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Electrocardiographic detection of hypertensive left atrial enlargement in the presence of obesity: re-calibration against cardiac magnetic resonance

Journal of Human Hypertension volume 31, pages 212–219 (2017)Cite this article

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Abstract

Left atrial enlargement (LAE) has adverse prognostic implications in hypertension. We sought to determine the accuracy of five electrocardiogram (ECG) criteria for LAE in hypertension relative to cardiac magnetic resonance (CMR) gold standard and investigate the effect of concomitant obesity. One hundred and thirty consecutive patients (age: 51.4±15.1 years, 47% male, 51% obese, systolic blood pressure (BP): 171±29 mm Hg, diastolic BP: 97±15 mm Hg) referred for CMR (1.5 T) from a tertiary hypertension clinic were included. Patients with concomitant cardiac pathology were excluded. ECGs were assessed blindly for the following: (1) P-wave >110 ms, (2) P-mitrale, (3) P-wave axis <30°, (4) area of negative P-terminal force in V1 >40 ms.mm and (5) positive P-terminal force in augmented vector left (aVL) >0.5 mm. Left atrial volume ≥55 ml m−2, measured blindly by CMR, was defined as LAE. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under the receiver operator curve were calculated. The prevalence of LAE by CMR was 26%. All the individual ECG LAE criteria were more specific than sensitive, with specificities ranging from 70% (P-axis <30o) to 99% (P-mitrale). Obesity attenuated the specificity of most of the individual ECG LAE criteria. Obesity correlated with significant lower specificity (48% vs 65%, P<0.05) and a trend towards lower sensitivity (59 vs 43%, P=0.119) when ≥1 ECG LAE criteria were present. Individual ECG criteria of LAE in hypertension are specific, but not sensitive, at identifying LAE. The ECG should not be used to excluded LAE in hypertension, particularly in obese subjects.

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Acknowledgements

This work was part-funded by the NIHR Bristol Cardiovascular Biomedical Research Unit, Bristol Heart Institute. We thank Mr Christopher Lawton, CMR Superintendent Radiographer and the CMR radiographer team within in the Bristol Heart Institute for their expertise in acquiring the CMR studies. The views expressed in this manuscript are those of the authors and not necessarily reflect those of the National Health Service, National Institute for Health Research or Department of Health. JCLR is funded by the Clinical Society of Bath Postgraduate Research Bursary 2014 and Royal College of Radiologists Kodak Research Scholarship 2014. ECH (BHF grant IBSRF FS/11/1/28400) and JRFP are both funded by the British Heart Foundation.

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Authors and Affiliations

  1. Cardiac Magnetic Resonance Department, NIHR Bristol Cardiovascular Biomedical Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK

    J C L Rodrigues, T Erdei, A G Dastidar, M C K Hamilton & N E Manghat

  2. Faculty of Biomedical Sciences, School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK

    J C L Rodrigues, E C Hart, J F R Paton & A K Nightingale

  3. Severn Postgraduate Medical Education Foundation School, NHS Health Education South West, Bristol, UK

    B McIntyre

  4. CardioNomics Research Group, Clinical Imaging and Research Centre, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK

    A E Burchell, L E K Ratcliffe, E C Hart, J F R Paton & A K Nightingale

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Rodrigues, J., Erdei, T., Dastidar, A. et al. Electrocardiographic detection of hypertensive left atrial enlargement in the presence of obesity: re-calibration against cardiac magnetic resonance. J Hum Hypertens 31, 212–219 (2017). https://doi.org/10.1038/jhh.2016.63

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