Change of Body Surface Electrocardiogram is Linked to Left ... · PDF fileLinked to Left Ventricular Geometric Alteration from Normal, Pre-Hypertension to Hypertension: Comparison

Hypertension

Change of Body Surface Electrocardiogram isLinked to Left Ventricular Geometric Alteration

from Normal, Pre-Hypertension to Hypertension:Comparison of NT-ProBNP and hs-CRP in

Determining Ventricular RemodelingChih-Hsuan Yen,1,2† Jui-Peng Tsai,1,2† Yih-Jer Wu,1,2,3 Jen-Yuan Kuo,1 Hung-I Yeh,1,2 Charles Jia-Yin Hou,1,2

Chuan-Chuan Liu4,5,6 and Chung-Lieh Hung1,2

Background: The presence of echocardiographic left ventricular remodeling and hypertrophy, a potential surrogate

of pathophysiology intermediate between hypertension and heart failure, has been strongly linked to increased

cardiovascular events. Electrocardiography (ECG) data regarding such a continuous change in pre-hypertension

and hypertension subjects and their comparison with biomarkers are still elusive.

Methods and Materials: We studied 364 subjects including 140 normal subjects (mean age 47.6 � 9.4, 49% female),

136 pre-hypertensives (mean age 50.6 � 9.6, 32% female) and 88 hypertensives (mean age 58.6 � 11.5, 44%

female). Baseline demographic data and levels of biomarkers [high-sensitivity C-reactive protein (hs-CRP) and

N-terminal-pro-B type natriuretic peptide (NT-ProBNP)] were collected, with various 12-lead surface ECG criteria

analyzed. Echo-derived left ventricular (LV) geometries were assessed through standardized methods. We used

nonparametric trend tests for comparing continuous variables across different groups with receiver-operating

characteristic (ROC) curves constructed from both ECG and biomarkers for identifying echo-defined ventricular

remodeling and hypertrophy.

Results: Of all 364 subjects under survey, several ECG-based parameters demonstrated continuous changes in an

ordered fashion across different groups (all p < 0.05) which paralleled those observed from biomarkers and

echo-derived LV geometric changes and function. NT-ProBNP alone identified echo-derived LV hypertrophy

(LVH) better than hs-CRP (AUC: 0.72 vs. 0.62, respectively, both p < 0.05) while neither showed satisfactory result

in identifying concentric remodeling. The ROC area under curve in identifying LVH showed comparative result

between some electrocardiography (ECG) parameters and NT-ProBNP, with Cornell product revealed to have the

highest predictive value (AUC: 0.73, p < 0.05).

Conclusion: Surface ECG yielded ability comparable to that of NT-ProBNP in identifying LVH. LV geometric

remodeling, when defined by surface ECG, seemed to progress in subjects from normal, pre-hypertension to

hypertension. This evidence suggests that aggressive control of blood pressure may be helpful at an earlier stage.

Key Words: Echocardiography � Electrocardiography � hs-CRP � Hypertension � Left ventricular hypertrophy

� NT-ProBNP

INTRODUCTION

Hypertension has becoming the leading epidemio-

logic issue owing to its widely affected population and

increasing economic burden.1 Ventricular hypertrophy,

which represents a more severe form of ventricular re-

modeling following hypertension, denotes a clinical sur-

rogate of target organ damage.2 Left ventricular hyper-

trophy (LVH) has been shown to predict cardiovascular

events including stroke, myocardial infarction, heart

failure and sudden cardiac death.3-6 Echocardiography, a

29 Acta Cardiol Sin 2011;27:29�37

Left Ventricular Geometries Determined by Surface ElectrocardiographyOriginal Article Acta Cardiol Sin 2011;27:29�37

Received: March 30, 2010 Accepted: July 27, 20101Division of Cardiology, Department of Internal Medicine, MackayMemorial Hospital; 2Department of Medicine, Mackay MedicalCollege, and Mackay Medicine Nursing and Management College;3Institute of Traditional Medicine, National Yang-Ming University;4Graduate Institute of Health Care Organization Administration,College of Public Health National Taiwan University; 5HealthEvaluation Center, Mackay Memorial Hospital, Taipei; 6Departmentof Medical Technology, Yuanpei University of Science and Technology,Hsin-Chu, Taiwan.Address correspondence and reprint requests to: Dr. Chung-Lieh Hung,Division of Cardiology, Department of Internal Medicine, MackayMemorial Hospital, No. 92, Chung-Shan North Road, Section 2,Mackay Memorial Hospital, Taipei 100, Taiwan. Tel: 886-2-2531-9260;Fax: 886-2-2543-3535 ext. 2459; E-mail: [email protected]† Both authors contributed to this work equally.

traditional standard clinical tool in determining such car-

diac structural and functional changes, is relatively ex-

pensive and time-consuming. Recently, N-terminal-pro-

B type natriuretic peptide (NT-proBNP)7 and the inflam-

matory marker high-sensitivity C-reactive protein (hs-

CRP)8 have been proved to link with an increasing risk

for cardiovascular events and altered LV structures.9-12

Conventional surface 12-lead electrocardiography (ECG)

such as Cornell voltage13 and Sokolow-Lyon voltage14

criteria, traditionally used as diagnostic parameters for

the presence of LVH, have lead to various diagnostic

capabilities.15,16

In previous studies, the combined utilization of both

B-type BNP and C-reactive protein in predicting the

presence of LVH has lead to promising results in hyper-

tensive people.17 However, the data containing both

biomarkers and various 12-lead surface ECG criteria in

diagnosing LVH compared to echocardiography were

lacking in Asian people. The present study was to assess

the clinical value of ECG in diagnosing LVH based on

different criteria and to compare such parameters with

biomarkers and echocardiography in healthy, or pre-

hypertensive (Pre-HTN) and hypertensive (HTN) Tai-

wanese.

METHODS AND MATERIALS

Study setting and subject population

The design of this study was approved by the local

ethics committee in accordance with the Declaration of

Helsinki (IRB No: 09MMHIS037). Participants enrolled

in this study consisted of 1) Normotensive subjects with-

out other known systemic diseases (n = 140, Group A);

2) Pre-HTN (n = 136, Group B) and; 3) HTN subjects (n

= 88, Group C), all of whom underwent general health

evaluation between January 2006 and December 2008. A

detailed review of medical history through structured

questionnaire with physical examination and chest ra-

diography were all performed. All baseline characteris-

tics and related anthropometrics including age, body

height, weight and body mass index (BMI) were ac-

quired, with routine laboratory data including bioche-

mistries (including hepatic, renal and lipid profiles) and

complete blood cell counts taken. Patients with known

cardiovascular surgery or rheumatic heart disease, overt

heart failure symptoms, atrial fibrillation rhythm, pre-

vious implantation of pacemaker and overt renal insuffi-

ciency (creatinine > 2.5 mg/dl) were all excluded in our

study. History of diabetes mellitus (DM) was defined as

fasting blood glucose level of more than 126 mg/dL or

any current usage of diabetes medication with previ-

ously diagnosed DM. Patients who had hypertension his-

tory, were taking anti-hypertension agents or had sys-

tolic blood pressure � 140 mmHg and/or diastolic blood

pressure � 90 mmHg were diagnosed as HTN. Pre-HTN

subjects were those with systolic blood pressure > 120

mmHg or diastolic blood pressure > 80 mmHg without

hypertension. Normal group was defined as systolic

blood pressure � 120 mmHg and diastolic blood pres-

sure � 80 mmHg without known cardiovascular or other

systemic diseases. Blood pressures at rest were taken

shortly before the subsequent echo study by medical

staff blinded to the other test results. An average of two

measurements was used as representative data. hs-CRP

level were determined by a highly sensitive, latex parti-

cle-enhanced immunoassay using Elecsys 2010 (Hitachi

Corp, Hitachinaka Ibaraki, Japan) with pro-B-type na-

triuretic peptide (pro-BNP) level by electro-hemilu-

minescence immunoassay ECLIA (Roche E17). Serum

samples were collected using standard sampling tubes or

tubes containing separating gel. After ensuring individu-

alized patient samples, calibrators and controls were at

ambient temperature (20-25 �C) and were measured

within 2 hours because of possible evaporation effects.

12-lead surface electrocardiography analysis

All participants underwent standardized 12-lead sur-

face electrocardiography examination. Recordings were

obtained using autonomic instruments (Page Writer Trim

III, Phillip, Andover, USA) with digitized data trans-

ferred and stored for further analysis. Readings were

performed and interpreted by two experienced car-

diologists independently of each other and blinded to

clinical information. Assessment with respect to QRS

duration was measured to the nearest 4 ms as possible,

with R-wave amplitudes in leads aVL, V5, V6, and S

wave amplitudes in leads V1 and V3 measured to the

nearest 0.5 mm (0.05 mV) by use of calipers as proposed

in the LIFE study.18 Age-adjusted Cornell voltage (RaVL

+ SV3 > 2.0 mV, plus 0.8 mV in women), Cornell product

((RaVL + SV3) � QRS duration > 2436 mV.ms), Soko-

Acta Cardiol Sin 2011;27:29�37 30

Chih-Hsuan Yen et al.

low-Lyon voltage (SV1 + RV5/6 > 3.5 mV), McPhie cri-

terion (the sum of the tallest R and deepest S in the

precordial leads > 4.5 mV) and Framingham score cri-

teria (RI + SIII > 2.5 mV, SV1 + RV5/6 > 3.5 mV, SV1/2/3 >

2.5 mV + RV4/5/6 > 2.5 mV plus left ventricular strain

pattern) were used to determinate the left ventricular

hypertrophy as defined by previous studies.15

Determination of LV geometry and function

A single experienced technician blinded to other

study results and details assessed the measures of trans-

thoracic echocardiography (Hewlett Packard Sonos 5500

series equipped with a 2.5-MHz transducer). LV end-

diastolic and end-systolic volumes were calculated by

the Z-derived method,19 which allows accurate quantifi-

cation of LV volume and mass even in subjects with di-

lated chambers. LV mass, relative wall thickness and

stroke volume (SV) were all derived using such method.

The LV concentricity was estimated by relative wall

thickness (RWT), with a value > 0.42 being defined as

concentric LV geometry. LV concentric hypertrophy was

estimated as relative wall thickness (RWT) > 0.42 and

LV mass index > 115 gm/m2male gender and > 95 gm/m2

female gender with eccentric hypertrophy defined to be

the same LV mass index criteria with RWT < 0.42.

Those patients with RWT > 0.42 with LV mass index

within normal rage were classified as concentric re-

modeling. LV systolic performance by calculating endo-

cardial and mid-wall LV fractional shortening was com-

puted by using a previously described formula.20 End-

systolic circumferential wall stress was also derived

from end-systolic pressure representing mean arterial

pressure as in the previously described equation.21 Both

mid-wall fractional shortening and circumferential wall

stress were used to estimate stress-corrected left ven-

tricular after-load. We took a relatively rigorous step to

preclude any patient with significant degree valvular

heart diseases or existence of significant pulmonary hy-

pertension (defined as estimated systolic pulmonary

arterial pressure more than 50 mmHg).22

Statistical analysis

Continuous data were shown as mean � standard

deviation and were compared with t-test or Mann-Whit-

ney test for unpaired data as appropriate, and categorical

data were presented as ratio and compared by chi-square

test or Fisher’s exact test. Data without normal distribu-

tion across ordered groups were further compared by us-

ing a non-parametric trend test (Wilcoxon rank-sum

test). One-way ANOVA test was used for an un-adjusted

comparison for three groups, with post hoc Bonferroni

correction for multiple comparisons between groups. All

p value were two-sided, with value less than 0.05 con-

sidered statistically significant.

RESULTS

Baseline characteristics and demographic

data

Baseline demographics and characteristics of these

364 enrolled subjects are listed in Table 1. From normal,

pre-HTN to HTN groups, age tended to be older with

larger waist circumference, body mass index, waist-to-

hip ratio, higher fasting glucose level and biomarker

levels including both hs-CRP and NT-ProBNP (all

trends p < 0.001). Participants with hypertension were

significantly older, had higher waist circumference,

higher systolic blood pressure, higher hs-CRP, NT-

ProBNP level and worse renal function than both pre-

HTN and normal subjects (all p < 0.05). Compared with

normal population, pre-HTN group tended to have

higher body mass index and fasting glucose level (all p <

0.05).

ECG criteria of left ventricular hypertrophy in

the pre-hypertensive and hypertensive

In Table 2, value from all electrocardiography (ECG)

derived parameters in these three groups were displayed.

There was an ordered increase of Sokolow-Lyon volt-

age, gender-adjusted Cornell voltage, Cornell product,

and McPhie and Gubner/Ungerleider voltage criteria

across different groups (all trend p < 0.001). ECG crite-

ria including gender-adjusted Cornell voltage, Cornell

product and Gubner/Ungerleider in the HTN group all

seemed significantly higher than in the pre-HTN and

normal group (all p value < 0.05). Compared with the

normal group, ECG parameters including Sokolow-Lyon

and McPhie voltage were higher in the pre-HTN and

HTN groups (both p < 0.05). Finally, PR interval was

significantly longer in the HTN group when compared to

those in the others (p < 0.05).


Left Ventricular Geometries Determined by Surface Electrocardiography

Changes of LV structure and function in the

pre-HTN and HTN groups

The distribution of LV geometric alteration in terms

of remodeling and hypertrophy is shown in Figure 1,

while other LV structural and functional parameters

based on echocardiography are further displayed in

Table 3. The hypertension group had higher percentage

of concentric and eccentric hypertrophy and lower ratio

of normal LV geometry compared with the normal

group, with the pre-HTN group falling in-between. A

graded increase in LA diameter, RWT, LV mass with and

without indexes and mass-to-volume ratio was observed

in a significant trend higher from normal to pre-HTN to

HTN groups (all trends p < 0.001). With a borderline



Table 1. Baseline demographic characteristics of the study population

Control (n = 140) Pre-HTN (n = 136) HTN (n = 88) Trend p

Age 47.2 � 9.60 50.6 � 9.6* 058.6 � 11.5*† < 0.001

Gender (female) 69 (49%) 48 (32%) 46 (44%) < 0.015

BW 62.3 � 12.1 66.9 � 11*. 67 � 12* < 0.001

Waist 78.8 � 9.70 83.4 � 9.2* 086.4 � 10.2*† < 0.001

Waist-hip ratio 0.85 � 0.08 00.89 � 0.07* 0.91 � 0.07* < 0.001

BMI 22.9 � 3.20 24.8 � 3.4* 026 � 3.7* < 0.001

SBP 105.6 � 7.200 123.7 � 6.5*0 137.3 � 17*†0. < 0.001

AC Sugar 91.4 � 8.50 101.4 � 23.9* 106.7 � 27.9*0 < 0.001

Cholesterol 196.9 � 3600. 203.2 � 37.10 199.7 � 37.60. 00.38

eGFR 86.5 � 15.2 0..87 � 15.2 0.80.7 � 16.7*† < 0.001

Smoking 37 (27.8) 35 (24.1) 17 (17.5) < 0.192

Hs-CRP (log) 0.13 � 0.17 0.20 � 0.48 0.0.30 � 0.50*† < 0.001

NT-ProBNP (log) 25.8 � 37.5 27.1 � 35.2 063.5 � 105*† < 0.001

BW, body weight; BMI, body mass index; SBP, systolic blood pressure; AC Sugar, fasting blood sugar; eGFR, estimated glomerular

filtration rate.

* denotes p < 0.05 compared with normal; † denotes p < 0.05 compared with pre-HTN; ‡ denotes p < 0.1 compared with pre-HTN;

* denotes p < 0.1 compared with normal.

Table 2. Various ECG parameters analyzed from the study population


Sokolow-Lyon 19.5 � 6.50 .22.8 � 6.4* 23.7 � 8.4*. < 0.001

Sokolow-Lyon/or strain 8 (5.7) 14 (9.5) 12 (11.4) < 0.255

Cornell (after gender adjust) .14 � 4.8 14.7 � 5.6. .16.8 � 5.6*† < 0.001

Cornell product 1216.2 � 44400. 1289.9 � 538.1. .1501.4 � 548.8*† < 0.001

Mcphie .22 � 6.4 .25.3 � 6.8* 27.1 � 8.1* < 0.001

Gubner & Ungerleider 6.1 � 3.1 07.6 � 4.1* 0.8.9 � 4.4*† < 0.001

Framingham score 5 (3.6%) 17 (11.5%) 15 (14.3%) < 0.009

QRS duration (max) 0.87 � 11.8 87.8 � 11.3 90.1 � 15.1 00.10

P duration (max) 1.67 � 0.58 1.69 � 0.54 1.69 � 0.54 00.55

PR interval 163.6 � 19.40 162.6 � 2900. .170.9 � 22.5*† < 0.001

HR from RR (1/min) 63.7 � 8.80 65.5 � 11.1 66.6 � 11.1 00.04

QT interval (max) 382.8 � 38.80 383.3 � 32.40 387.8 � 4600. 00.85

QT interval corrected (max) .395 � 23.7 393.5 � 36.70 0404 � 40.2† < 0.001

P axis 51.6 � 26.1 45.9 � 25.2 50.5 � 27.9 00.04

QRS axis 48.4 � 34.9 41.5 � 35.9 41.8 � 43.9 00.01

T axis 31.8 � 25.8 33.4 � 20.7 33.6 � 32.7 00.58



increase of LV end-diastolic volume in the pre-HTN and

HTN groups (trend p = 0.06), stress-corrected mid-wall

fractional shortening tended to decrease, while LV wall-

stress increased (both trends p < 0.05). Compared with

normal and pre-HTN groups, subjects in the HTN group

had significantly larger RWT, LV mass with and without

index, mass-to-volume ratio while showing obviously

decreased LV contraction in terms of reduced fractional

shortening with or without stress correction (all p < 0.05).

Role of ECG criteria, NT-ProBNP and hs-CRP

levels in the discrimination of LV remodeling

and hypertrophy

In Figure 2, we further demonstrated the diagnostic



Table 3. Various echo-derived cardiac structures and parameters analyzed from the study population


LA diameter 30.9 � 4.90 32.9 � 4.8* 0034.4 � 5.1*‡ < 0.001

LVESV 33.8 � 9.30 34.7 � 10.0 34.7 � 8.7 00.52

LVEDV 98.6 � 18.2 104.4 � 21.1* 103.0 � 21.1 00.06

LV EF 65.9 � 6.00 66.9 � 5.90 66.2 � 5.5 00.55

RWT 0.38 � 0.06 00.40 � 0.07* 0000.43 � 0.07*† < 0.001

Mass-to-V Ratio 1.38 � 0.29 1.53 � 0.3* 0001.71 � 0.36*† < 0.001

LV mass 136.1 � 3500. 157.1 � 37.3* 00173.6 � 38.5*† < 0.001

LV mass index 75 � 16 00.89 � 18.9* 00093.8 � 18.3*† < 0.001

FS endo 36.4 � 4.70 37.2 � 4.70 36.6 � 4.3 0.5

FS mmw 00.2 � 0.02 00.2 � 0.02 0000.19 � 0.03*† < 0.001

FS cmw 0.22 � 0.03 0.22 � 0.03 0000.21 � 0.03*† 00.03

Cscom 81.3 � 18.3 086.4 � 19.1* 0087.5 � 19.5* 00.01

Cscom, circumferential wall stress; EDV, end-diastolic volume; EF, ejection fraction; ESV, end-systolic volume; FS endo, endocardial

fractional shortening; FS, midwall fractional shortening; FS cmw, stress-corrected fractional shortening; LA, left atrium/atrial; LV,

left ventricular; Mass-to-V, mass to volume; RWT, relative wall thickness.



Figure 1. Shown here are the distribution and proportions of different geometries and cardiac structures from normal, pre-HTN to HTN groups.

Higher prevalence of cardiac remodeling and hypertrophy was associated with pre-HTN and HTN groups.

accuracy of LV hypertrophy and remodeling from re-

ceiver-operating characteristics curves (ROC) by utiliz-

ing various ECG parameters and both biomarkers. Ge-

nerally, diagnostic value tended to be higher in predict-

ing LV hypertrophy but not remodeling by all clinical

modalities. Of all ECG-derived parameters, gender-

adjusted Cornell voltage and Cornell product seemed to

have largest area under curve in predicting LV hyper-

trophy (AUC: 0.71 vs. 0.73, respectively). NT-ProBNP

seemed to have larger area under curve in the discrimi-

nation of LV hypertrophy when compared with hs-CRP

(AUC: 0.72 vs 0.62). Combined usage of the two bio-

markers did not significantly increase the AUC for pre-

dicting LV hypertrophy and remodeling, (AUC: 0.72 for

LVH and 0.59 for remodeling, respectively), and pro-

duced to similar results as NT-ProBNP for hypertrophy

and hs-CRP for remodeling.

DISCUSSION

This study revealed that continuous changes in various

ECG parameters from normal, pre-HTN to HTN groups

were observed which paralleled several echo-derived car-

diac structural and functional changes and correlated with

some clinical variables. More intriguingly, several electro-

cardiography parameters had comparable diagnostic accu-

racy in predicting LVH defined by echo method when

compared to the biomarker NT-ProBNP. However, neither

ECG-derived parameters nor biomarkers identified the

minor form of LV geometric phenotypes in terms of con-

centric remodeling with satisfactory result.

Left ventricular remodeling and hypertrophy, which

represents a clinical feature of target organ damage in

hypertensive subjects, denotes the pathophysiologic in-

termediate between chronic ventricular pressure over-



Figure 2. Biomarkers and various ECG parameters and the corresponding area under curve in the identification of cardiac hypertrophy or

remodeling is displayed.

load and heart failure6 and has been strongly linked to

increased cardiovascular events.3-5,23,24 In terms of con-

centric remodeling, earlier-stage LV geometric pheno-

types when assessed by either relative wall thickness or

mass-to-volume ratio, may represent a precursor of

LVH, has been reported as a predictor of cardiovascular

events and is related to several cardiovascular risk fac-

tors.25 Furthermore, the regression of left ventricular re-

modeling and LVH indicates improvement of cardiovas-

cular function and prognosis.26,27 In this regard, optimal

monitoring of the management of hypertensive patients

with LVH may thus rely on precise and reproducible

electrocardiography or echocardiography methods and

medical therapy. Echocardiography as a robust clinical

diagnostic tool has been proven to be reliable in differ-

entiating various phenotypes of left ventricular structural

and functional changes but is obviously limited by its

higher costs and time-consuming procedure.28 Tradi-

tional application of 12-lead surface electrocardiography

in assessing various ventricular geometric phenotypes,

such as Cornell voltage12 and Sokolow-Lyon voltage13

criteria, were not promising in some previous studies. In

the LIFE study, Peter et al. observed that anti-hyperten-

sive treatment may result in the regression of electro-

cardiographic LVH which parallels reduced cardiovascu-

lar events29 and may indicate the validation and feasibil-

ity of surface ECG relating to clinical outcomes.

Elevation of NT-proBNP, a biologically inactive

peptide from ProBNP precursor in response to increased

ventricular wall stress, was proven to be a useful indica-

tor of left ventricular dysfunction after acute myocardial

infarction, heart failure, or even in patients with normal

blood pressure.30,31 More recently, biomarkers such as

BNP, NT-ProBNP or their combination usage with C-

reactive protein have been adopted as alternative and

useful markers in discriminating such cardiac structural

changes and functional decay in hypertensive sub-

jects.16,32 Furthermore, higher NT-ProBNP levels were

proven to be more indicative of ventricular hypertrophy

per se rather than the existence of hypertension.33 Dif-

ferent from the previous study by David et al., our data

didn’t show the combination superiority of two bio-

markers in assessing echo-defined LVH.17 Also, we ob-

served a continuous, graded progress of ECG parameters

from normal, pre-hypertensive to hypertensive groups,

which was in line with the scenario of biomarkers and

echocardiographic changes reflecting the clinical con-

tinuum of hypertension pathology. Interestingly, while

comparable effects were observed for both biomarkers

and several ECG-based parameters in identifying echo-

defined ventricular hypertrophy, the clinical values for

predicting concentric remodeling by these conventional

ECG parameters were less impressive which was similar

with previous study.34

According to JNC VII guidelines, pre-hypertension

is the term used to describe intermediate blood pressure

value between normotension (< 120/80 mmHg) and tra-

ditional hypertension (� 140/90 mmHg).35 In the Fra-

mingham study series, the 12-year risk of ischemic heart

disease of patients with systolic blood pressure between

130 and 139 mmHg was twice that of those with blood

pressure less than 120 mmHg.30 Previous study in Singa-

pore by Lee et al. illustrated the impact of pre-hyper-

tension on all-cause and cardiovascular mortality.36

From epidemiologic studies, aging per se was a strong

factor contributing to vascular stiffening and subsequent

elevated blood pressure.37 Theoretically, in the aging so-

ciety of the modern world, the population of pre-hyper-

tension should be increasing and will thus become a ma-

jor health-care burden in the near future. A more easily

applied and clinically feasible tool, such as ECG, may be

more helpful in the initial screening for this population.

LIMITATIONS

Although left ventricular remodeling process charac-

terized by surface ECG seemed to progress in subjects

from normal, pre-HTN to HTN and correlated with echo-

derived parameter and biomarkers, several limitations

still need to be acknowledged. First, we only assessed

and summed up the ECG criteria for quantitative LVH

analysis; more detailed ECG characters from individual

leads were not included. Second, this was a relative small,

retrospective and observational study; the generalizability

for a broader population and the follow up information

with respect to our findings was not proved.

CONCLUSION

ECG-based parameters may yield similar capability



as NT-ProBNP for diagnosing LVH. Further, left ven-

tricular remodeling process, when assessed by surface

ECG parameters, seemed to progress in subjects from

normal, pre-hypertension to hypertension and correlated

with several echo-derived parameters and biomarkers.

This evidence suggested that detection and aggressive

control of blood pressure may be helpful at an earlier

stage.

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