PURPOSE: We aimed to assess the diagnostic accuracy of the currently recommended ECG criteria for right ventricular hypertrophy (RVH) in patient with idiopathic pulmonary arterial hypertension (PAH) or PAH associated with connective tissue disease (CTD).
METHODS: 12-lead ECG and cardiovascular magnetic resonance (CMR) were performed simultaneously in 20 (9 men, 11 women, aged 49.8 ± 16.3 years) consecutive patients with idiopathic PAH or PAH associated with CTD diagnosed between January 2009 and November 2010 in a single center. All 21 ECG criteria for RVH as suggested in ACC/AHA/ HRS guidelines were evaluated and compared with right ventricular mass index (RVMI) measured in CMR, a gold standard. The age and gender adjusted cut-off values for RVH in CMR were: for men 30 g/m2 (<35 years) and 26 g/m2 (≥35 years); for women 27 g/m2 (<35 years) and 25 g/m2 (≥35 years of age). ROC analysis was used to assess the discriminative capacity of a single criterion.
RESULTS: The mean RVMI was 34.99 ± 20.09 g/m2; 14 (70%) patients had RVH in CMR. The following ECG criteria correlated with RVMI: RV1 (r=0.95, p<0.0001), R:SV1 (r=0.92, p<0.0001), RV1+SV5,6 (r=0.84, p <0.0001), max RV1,2+max SI,aVL -SV1 (r=0.81, p<0.0001), PII (r=0.74; p<0.0001), RaVR (r=0.5, p=0.03), SV6 (r=0.48, p= 0.03). The R:S V1>R:S V3 and R:S V1>R:SV4 were more commonly present in patients with than without RVH (8 vs 0, P=0.03). By CMR criteria the RV1 >6 showed sensitivity of 50% and specificity of 100% (AUC = 0.83; p=0.0003) and respectively the R:SV1 >1: 88% and 100% (AUC = 0.89; p=0.0001); the RaVR >4: 28% and 100% (AUC=0.80; p=0.002); the max RV1,2+max SI,aVL -SV1 >6: 92% and 50% (AUC = 0.78; p=0.008); the RV1+SV5,6 >10.5: 80% and 50% (AUC = 0.75; p=0.03); the presence of R:S V1>R:S V3 and R:S V1>R:SV4: 89% and 100% (AUC = 0.94; p<0.0001). The other criteria did not discriminate well between patients with and without RVH.
CONCLUSIONS: The R:SV1 >1 and the presence of R:S V1>R:S V3 and R:S V1>R:SV4 have highest specificity and sensitivity however they are not useful when S in these leads are zero (8 of our patients). The other criteria are highly specific with low sensitivity as RV1 >6, RaVR >4 or highly sensitive with low specificity as max RV1,2+max SI,aVL -SV1 >6 and RV1+SV5,6 >10.5 .
CLINICAL IMPLICATIONS: Out of 21 ECG criteria for RVH only 7 are useful to discriminate between patients with and without RVH as assessed in CMR, a gold standard. Depending on the clinical context more specific or more sensitive criteria can be used.
DISCLOSURE: The following authors have nothing to disclose: Grzegorz Kopec, Anna Tyrka, Tomasz Miszalski, Maciej Sobien, Marcin Waligora, Piotr Podolec
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