Left ventricular dysfunction screening in hypertensive patients with N-terminal pro–B-type natriuretic peptide and electrocardiogram

Drake, Weiying; Mani, Giselle; Freeman, D.; Best, Randall M.; Newby, L. Kristin; Chandra, Abhinav

doi:10.1016/j.ajem.2010.11.021

Cited by 6 publications

(3 citation statements)

References 12 publications

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“…Thus the release of NT-proBNP promoted by LVH in our patients may well have been dampened by the counterinfluence of obesity and metabolic risk factors. Recently data has suggested that a combined approach using ECG and NT-proBNP can improve identification of LVH among patients with hypertension presenting to emergency departments [ 13 ]. However, this study was from a small number of patients (49) among whom 43% had LVH from the ECG and while promising these results would need to be confirmed in a larger study and this approach has not been evaluated among patients with diabetes.…”

Section: Discussionmentioning

confidence: 99%

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Screening for left ventricular hypertrophy in patients with type 2 diabetes mellitus in the community

Somaratne

Whalley

Poppe

et al. 2011

Cardiovasc Diabetol

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BackgroundLeft ventricular hypertrophy (LVH) is a strong predictor of cardiovascular disease and is common among patients with type 2 diabetes. However, no systematic screening for LVH is currently recommended for patients with type 2 diabetes. The purpose of this study was to determine whether NT-proBNP was superior to 12-lead electrocardiography (ECG) for detection of LVH in patients with type 2 diabetes.MethodsProspective cross-sectional study comparing diagnostic accuracy of ECG and NT-proBNP for the detection of LVH among patients with type 2 diabetes. Inclusion criteria included having been diagnosed for > 5 years and/or on treatment for type 2 diabetes; patients with Stage 3/4 chronic kidney disease and known cardiovascular disease were excluded. ECG LVH was defined as either the Sokolow-Lyon or Cornell voltage criteria. NT-proBNP level was measured using the Roche Diagnostics Elecsys assay. Left ventricular mass was assessed from echocardiography. Receiver operating characteristic curve analysis was carried out and area under the curve (AUC) was calculated.Results294 patients with type 2 diabetes were recruited, mean age 58 (SD 11) years, BP 134/81 ± 18/11 mmHg, HbA1c 7.3 ± 1.5%. LVH was present in 164 patients (56%). In a logistic regression model age, gender, BMI and a history of hypertension were important determinants of LVH (p < 0.05). Only 5 patients with LVH were detected by either ECG voltage criteria. The AUC for NT-proBNP in detecting LVH was 0.68.ConclusionsLVH was highly prevalent in asymptomatic patients with type 2 diabetes. ECG was an inadequate test to identify LVH and while NT-proBNP was superior to ECG it remained unsuitable for detecting LVH. Thus, there remains a need for a screening tool to detect LVH in primary care patients with type 2 diabetes to enhance risk stratification and management.

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Section: Discussionmentioning

confidence: 99%

“…Recent data suggests that NT-proBNP may be of value in identification of LVH among patients with hypertension presenting to emergency departments [ 13 ]. However, to date there have been no studies comparing diagnostic accuracy between NT-proBNP and ECG for detection of LVH in patients with type 2 diabetes.…”

Section: Introductionmentioning

confidence: 99%

Screening for left ventricular hypertrophy in patients with type 2 diabetes mellitus in the community

Somaratne

Whalley

Poppe

et al. 2011

Cardiovasc Diabetol

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“…That our bestcase sensitivity was nearly half of what was reported in the only other ED-based study of ECG test characteristics for detection of LVH in hypertensive patients (29% vs. 56%) supports this supposition, as that study included patients who had echocardiograms performed as part of in-hospital evaluations, presumably for suspicion of underlying cardiac disease. 20 It has been estimated that up to 56% of patients with HTN are asymptomatic 21 and according to our data, at least half will have underlying LVH. However, our data also suggest that ECG does not adequately screen for LVH, missing more than 70% with objectively determined increases in LV mass.…”

Section: Discussionmentioning

confidence: 99%

Test Characteristics of Electrocardiography for Detection of Left Ventricular Hypertrophy in Asymptomatic Emergency Department Patients With Hypertension

Mahn

Dubey

Brody

et al. 2014

Academic Emergency Medicine

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Objectives: The objective was to evaluate the diagnostic test characteristics of three validated electrocardiographic (ECG) criteria for the diagnosis of left ventricular hypertrophy (LVH) in undifferentiated, asymptomatic emergency department (ED) patients with hypertension (HTN).Methods: This was a prospective cohort study of ED patients with asymptomatic HTN at a single tertiary care facility. Patients 35 years of age or older with systolic blood pressure (sBP) ≥ 140 mm Hg or diastolic blood pressure (dBP) ≥ 90 mm Hg on two separate readings (at least 1 hour apart) were eligible for inclusion. At enrollment, ECGs were obtained for all patients. Presence of LVH on ECG was defined using Cornell voltage, Cornell product, and Minnesota Code 3.1/3.2 criteria. Echocardiography was then performed, with LVH defined by the presence of one or more of the following validated criteria: interventricular septal or posterior wall thickness ≥ 1.3 cm, LV mass ≥ 225 g (male) or ≥ 163 g (female), or LV mass indexed to height raised to the power of 2.7 ≥ 48 g/m 2.7 (male) or ≥ 45 g/m 2.7 (female). Descriptive statistics and diagnostic characteristics (i.e., sensitivity and specificity) with corresponding 95% confidence intervals (CIs) for each of the three ECG criteria were derived for both the composite and the individual echocardiographic determinants of LVH. Logistic regression was also used to model LVH before and after subsequent inclusion of clinically relevant variables.Results: A total of 161 patients (93.8% African American; mean [AESD] age = 49.8 [AE8.3] years) were enrolled, and LVH was present in 89 patients (55.2%, 95% CI = 47.6% to 62.8%). On ECG analysis, mean Cornell voltage (21.5 mV vs. 28.7 mV; difference = -7.2 mV, 95% CI = -3.8 to -10.7 mV) and Cornell product (1868.4 msec 9 mV vs. 2616.4 msec 9 mV; difference = -748.0 msec 9 mV, 95% CI = -401.2 to -1094.8 msec 9 mV) were significantly lower among those without LVH on echocardiography. Subjects without LVH on echocardiography were less likely to meet Cornell voltage (30.5% vs. 48.3%; difference = -17.8%, 95% CI = -2.5% to -31.7%) or Cornell product (26.4% vs. 49.4%; difference = -23.0%, 95% CI = -8.0% to -36.5%) criteria for LVH. The diagnosis of LVH by Minnesota Code was less common (18.1% vs. 25.8%; difference = -7.7%, 95% CI = -20.1% to 5.3%) with no difference by group. Sensitivity and specificity were as follows: for the Cornell voltage, sensitivity 25.4% (95% CI = 15.3% to 37.9%), specificity 50.0% (95% CI = 67.6% to 93.2%); for the Cornell product, sensitivity 25.4% (95% CI = 15.3% to 37.9%), specificity 75.0% (95% CI = 19.4% to 99.4%); and for the Minnesota code, sensitivity 26.9% (95% CI = 16.6% to

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Hypertension in the Emergency Department

2016

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Hypertension is the leading risk factor for the global burden of disease, yet more than 20% of adults with hypertension are unaware of their condition. Underlying hypertension affects over 25% emergency department attendees, and the condition is more commonly encountered in emergency departments than in primary care settings. Emergency departments are strategically well placed to fulfill the important public health goal of screening for hypertension, yet less than 30% of patients with mild to severe hypertension are referred for follow up. In predominantly African American populations, subclinical hypertensive disease is highly prevalent in ED attendees with asymptomatic elevated blood pressure. Although medical intervention is not usually required, in select patient populations, it may be beneficial for antihypertensive medications to be started or adjusted in the emergency department, aiming for optimizing blood pressure control earlier while waiting for continuing care.

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Left ventricular dysfunction screening in hypertensive patients with N-terminal pro–B-type natriuretic peptide and electrocardiogram

Cited by 6 publications

References 12 publications

Screening for left ventricular hypertrophy in patients with type 2 diabetes mellitus in the community

Screening for left ventricular hypertrophy in patients with type 2 diabetes mellitus in the community

Test Characteristics of Electrocardiography for Detection of Left Ventricular Hypertrophy in Asymptomatic Emergency Department Patients With Hypertension

Hypertension in the Emergency Department

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