: An RA enlargement was detected in 64.2% subjects. The P wave height > 2.5 mm in lead II criterion had the best specificity (100%) and PPV (100%), but low sensitivity (19%) and accuracy (48%). The combined 2 ECG criteria (QRS axis > 90°, R/S ratio > 1 in V1) had 82% sensitivity, 56% specificity, 73% accuracy, 77% PPV, and 63% NPV. The combined 3 ECG criteria (QRS axis > 90°, R/S ratio > 1 in V1, and P wave height > 1.5 mm in V2) had 35% sensitivity, 86% specificity, 53% accuracy, 82% PPV, and 43% NPV. CONCLUSIONS: The combined 2 ECG criteria (QRS axis > 90° and R/S ratio > 1 in V1) had increased sensitivity, better accuracy, and more balance of PPV and NPV as compared with P wave > 2.5 mm in II criterion and combined 3 ECG criteria to diagnose RA enlargement in adults with uncorrected ASD.

Prospective validation of current quantitative electrocardiographic criteria for ST-elevation myocardial infarction.

BACKGROUND: Rapid and reliable diagnosis of ST-elevation myocardial infarction (STEMI) as a surrogate for acute coronary occlusion is critical for early reperfusion therapy. OBJECTIVES: We aimed to examine the diagnostic performance of current guideline-recommended Electrocardiogram (ECG) STEMI criteria. METHODS: In a prospective diagnostic multicenter study, we objectively quantified the extent of ST-segment elevation in all ECG leads using an automated software-based analysis of the digital 12-lead-ECG in adult patients presenting to the emergency department (ED) with suspected myocardial infarction (MI). Classification according to current guideline-recommended ECG criteria for STEMI at ED presentation was compared against a final diagnosis adjudicated by two independent cardiologists after reviewing all available medical records including serial ECGs, cardiac imaging and coronary angiograms. RESULTS: Among 2486 patients, 52 (2%) were found to have significant ST-segment elevation on ECG at ED presentation according to current guideline-recommended ECG criteria for STEMI. Eighty-one (3%) patients received a final adjudicated diagnosis of STEMI. Only 35% (28 of 81) of all patients with a final diagnosis of STEMI were correctly identified (PPV 54% (95% CI 41-66%), sensitivity 35% (95% Cl 24-46%), NPV 97.8% (95% CI 97.5-98.1%). Four reasons for missing STEMIs emerged: timing (significant STE at an earlier/later time point) in 25%, incorrect measurement points in 30%, non or borderline-significant STE in 36% and inferoposterior MI localisation in 9%. CONCLUSIONS: A computerized analysis of current guideline-recommended ECG criteria for STEMI showed suboptimal diagnostic performance when applied to a single 12­lead ECG performed at ED presentation. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00470587.

aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion.

BACKGROUND: Identification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression. METHODS: STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression. RESULTS: Emergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001). CONCLUSIONS: STE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.

Newly proposed electrocardiographic criteria for the diagnosis of left ventricular hypertrophy in a Chinese population.

BACKGROUND: The electrocardiographic criteria currently available for the diagnosis of left ventricular hypertrophy (LVH) are low in sensitivity. Thus, we compared the diagnostic performance of newly proposed electrocardiographic criteria to the existing criteria in a Chinese population. METHODS: A total of 235 consecutive hypertensive patients, hospitalized in our department between May 2017 and April 2018, were included. They were divided into two groups based on the gold standard echocardiogram: those with (n = 116) and without LVH (n = 119). The newly proposed ECG criteria were calculated by summating the amplitude of the deepest S wave (SD ) in any single lead and the S-wave amplitude of lead V4 (SV4 ). The area under the curve was calculated and compared against the sex-specific Cornell limb lead and Sokolow-Lyon criteria. RESULTS: ECG analysis of the cohort showed that the newly proposed criteria had the highest sensitivity in diagnosing LVH (male: 65.5%; female: 81%), followed by the Cornell limb lead criteria (male: 55.2%; female: 56.9%). The specificities of both sets of criteria were higher than 70%, with no significant differences between them. Receiver operator curve analysis showed an optimal cutoff of ≥2.1 mV for females (AUC: 0.832; 95% CI: 0.757-0.906) and ≥2.6 mV for males (AUC: 0.772; 95% CI: 0.687-0.856). CONCLUSION: The newly proposed SD  + SV4 criteria provide an improved sensitivity for the ECG diagnosis of LVH compared to existing criteria, but its routine use will require further validation in larger populations.

Combining ECG Criteria for Left Ventricular Hypertrophy Improves Risk Prediction in Patients With Hypertension.

BACKGROUND: Patients with hypertension with ECG left ventricular hypertrophy (LVH) have higher cardiovascular morbidity and mortality, but single ECG criteria may underestimate risk. Whether continued presence or new development of ECG LVH by 2 criteria can further concentrate risk during blood pressure lowering is unclear. METHODS AND RESULTS: Incident stroke, myocardial infarction, cardiovascular death, the composite of these outcomes, and all-cause mortality were examined in relation to the presence of on-treatment ECG LVH by Cornell product and/or Sokolow-Lyon voltage during a mean of 4.8±0.9 years follow-up in 9193 patients with hypertension randomized to losartan- or atenolol-based regimens. Patients were categorized into 4 groups according to the presence or absence of ECG LVH by each criterion at baseline and yearly during the study. At baseline, LVH by both criteria was present in 960 patients (10.4%). Compared with the absence of ECG LVH by both criteria, persistence or development of ECG LVH by both criteria entered as a time-varying covariate was associated with >3-fold increased risks of events in multivariable Cox analyses adjusting for randomized treatment, baseline risk factors, and on-treatment heart rate and systolic and diastolic blood pressures. Patients with ECG LVH by either Cornell product or Sokolow-Lyon voltage had 45% to 140% higher risks of all end points. CONCLUSIONS: Persistence or development of ECG LVH by both Cornell product and Sokolow-Lyon voltage criteria during antihypertensive therapy is associated with markedly increased risks of cardiovascular end points and all-cause mortality. Further study is indicated to determine whether additional therapy in these patients can reduce their risk. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00338260.

A decision support system and rule-based algorithm to augment the human interpretation of the 12-lead electrocardiogram.

BACKGROUND: The 12-lead Electrocardiogram (ECG) has been used to detect cardiac abnormalities in the same format for more than 70years. However, due to the complex nature of 12-lead ECG interpretation, there is a significant cognitive workload required from the interpreter. This complexity in ECG interpretation often leads to errors in diagnosis and subsequent treatment. We have previously reported on the development of an ECG interpretation support system designed to augment the human interpretation process. This computerised decision support system has been named 'Interactive Progressive based Interpretation' (IPI). In this study, a decision support algorithm was built into the IPI system to suggest potential diagnoses based on the interpreter's annotations of the 12-lead ECG. We hypothesise semi-automatic interpretation using a digital assistant can be an optimal man-machine model for ECG interpretation. OBJECTIVES: To improve interpretation accuracy and reduce missed co-abnormalities. METHODS: The Differential Diagnoses Algorithm (DDA) was developed using web technologies where diagnostic ECG criteria are defined in an open storage format, Javascript Object Notation (JSON), which is queried using a rule-based reasoning algorithm to suggest diagnoses. To test our hypothesis, a counterbalanced trial was designed where subjects interpreted ECGs using the conventional approach and using the IPI+DDA approach. RESULTS: A total of 375 interpretations were collected. The IPI+DDA approach was shown to improve diagnostic accuracy by 8.7% (although not statistically significant, p-value=0.1852), the IPI+DDA suggested the correct interpretation more often than the human interpreter in 7/10 cases (varying statistical significance). Human interpretation accuracy increased to 70% when seven suggestions were generated. CONCLUSION: Although results were not found to be statistically significant, we found; 1) our decision support tool increased the number of correct interpretations, 2) the DDA algorithm suggested the correct interpretation more often than humans, and 3) as many as 7 computerised diagnostic suggestions augmented human decision making in ECG interpretation. Statistical significance may be achieved by expanding sample size.

Comparison of Electrocardiographic Criteria for Identifying Left Ventricular Hypertrophy in Athletes from Different Sports Modalities

OBJECTIVES: In athletes, isolated electrocardiogram high voltage criteria are widely used to evaluate left ventricular hypertrophy, but positive findings are thought to represent normal electrocardiogram alterations. However, which electrocardiogram criterion can best detect left ventricular hypertrophy in athletes of various sport modalities remains unknown. METHODS: Five electrocardiogram criteria used to detect left ventricular hypertrophy were tested in 180 male athletes grouped according to their sport modality: 67% low-static and high-dynamic components and 33% high-static and high-dynamic components of exercise. The following echocardiogram parameters are the gold standard for diagnosing left ventricular hypertrophy: left ventricular mass index ≥134 g.m-2, relative wall thickness ≥0.42 mm, left ventricular diastolic diameter index ≥32 mm.m-2, septum wall thickness ≥13 mm, and posterior wall thickness ≥13 mm. Results for the various criteria were compared using the kappa coefficient. Significance was established at p<0.05. RESULTS: Fifty athletes (28%) presented with left ventricular hypertrophy according to electrocardiogram findings, with the following sensitivities and specificities, respectively: 38-53% and 79-83% (Perugia), 22-40% and 89-91% (Cornell), 24-29% and 90% (Romhilt-Estes), 68-87% and 20-23% (Sokolow-Lyon), and 0% and 99% (Gubner). The Perugia and Cornell criteria had higher negative predictive values for the low-static and high-dynamic subgroup. Kappa coefficients were higher for Romhilt-Estes, Cornell and Perugia criteria than for Sokolow-Lyon and Gubner criteria. CONCLUSION: All five evaluated criteria are inadequate for detecting left ventricular hypertrophy, but the Perugia, Cornell and Romhilt-Estes criteria are useful for excluding its presence. The Perugia and Cornell criteria were more effective at excluding left ventricular hypertrophy in athletes involved in a sport modality with low-static and high-dynamic component predominance.

A New Combined Parameter to Predict Premature Ventricular Complexes Induced Cardiomyopathy: Impact and Recognition of Epicardial Origin.

INTRODUCTION: Reversible premature ventricular complexes-induced cardiomyopathy (PVC-CMP) is a well-described, multi-factorial entity. Single predictors, such as PVC burden or QRS duration, may not apply equally to all patients in contemporary unselected populations including patients with structural heart disease (SHD) or with particular origin such as epicardial (EPI) PVC. We sought to evaluate clinical criteria associated with PVC-CMP notably focusing on the EPI origin impact and ECG recognition and the value of a new composite predictor of PVC-CMP, the PVC-CMP-Index. METHODS AND RESULTS: We studied 107 consecutive patients (69 men; mean age = 56 ± 16 years) with frequent PVC (23.1 ± 11.5%) referred for PVC ablation. Thirty-six patients (33.6%) had an underlying SHD and 25 patients (23.4%) an EPI PVC origin. After a mean follow-up of 22.7 ± 15.3 months, 72.9% achieved a long-term successful ablation and 54.2% had PVC-CMP. PVC-CMP prevalence was significantly higher in patients with an EPI compared to endocardial PVC focus (84.0% vs. 45.1%, respectively, P < 0.001). EPI PVC origin (OR = 68.7 IC95% [3.5-1363], P = 0.005), as well as SHD (OR = 12.3 IC95% [1.6-92.6], P = 0.015), was independent predictor of PVC-CMP. While PVC burden (AUC = 0.78) or PVC-QRS width (AUC = 0.68) independently predicted PVC-CMP, the PVC-CMP-Index (values ≥39) defined as: PVC burden (0-1) × PVC-QRS width (milliseconds) × a constant C (1.28 for SHD or 2 for ECG suggesting EPI origin based on our ECG 3-step algorithm), highly correlated with PVC-CMP (AUC = 0.91, sensitivity = 93%, specificity = 80%). CONCLUSION: We developed a new index, which incorporates PVC burden, QRS width, and presence of SHD or suspected EPI origin that best predicted PVC-CMP.

Surface electrocardiogram detects signs of right ventricular pressure overload among acute-decompensated heart failure with preserved ejection fraction patients.

BACKGROUND: Pulmonary hypertension (PH) is a common finding among patients with heart failure and preserved ejection fraction (HFpEF) and contributes to develop right ventricular systolic dysfunction (RVSD). AIMS: We evaluated the diagnostic accuracy of Flowers and Horan electrocardiographic criteria to detect significant right ventricular pressure overload. METHODS: 123 patients were prospectively included. We used the Flowers and Horan (FH) ECG criteria to define RV enlargement (score >10). Echocardiographic measurements were performed blinded to the electrocardiographic results. RESULTS: Severe PH was found in 51.5%. Seventeen patients (16.5%) had a FH score >10 points. This was associated to RVSD (RR 2.66; 1.51-4.67 CI 95%, p=0.002), with 90.5% specificity and 34.4% sensitivity and to severe PH (RR 1.70; 1.16-2.50 CI 95%, p=0.028) with 91.9% specificity and 27.5% sensitivity. CONCLUSIONS: The ECG is a useful tool to classify HFpEF patients with echocardiographic signs of right ventricular pressure overload, in the absence of RBBB.

New methodologies for measuring Brugada ECG patterns cannot differentiate the ECG pattern of Brugada syndrome from Brugada phenocopy.

BACKGROUND: Brugada phenocopies (BrP) are clinical entities characterized by ECG patterns that are identical to true Brugada syndrome (BrS), but are elicited by various clinical circumstances. A recent study demonstrated that the patterns of BrP and BrS are indistinguishable under the naked eye, thereby validating the concept that the patterns are identical. OBJECTIVE: The aim of our study was to determine whether recently developed ECG criteria would allow for discrimination between type-2 BrS ECG pattern and type-2 BrP ECG pattern. METHODS: Ten ECGs from confirmed BrS (aborted sudden death, transformation into type 1 upon sodium channel blocking test and/or ventricular arrhythmias, positive genetics) cases and 9 ECGs from confirmed BrP were included in the study. Surface 12-lead ECGs were scanned, saved in JPEG format for blind measurement of two values: (i) ß-angle; and (ii) the base of the triangle. Cut-off values of ≥58° for the ß-angle and ≥4mm for the base of the triangle were used to determine the BrS ECG pattern. RESULTS: Mean values for the ß-angle in leads V1 and V2 were 66.7±25.5 and 55.4±28.1 for BrS and 54.1±26.5 and 43.1±16.1 for BrP respectively (p=NS). Mean values for the base of the triangle in V1 and V2 were 7.5±3.9 and 5.7±3.9 for BrS and 5.6±3.2 and 4.7±2.7 for BrP respectively (p=NS). The ß-angle had a sensitivity of 60%, specificity of 78% (LR+ 2.7, LR- 0.5). The base of the triangle had a sensitivity of 80%, specificity of 40% (LR+ 1.4, LR- 0.5). CONCLUSIONS: New ECG criteria presented relatively low sensitivity and specificity, positive and negative predictive values to discriminate between BrS and BrP ECG patterns, providing further evidence that the two patterns are identical.

Methods for Improving the Diagnosis of a Brugada ECG Pattern.

Brugada syndrome (BrS) is an inherited channelopathy that predisposes individuals to malignant arrhythmias and can lead to sudden cardiac death. The condition is characterized by two electrocardiography (ECG) patterns: the type-1 or "coved" ECG and the type-2 or "saddleback" ECG. Although the type-1 Brugada ECG pattern is diagnostic for the condition, the type-2 Brugada ECG pattern requires differential diagnosis from conditions that produce a similar morphology. In this article, we present a case that is suspicious but not diagnostic for BrS and discuss the application of ECG methodologies for increasing or decreasing suspicion for a diagnosis of BrS.