Accuracy and prognostic significance of electrocardiographic markers of left ventricular hypertrophy in a general population : findings from the Pressioni Arteriose Monitorate E Loro Associazioni population

AIM: We assessed the value of three electrocardiographic (ECG) voltage criteria in detecting left ventricular hypertrophy (LVH) and in predicting cardiovascular events and all-cause mortality in the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) population. METHODS: At entry, 1549 individuals (age 50 ± 13 years, 50.5% men) underwent diagnostic tests including laboratory investigations, 24-h ambulatory blood pressure monitoring, and standard ECG and echocardiography. RESULTS: The sensitivity of ECG criteria for LVH was lowest for Sokolow-Lyon voltage (1.5 and 0.78%), intermediate for Cornell voltage (20.5 and 19.0%), and highest for RaVL wave amplitude (26.0 and 36.2%), independently of whether left ventricular mass was indexed to body surface area or height, respectively. After adjustment for age, sex, night-time SBP, low-density lipoprotein and high-density lipoprotein cholesterol, serum glucose, BMI, smoking, and previous cardiovascular events, only Cornell voltage index [hazard ratio for a 0.1  mV increase: 1.050, 95% confidence interval (CI): 1.017-1.083, P < 0.003] predicted an increased risk of cardiovascular events as well as all-cause mortality. Furthermore, when the categorical relationship between ECG-graphic LVH and cardiovascular outcomes was investigated in multiple models, only LVH identified by the Cornell voltage index remained an independent predictor of cardiovascular events (hazard ratio = 2.466, CI 1.459-4.168, P = 0.0008) and all-cause deaths (hazard ratio = 2.984, CI 1.380-6.449, P = 0.005). CONCLUSION: Despite the limited sensitivity of ECG voltage criteria in detecting LVH, our results show that Cornell voltage index may improve cardiovascular risk stratification in a general population independently of several confounding factors.