Improved scoring system for the electrocardiographic diagnosis of left ventricular hypertrophy

Table 1 Patient characteristics

Characteristic - no. (%) unless noted	Derivation cohort (n = 5486)	Validation cohort (n = 910)
Age (mean ± SD)	59.1 ± 15.8	58.6 ± 15.2
18-29	265 (4.8)	30 (3.3)
30-39	408 (7.4)	91 (10.0)
40-49	708 (12.9)	105 (11.5)
50-59	1295 (23.6)	224 (24.6)
60-69	1358 (24.8)	242 (26.6)
70 +	1452 (26.5)	218 (24.0)
Male sex	2869 (52.3)	448 (49.2)
Body mass index
mean ± SD	28.0 ± 6.6	28.5 ± 6.5
Median (range)	26.9 (12.9-75.2)	27.5 (15.8-66.1)
Left ventricular mass by echocardiogram
mean ± SD	167.2 ± 62.1	173.3 ± 64.8
Median (intraquartile range)	155.4 (123.3-200.4)	163.0 (124.1-205.0)
Left ventricular hypertrophy present by echocardiogram	333 (6.1)	80 (8.6)
Time between echocardiogram and electrocardiogram in days (mean, intraquartile range)	6.7 (0-13)	5.9 (0-11)

Table 2 Multivariate logistic regression analysis for left ventricular hypertrophy

Characteristic	Wald Chi-Square	P value
Q-wave amplitude in V3	19.3	P < 0.0001
R-wave amplitude in V6	39.7	P < 0.0001
S-wave amplitude in V3	135	P < 0.0001
QRS Duration	115.4	P < 0.0001
Discordant R-axis and T-axis (difference ≤ 75 or > 75)	14.6	P = 0.0001
Maximum (positive deflection) T-wave amplitude in V6	38.5	P < 0.0001
Maximum P'-wave amplitude in V1	18.5	P < 0.0001
P-wave peak amplitude in V6	0.19	P = 0.659
Weight	0.008	P = 0.927
Height	25.2	P < 0.0001
Sex	6.3	P = 0.012
Age	0.03	P = 0.864

Table 3 Components of the electrocardiographic diagnostic score for left ventricular hypertrophy

Criteria	Number of points
Sum of R-wave amplitude in V6 + S-wave amplitude in V3 + Q-wave amplitude in V3 > 4.0 mV in males and 3.2 mV in females	1
QRS duration > 100 ms	1
Absence of positive component of T-wave in V6 (maximum T-wave amplitude < 0) when overall QRS vector in V6 positive (i.e., R-wave larger than S-wave)	1
Discordant limb lead R- and T-wave axis (R- minus T-wave axis ≤ 75 or > 75 degrees)	0.5
Amplitude of negative terminal p-wave deflection in V1 greater than amplitude of positive deflection	0.5

Table 4 Multivariate logistic regression analysis for left ventricular hypertrophy stratified by sex

	Male (n = 2869)		Female (n = 2617)
Characteristic	Wald Chi-Square	P value	Wald Chi-Square	P value
Q-wave amplitude in V3	14.7	P = 0.0001	5.0	P = 0.025
R-wave amplitude in V6	25.5	P < 0.0001	10.0	P = 0.001
S-wave amplitude in V3	77.0	p < 0.0001	53.6	P < 0.0001
QRS Duration	62.2	P < 0.0001	51.2	P < 0.0001
Discordant R-axis and T-axis (difference ≤ 75 or > 75)	17.8	p < 0.0001	0.63	P = 0.426
Maximum (positive deflection) T-wave amplitude in V6	16.0	P < 0.0001	26.1	P < 0.0001
Maximum P'-wave amplitude in V1	9.4	P = 0.002	4.6	P = 0.031
P-wave peak amplitude in V6	1.0	P = 0.314	3.5	P = 0.061
Weight	0.50	P = 0.477	0.9	P = 0.340
Height	6.8	P = 0.009	21.8	P < 0.0001
Age	1.4	P = 0.245	1.06	P = 0.303

Table 5 Sensitivity, specificity, and positive and negative predictive values of selected electrocardiographic criteria for left ventricular hypertrophy

		Derivation cohort				Validation cohort
Criteria	Cutoff	Sensitivity (95% CI)	Specificity (95% CI)	PPV	NPV	Sensitivity	Specificity
Derived Criteria	1.5 points	67.9 (62.6-72.9)	81.4 (80.3-82.4)	19.0	97.5	62.5	83.2
""	2 points	42.3 (37.0-47.7)	93.0 (92.3-93.7)	28.2	96.2	37.5	93.4
""	2.5 points	30.0 (25.2-35.3)	96.6 (96.1-97.1)	37.6	95.6	30.0	96.8
Cornell	-	37.8 (32.6-43.1)	92.3 (91.6-93.0)	24.1	95.8	36.2	90.3
Sokolow-Lyon	-	16.5 (12.5-20.5)	95.9 (95.4-96.5)	20.7	94.7	20.0	96.3
Cornell Product		55.0 (49.6-60.3)	88.3 (87.5-89.2)	23.3	96.8	53.8	88.1
Sokolow-Lyon Product		22.5 (18.0-27.0)	95.9 (95.3-96.4)	26.0	95.0	23.8	95.6
Gubner-Ungerleider		27.0 (22.3-31.8)	88.9 (88.0-89.8)	13.6	95.0	27.5	87.7
Sum-of-12-Lead		57.4 (51.9-62.7)	76.1 (74.9-77.3)	13.4	96.5	57.5	77.1
Romhilt-Estes	5 points	35.4 (30.3-40.8)	94.4 (93.7-95.0)	26.2	95.8	35.0	95.0
""	4 points	51.1 (45.5-56.5)	88.2 (87.3-89.0)	21.8	96.5	57.5	90.0
Framingham-adjusted Cornell		42.3 (37.0-47.7)	90.1 (89.3-90.9)	21.7	96.0	51.3	87.6
R-wave amplitude in aVL	1.1 mV	20.1 (16.0-24.8)	92.6 (91.8-93.3)	14.9	94.7	21.3	92.1
Peguero-Lo Presti		24.9 (20.3-29.6)	94.7 (94.1-95.3)	23.3	95.1	26.3	93.5

CI: Confidence interval; PPV: Positive predictive values; NPV: Negative predictive values.