Left ventricular hypertrophy and cardiovascular disease risk prediction and reclassification in blacks and whites: The Atherosclerosis Risk in Communities Study

doi:10.1016/j.ahj.2014.09.013

American Heart Journal

Volume 169, Issue 1, January 2015, Pages 155-161.e5

https://doi.org/10.1016/j.ahj.2014.09.013 Get rights and content

Background

Left ventricular hypertrophy (LVH) is a major independent predictor of cardiovascular disease (CVD) survival and is more prevalent in blacks than whites. In a large biracial population, we evaluated the ability of electrocardiography (ECG)-determined LVH (ECG-LVH) to reclassify CVD/coronary heart disease (CHD) events beyond traditional risk factors in blacks and whites.

Methods

The analysis included 14,489 participants (mean age 54 ± 5.7 years; 43.5% men; 26% black) from the ARIC cohort, with baseline (1987-1989) ECG, followed up for 10 years. Predicted risk for incident CVD and CHD were estimated using the 10-year Pooled Cohort and Framingham risk equations (base models 1A/1B), respectively. Models 2A and 2B included respective base model plus LVH by “any” of 10 traditional ECG-LVH criteria. Net reclassification improvement (NRI) was calculated, and the distribution of risk was compared using models 2A and 2B versus models 1A and 1B, respectively.

Results

There were 792 (5.5%) 10-year Pooled Cohort CVD events and 690 (4.8%) 10-year Framingham CHD events. Left ventricular hypertrophy defined by any criteria was associated with CVD and CHD events (hazard ratio [95% CI] 1.62 [1.38-1.90] and 1.56 [1.32-1.86], respectively]. Left ventricular hypertrophy did not significantly reclassify or improve C statistic in models 2A/B (C statistics 0.767/0.719; NRI = 0.001 [P = not significant]), compared with the base models 1A/B (C statistics 0.770/0.718), respectively. No racial interactions were observed.

Conclusions

In this large cohort of black and white participants, ECG-LVH was associated with CVD/CHD risk but did not significantly improve CVD and CHD events risk prediction beyond the new Pooled Cohort and most used Framingham risk equations in blacks or whites.

Section snippets

Study population

We used data from the ARIC study, which is a prospective, population-based cohort study designed to investigate the etiology and natural history of CVD. From 1987 to 1989, 15,792 men and women aged 45 to 64 years were enrolled from 4 US communities: Jackson, MS; Washington County, MD; Forsyth County, NC; and suburbs of Minneapolis, MN. Details of the study design have been previously published.¹⁰ The study was approved by institutional review boards at each participating center, and all study

Results

Our study included 14,489 ARIC participants; 6,303 (43.5%) were men, and 3,767 (26%) were black (Table I). At baseline, 2,833 (19.6%) had LVH by any of our 10 defined criteria. The highest prevalence of LVH was observed with the Lewis index (10.5%), whereas the lowest prevalence of 1.6% was observed using the Framingham ECG score (Table II). Left ventricular hypertrophy was more prevalent in blacks compared with whites, regardless of the criteria used in its definition. We assessed CVD in our

Discussion

To our knowledge, this is the first study to show that independent of black/white race, the presence of LVH by any or all of the LVH-ECG criteria did not significantly reclassify CVD events risk by NRI and did not show significant improvement in CVD events risk prediction by C statistic, beyond the Pooled Cohort equation made up of traditional cardiovascular risk factors. In supplemental data, our findings were similar, when we evaluated the ability of LVH to predict/reclassify CHD risk beyond

Conclusion

We found that, in both black and white participants, despite its significant associations with CVD/CHD risk, LVH (determined by any individual or all of the LVH ECG criteria) did not significantly add to reclassification or prediction of CVD or CHD events beyond the Pooled Cohort and Framingham risk equations made up of traditional cardiovascular risk factors. No major differences between black and white participants were observed.

Disclosures

None.

Novelty and significance

What is new:

•
To our knowledge, this is the first study that has the ability of LVH to predict risk of cardiovascular disease events beyond the newest as well as the oldest (and most used) risk prediction tools
•
The findings of our study—that LVH does not add predictive value and does not improve reclassification of cardiovascular events beyond traditional cardiovascular risk factors in both African Americans and white populations or in African Americans compared with their white counterparts
•
Our

Acknowledgements

The authors thank the staff and participants of the ARIC study for their important contributions.

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Life's Simple 7 and Peripheral Artery Disease Risk: The Atherosclerosis Risk in Communities Study
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Citation Excerpt :
Specifically, all records with an ICD-9 code 440.2 (atherosclerosis of native arteries and extremities), 440.3 (atherosclerosis of bypass graft of the extremities), 440.4 (chronic total occlusion artery extremities), 84.1x (lower-extremity amputation), 38.18 (leg endarterectomy), 39.25 (aorto-iliac-femoral bypass), 39.29 (leg bypass surgery), and 39.50 (percutaneous transluminal angioplasty of non-coronary vessels) qualified as hospitalized PAD. All covariates were assessed at Visit 1 and Visit 3 and included age (years), sex, race, ARIC field center, education level (high school or less, some college, and college or more), alcohol consumption (drinks/week), medication use (anti-diabetic, antihypertensive, aspirin, and lipid-lowering therapy), electrocardiogram-defined left ventricular hypertrophy (LVH),20 CHD, HF, and stroke. Medication use (anti-diabetic, antihypertensive, aspirin, and lipid-lowering therapy) was ascertained by asking participants to bring containers of current medications.
The American Heart Association's Life's Simple 7 includes seven metrics of ideal cardiovascular health to target for cardiovascular disease prevention. This study determined the relationship between Life's Simple 7 and incident peripheral artery disease in a biracial cohort of middle- and older-aged adults.
This analysis included 12,865 participants from the Atherosclerosis Risk in Communities study recruited between 1987 and 1989 (mean age=54years, 55% women, 25% black) and free of peripheral artery disease or other cardiovascular disease at baseline. Overall, Life's Simple 7 score was calculated as the sum of the Life's Simple 7 component scores (two points if ideal, one point if intermediate, and zero if poor) and classified as inadequate (zero to four), average (five to nine), or optimal (ten to 14) cardiovascular health and linked to incident peripheral artery disease identified by hospital discharge diagnosis and leg revascularization. Analysis was conducted in 2017.
A total of 434 incident peripheral artery disease cases occurred over a median follow-up of 24.4years. Compared with the inadequate category (n=1,008), participants in the average (n=8,395) and optimal (n=3,462) categories each had a substantially lower risk of developing peripheral artery disease in a Cox proportional hazards model adjusted for potential confounders (hazard ratio=0.36, 95% CI=0.28, 0.46 for average, and hazard ratio=0.09, 95% CI=0.06, 0.15 for optimal). In a similar model, a one-point higher Life's Simple 7 score was associated with a 25% lower risk of incident peripheral artery disease (hazard ratio=0.75, 95% CI=0.72, 0.79).
Better cardiovascular health, as defined by higher Life's Simple 7 score, is associated with a substantially lower risk of peripheral artery disease.
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2018, Journal of the American College of Cardiology
Predictive value of electrocardiographic left ventricular hypertrophy in the general population: A meta-analysis
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Citation Excerpt :
The included studies were published between 2001 and 2019. Six articles [7,9,10,16,19,20] adopted prospective designs and others were retrospective studies. A total of 58,400 participants were included in these 10 articles.
Conflicting results have been reported on the predictive value of the electrocardiographic left ventricular hypertrophy (LVH) in the general population. This meta-analysis sought to compare the predictive value of different electrocardiographic criteria of LVH in the general population.
We comprehensively searched PubMed and Embase databases until May 9, 2020 to identify observational studies investigating the predictive value of different electrocardiographic criteria for LVH (Sokolow-Lyon voltage, Cornell voltage or Cornell product) in the general population. Outcome measures were major adverse cardiovascular events (MACEs), cardiovascular or all-cause mortality.
Ten studies enrolling 58,400 individuals were included. Comparison with and without electrocardiographic LVH, the pooled risk ratio (RR) of MACEs was 1.62 (95% confidence interval [CI] 1.40–1.89) for the Sokolow-Lyon voltage criteria, 1.70 (95% CI 1.27–2.29) for the Cornell voltage criteria, and 1.56 (95% CI 1.17–2) for the Cornell product criteria. The pooled RR of all-cause mortality was 1.47 (95% CI 1.10–1.97) for the Sokolow-Lyon voltage criteria and 1.87 (95% CI 1.29–2.71) for the Cornell voltage criteria. Furthermore, the pooled RR of cardiovascular mortality was 1.38 (95% CI 1.19–1.60) for the Sokolow-Lyon criteria, 1.66 (95% CI 1.24–2.33) for the Cornell voltage criteria, and 1.82 (95% CI 0.65–5.09) for the Cornell product criteria.
Different electrocardiographic criteria for evaluating LVH had a similar value in predicting MACEs among the general population. LVH detected by the Cornell voltage appeared to have a stronger predictive value in prediction of cardiovascular or all-cause mortality.
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Clinical InvestigationCoronary Artery DiseaseLeft ventricular hypertrophy and cardiovascular disease risk prediction and reclassification in blacks and whites: The Atherosclerosis Risk in Communities Study

Background

Methods

Results

Conclusions

Section snippets

Study population

Results

Discussion

Conclusion

Disclosures

Novelty and significance

Acknowledgements

Ann Epidemiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Am Heart J

J Clin Epidemiol

J Clin Epidemiol

Am Heart J

Am J Hypertens

Cardiovascular risk-estimation systems in primary prevention: do they differ? Do they make a difference? Can we see the future?

Circulation

2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Circulation

Competing cardiovascular outcomes associated with electrocardiographic left ventricular hypertrophy: the Atherosclerosis Risk in Communities Study

Heart

Clinical Investigation
Coronary Artery Disease
Left ventricular hypertrophy and cardiovascular disease risk prediction and reclassification in blacks and whites: The Atherosclerosis Risk in Communities Study