Low QRS voltages and left ventricular hypertrophy: a risky association

Abstract

Background Low-QRS voltages (LQRSV) are an unexpected finding in left ventricular (LV) hypertrophy, i.e, hypertrophic cardiomyopathy (HCM) or athlete’s heart. Methods Prevalence and clinical correlates of LQRSV were investigated in 197 consecutive HCM patients, aged 58±13 years and comparatively in 771 Olympic athletes, aged 23± 4. Clinical characterization included family/personal history, symptoms, NYHA functional class, ECG pattern, ventricular arrhythmias and cardiac magnetic resonance (CMR). Results 22 (11%) of HCM, and 18 (2.3%) of athletes presented LQRSV. At initial evaluation, in HCM, LQRSV showed no differences vs. non-LQRSV for functional class (90% vs. 91%, in class I-II; p=0.983), symptoms (27% vs. 18%; p=0.478), ventricular arrhythmias (40% vs. 39%; p=857), but showed larger extent of LGE at CMR (4.1±1.5 vs. 1.5±0.7 affected segments; p<0.001). In athletes, LQRSV was associated with larger prevalence of inverted T-waves (22% vs. 9%; p<0.001) and ventricular arrhythmias (28% vs. 8%; p=0.005). In one LQRSV athlete arrhythmogenic cardiomyopathy was identified. Over 4.5±2.6-year follow-up, presence of LQRSV in HCM was associated with larger incidence of functional deterioration (31% vs. 14%; p=0.038); stroke (22% vs. 6%; p=0.008) and ICD implant (27% vs. 10%; p=0.015). No clinical events occurred in LQRSV athletes without initial evidence of cardiac disease. Conclusion LQRSV are relatively common (11%) in HCM and have clinical relevance, being predictive over a medium-term for a worsening functional class, incidence of stroke and ICD implant. Instead, LQRSV are rare (2.3%) in athletes, but may occasionally be a marker that raises suspicion for underlying cardiac disease at risk.

The pivotal role of ECG in cardiomyopathies

“…A recent study published by Pelliccia et al ( 94 ) demonstrated that low QRS voltages are present in 11% of patients with HCM and are associated with a larger extent of LGE on MRI ( Figure 5D,E ); furthermore, after a follow-up of 4.5 ± 2.6 years, the presence of LQRSV in HCM are associated with a higher incidence of functional deterioration, stroke, and ICD implant.…”

The Stanford Legacy and the Future of Electrocardiographic Screening of Athletes

“…Recent studies have proposed criteria for LQRSV when screening athletes for cardiovascular disease. 30 These criteria have not yet been evaluated in a large population of healthy young athletes. The target population was 10,728 (42.5% female, 57.5% male, mean age 18.1 ± 4.3 years) athletes who participated in mass ECG screenings between 2014 and 2021 at multiple sites across the United States including grade schools (11%), high schools (32%), colleges (50%), and professional athletic teams (6%) with digitally recorded ECGs and a standardized protocol.…”

ISE/ISHNE expert consensus statement on the ECG diagnosis of left ventricular hypertrophy: The change of the paradigm

“…In patients with HF with reduced ejection fraction, the presence of LBBB was associated with increased mortality (Baldasseroni et al., 2002 ; Witt et al., 2016 ). In contrast, the low QRS amplitude in subjects with LVH is reported as a cardiovascular risk factor (Bacharova et al., 2015 ; Pelliccia et al., 2023 ).…”

“…However, the ECG imparts unique information on the electric field associated with LVH. Increased QRS amplitude (Adam Leigh et al, 2016;Zhang et al, 2020), in the presence of LVH, are significant independent cardiovascular risk factors (Bacharova et al, 2015;Pelliccia et al, 2023).…”

“…However, the ECG imparts unique information on the electric field associated with LVH. Increased QRS amplitude (Adam Leigh et al., 2016 ; Zhang et al., 2020 ), in the presence of LVH, are significant independent cardiovascular risk factors (Bacharova et al., 2015 ; Pelliccia et al., 2023 ). Therefore, the electrical characteristics of the heart depicted by the ECG provide valuable information adjunctive to imaging and cannot be neglected.…”