Clinical and Experimental Hypertension. Part A: Theory and Practice

ISSN: 0730-0077 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iceh19

Echocardiographic Left Ventricular Hypertrophy: Clinical Characteristics. The Framingham Heart Study Daniel Levy, Joanne M. Murabito, Keaven M. Anderson, Jane C. Christiansen & William P. Castelli To cite this article: Daniel Levy, Joanne M. Murabito, Keaven M. Anderson, Jane C. Christiansen & William P. Castelli (1992) Echocardiographic Left Ventricular Hypertrophy: Clinical Characteristics. The Framingham Heart Study, Clinical and Experimental Hypertension. Part A: Theory and Practice, 14:1-2, 85-97, DOI: 10.3109/10641969209036173 To link to this article: http://dx.doi.org/10.3109/10641969209036173

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Date: 27 April 2016, At: 16:39

CLIN. AND EXPER. HYPER.-THEORY AND PRACTICE, A14(1&2),

85-97 (1992)

Echocardiographic Left Ventricular Hypertrophy: C1 inical Characteristics.

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The Framingham Heart Study

Daniel Levy, MD Joanne M. Murabito, MD Keaven M. Anderson, PhD Jane C. Christiansen, MPH William P. Castelli, MD

From the Framingham Heart Study, 5 Thurber Street, Framingham, MA; the Division of Epidemiology and Clinical Applications of the National Heart, Lung, and Blood Institute, Bethesda, MD; the Epidemiology and Preventive Medicine section o f Boston University School of Medicine, Boston, MA; and the Divisions of Cardiology and Clinical Epidemiology o f Beth Israel Hospital and Harvard Medical School, Boston, MA.

ABSTRACT Recent data suggest that echocardiographic left ventricular (LV) hypertrophy is associated with increased cardiovascular morbidity and mortality. Based upon appl ication of sex-specif ic echocardiographic criteria for LV hypertrophy, the clinical characteristics o f 863 subjects with and 4097 sub-

Address for reprints: Daniel Levy, MD. Framingham Heart Study 5 Thurber Street Framingham, MA 01701

Copyright 0 1992 by Marcel Dekker, Inc.

86

LEVY ET A L .

jects without LV hypertrophy are examined.

Subjects with LV hypertrophy are

older, more obese, have higher blood pressure, and are more 1 ikely to have pre-existing coronary artery disease.

In addition subjects with LV hypertro-

phy have a higher prevalence of reduced echocardiographic fractional shortening. We conclude that

subjects with echocardiographic LV hypertrophy are at

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high risk for cardiovascular disease complications by virtue of their clinical profile.

Additional investigation of the benefits of therapeutic interven-

tions directed toward the prevention or regression of LV hypertrophy is warranted.

INTRODUCTION Left ventricular (LV) hypertrophy detected by electrocardiography is an important predictor of cardiovascular morbidity and mortality (1-4).

Echocar-

diographic assessment of LV mass in clinical and population studies has led to development of echocardiographic criteria for LV hypertrophy (5-6). Emerging evidence suggests echocardiographic LV hypertrophy

is a1 so

predictive of

cardiovascular morbidity and mortality (7-11). The Framingham Heart Study population has undergone routine echocardiographic assessment which facil itated the development of sex-specif ic criteria for LV hypertrophy (6).

Application of these criteria to

Framingham Heart

Study subjects resulted in detection of LV hypertrophy in more than 15% of an adult population sample.

LV hypertrophy has been found to be associated with

obesity, hypertension, and coronary and valvular heart disease (12-13). This study examines these and other clinical characteristics of subjects with LV hypertrophy in comparison to those without this echocardiographic finding.

&S

Poaul at ion A prospective epidemiological study was begun in 1948 with a sample of

the residents of Framingham, Massachusetts between the ages o f 28 and 62 years

a7

ECHOCARDIOGRAPHIC LV HYPERTROPHY

selected to undergo biennial examination.

Offspring of the original cohort

and spouses of offspring were entered into the study in 1972.

The study

design and selection criteria have been previously reported (14-17). Echocardiograms were obtained in 2291 of 2351 surviving original cohort subjects undergoing their sixteenth biennial examination and 3857 of 3867 offspring undergoing their second examination. At the time of echocardiographic exami-

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nation height, weight, resting blood pressure, and 12-lead electrocardiograms were obtained.

The diagnosis of coronary artery disease was made after review

of the cl inical history, hospital records, and electrocardiographic tracings. Valvular disease was determined on the basis of

a grade >= III/VI systolic

murmur, or any diastolic murmur detected on physical examination, or echocardiographic evidence of valvular heart disease (including mitral valve pro-

1 apse). Fchocard iowaph ic Nethods Echocardiographic methods have been previously reported (6). Routine Mmode echocardiography was facil itated by two-dimensional imaging in more than 90% of subjects.

Measurements were made according to American Society of

Echocardiography recommendat ions using a leading edge to leading edge convention (18). LV internal dimension, ventricular septum, and LV posterior wall were measured at end diastole as defined by the onset of the QRS complex. For the study to be considered adequate each of these structures had to be measurable.

Using the cubed formula of Troy et al. (19) LV mass

follows: LV mass (grams)=l.O5[(LV

internal diameter

t

was derived as

LV septal thickness t

posterior wall t h i ~ k n e s s ) -~ (LV internal diameter)3 1.

Measurements were

also made in diastole according to the methods of Devereux and Reichek (20) ("Penn" convention) with left ventricular mass estimated from the formula: left ventricular mass (grams)

=

1.04[(LVID

t

VST

t

PWT)3 - (LVIO)3] - 13.6;

where LVID=left ventricular internal diameter, VST=ventricular septal thickness and PWT=posterior wall thickness.

Unless otherwise stated, measurements

based upon American Society of Echocardiography methods and formula are pre-

LEVY ET AL.

88

sented.

"Penn" measurement derived c r i t e r i a f o r LV hypertrophy are provided

f o r reference because o f t h e i r b e t t e r c o r r e l a t i o n w i t h autopsy d e r i v e d l e f t v e n t r i c u l a r mass.

A h e a l t h y subset of 864 study p a r t i c i p a n t s , ages 18 t o 79, was used t o C r i t e r i a f o r upper l i m i t s o f normal LV

generate normative reference data (6).

mass, based upon mean values p l u s two standard d e v i a t i o n s f o r LV mass/height

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a r e 163 grams/meter f o r men and 121 grams/meter values based upon "Penn"

methods

are

f o r women.

143 grams/meter

for

Corresponding men and 102

grams/meter f o r women. The same h e a l t h y reference group was used t o determine t h e lower 1 i m i t s o f normal echocardiographic f r a c t i o n a l shortening (percent d i f f e r e n c e between LV d i a s t o l i c and LV s y s t o l i c i n t e r n a l diameter) based on two standard d e v i a t i o n s below t h e mean. Flectrocardioaraohic Methods

A t t h e index examination,

standard 12-lead electrocardiograms were

i n t e r p r e t e d by t h e examining physician.

Framingham Heart Study c r i t e r i a f o r

electrocardiographic LV hypertrophy have been p r e v i o u s l y described (1-2).

The

diagnosis o f LVH was made on the b a s i s o f f u l f i l l m e n t o f 21 o f t h e f o l l o w i n g voltage c r i t e r i a :

R wave >1.1 mV i n AVL, R wave >=2.5 mV i n l e f t p r e c o r d i a l

leads, S wave >=2.5 mV i n r i g h t precordium, sum o f p r e c o r d i a l SVltRV5 >=3.5 mV, sum o f l i m b l e a d

RItSIII >=2.5 mV), R wave o r S wave i n AVF >=2.0 mV.

For

t h e purposes o f t h e present study, p a t i e n t s w i t h evidence o f LVH by voltage alone and those w i t h a d d i t i o n a l r e p o l a r i z a t i o n changes ( " s t r a i n p a t t e r n " ) were combined *

.

. cal

Methods

Linear regression analyses were used t o compute age-adjusted values o f continuous v a r i a b l e s . variables.

D i r e c t age-adjustment was used t o compare dichotomous

A l i n e a r regression model was used t o a d j u s t f o r age and t e s t f o r

d i f f e r e n c e s o f continuous v a r i a b l e s between subjects w i t h and those w i t h o u t echocardiographic LV hypertrophy. t o t e s t f o r differences

The Mantel -Haenszel (21) procedure was used

i n c a t e g o r i c a l v a r i a b l e s a f t e r a d j u s t i n g f o r age.

A

ECHOCARDIOGRAPHIC LV HYPERTROPHY

Table 1 C1 i n i c a l C h a r a c t e r i s t i c s o f Subjects According t o L e f t V e n t r i c u l a r Hypertrophy Status Age and Age-adjusted mean values

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MEN

WOMEN LVH

n=1868

n=352

Age

48.7

55.9

**

49.1

62.9

S y s t o l i c BP

128

135

**

124

131

D i a s t o l i c BP

80

83

**

75

78

Hypertension Rx

13.2%

23.8%

**

14.8%

28.2%

** ** ** **

Heart Rate

65

63

NS

69

68

NS

Body Mass Index

26

29

**

24

29

ECG LVH

2.1%

8.8%

**

0.8%

3.2%

** 18.4% **

4.3%

9.3%

** ** **

17.6%

21.5% NS

Coronary Disease 6.3% Val ve Disease

9.6%

**=P