Prognostic utility of baseline electrocardiography for patients older than 65 years with hypertension. Is left ventricular hypertrophy the only thing that matters?

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"apellidos" => "Armario" "email" => array:2 [ 0 => "parmario@csi.cat" 1 => "parmariog@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Área de Atención Integrada Riesgo Vascular, Servicio de, Medicina Interna, Hospital Moisès Broggi Sant Joan Despí, Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] 1 => array:3 [ "autoresLista" => "R. Freixa-Pamias" "autores" => array:1 [ 0 => array:3 [ "nombre" => "R." "apellidos" => "Freixa-Pamias" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Moisès Broggi Sant Joan Despí, Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0015" ] 1 => array:3 [ "entidad" => "Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0020" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad pronóstica de la electrocardiograma basal en pacientes hipertensos mayores de 65 años. Es solo la hipertrofia ventricular izquierda lo que importa?" ] ] "textoCompleto" => "Electrocardiography (ECG) for use with asymptomatic adult patients is a standard technique in primary care, typically with normal results. However, recent guidelines have not recommended baseline or stress ECG in asymptomatic individuals with low cardiovascular risk, because it adds no relevant information to the conventional estimate of cardiovascular risk as measured through a proper review of the medical history, physical examination, appropriate blood pressure (BP) measurement, lipid level determination and diabetes screening.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Nevertheless, an annual baseline ECG is requested for 21.5% of low-risk patients.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> This is an important issue, because it has been observed that baseline ECGs increase the number of cardiology consultations and lead to a possible cascade of tests.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The topic is more controversial for patients with intermediate-high risk, such that the new guidelines do not consider that a risk-benefit ratio that justifies screening for this patient population has been sufficiently demonstrated. The key issue is whether detecting ECG abnormalities in high-risk asymptomatic patients translates into the administration of a more intense treatment that would document a reduction in cardiovascular events.If we focus on patients with hypertension, ECG helps detect left ventricular (LV) hypertrophy, which is a sign of target organ impairment and an important independent predictor of cardiovascular disease and sudden death.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> ECG is a reasonable, low-cost test that helps detect various abnormalities in patients with hypertension, not only LV hypertrophy but also signs of LV overload, growth of cavities, ischemia, arrhythmias and conduction disorders. The 2018 European Society of Cardiology/European Society of Hypertension guidelines include atrial fibrillation (AF) for the first time as a cardiovascular disease<a class="elsevierStyleCrossRef" href="#bib0025">5</a> and specify the need for documenting the rhythm and diagnosing cases of asymptomatic AF. In recent years, there has been increasing interest in identifying the presence of partial or advanced interatrial blocks in the baseline ECG, especially with biphasic P waves in the inferior leads, given their relationship with AF and ischemic stroke.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>For detecting LV hypertrophy, ECG has good specificity but insufficient sensitivity. Nevertheless, given the high prevalence of arterial hypertension in the general population, ECG is the ideal screening and follow-up method for patients with hypertension in clinical practice. To increase the sensitivity, a combination of various criteria has been proposed. In clinical practice and research, however, the Cornell double product is one of the most widely used criteria (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0025">5</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>When the voltage criteria are combined with ST-T abnormalities or LV overload criteria, this test’s predictive value is improved, given that the ST-T abnormalities identify patients at very high risk.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Using data from the LIFE study published more than 15 years ago, Okin et al.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> showed that the LV overload pattern was still an independent marker of cardiovascular mortality, even after adjusting for the classical cardiovascular risk factors, BP and the severity of the LV hypertrophy criteria in the ECG.Most importantly, it is possible in clinical practice to reduce LV hypertrophy, and these changes are associated with a lower cardiovascular risk. Although it had already been observed in previous studies, the publication of the LIFE study confirmed these results. The absence of LV hypertrophy in the follow-up ECG was associated with a reduction in the risk of new cardiovascular events and sudden death, regardless of treatment, BP reduction, prevalence of coronary artery disease and other cardiovascular risk factors.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> The same study observed that improvements in the Cornell double product during follow-up were associated with a reduced probability of de novo AF.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> In contrast, the development during follow-up of a LV systolic overload pattern in the ECG was associated with increased cardiovascular and total morbidity.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>As for the elderly population, data from the Syst-Eur study<a class="elsevierStyleCrossRef" href="#bib0070">14</a> on patients older than 60 years with isolated systolic arterial hypertension (systolic BP, 160–219 mm Hg; diastolic BP < 90 mm Hg) showed that favorable changes in voltage in the ECG during follow-up were associated with a lower risk of cardiac events (HR, 0.86; p ≤ .05). This issue of the journal publishes the results of a study<a class="elsevierStyleCrossRef" href="#bib0075">15</a> conducted with 1003 patients older than 65 years (mean age, 72.9 years) with hypertension, 13.9% of whom experienced a major cardiovascular event during the follow-up. The study’s authors observed that the LV overload pattern, complete block and left bundle branch block were independent ECG predictors of cardiovascular events. These data confirm the prognostic importance of signs of LV overload in the ECG in managing patients with hypertension and the role of the complete left bundle branch block, a topic that has not been investigated much in the literature.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> The authors also assessed other parameters with less evidence in the literature such as right bundle branch block<a class="elsevierStyleCrossRef" href="#bib0085">17</a> and bifascicular block, which were shown to not have an independent prognostic value.Despite its lower sensitivity than echocardiography, baseline ECG continues to occupy an essential role in managing patients with hypertension, especially populations older than 65 years, given that it provides complementary information to echocardiography.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Moreover, the systematic performance of echocardiography is not justified for all patients with hypertension, given the high prevalence of hypertension in the general population, especially in this age group in which the prevalence is >60%." "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-06-03" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Armario P, Freixa-Pamias R. Utilidad pronóstica de la ECG basal en pacientes hipertensos mayores de 65 años. Es solo la hipertrofia ventricular izquierda lo que importa? Rev Clin Esp. 2020;220:123–125." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ECG, electrocardiogram; LVH, left ventricular hypertrophy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Criteria \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Parameters \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HVI criterion \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cornell (voltage) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RaVL + SV3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M: >28 mm F: >20 mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">New criterion (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RaVL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RaVL >11 mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cornell (product) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M: (RaVL + SV3 [mm]) × QRS (ms) F: (RaVL + SV3 [mm] + 6) × QRS (ms) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>2440 mm × ms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sokolow-Lyon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SV1 + RV5-6 (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>35 mm \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2244419.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Proposed criteria for the definition of left ventricular hypertrophy in electrocardiography." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Screening for cardiovascular disease risk with electrocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "US Preventive Services Task Force" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2018.6848" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2018" "volumen" => "319" "paginaInicial" => "2308" "paginaFinal" => "2314" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29896632" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Electrocardiograms in low-risk patients undergoing an annual health examination" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.S. 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