J Korean Med Sci.  2015 Apr;30(4):407-413. 10.3346/jkms.2015.30.4.407.

Addition of N-terminal Pro-B-type Natriuretic Peptide Levels to Electrocardiography Criteria for Detection of Left Ventricular Hypertrophy: The ARIRANG Study

• Ahn MS
• Yoo BS
• Lee JH
• Lee JW
• Youn YJ
• Ahn SG
• Kim JY
• Lee SH
• Yoon J
• Park JK
• Ahn SV
• Choi E

• KMID: 2164448
• DOI: http://doi.org/10.3346/jkms.2015.30.4.407

Abstract

The utility of electrocardiography (ECG) in screening for left ventricular hypertrophy (LVH) in general populations is limited mainly because its low sensitivity. B-type natriuretic peptide (BNP) is released due to the remodeling processes of LVH and could improve the diagnostic accuracy for the ECG criteria for LVH. We hypothesized that addition of BNP levels to ECG criteria could aid LVH detection compared with ECG alone in a general population. We enrolled consecutive 343 subjects from a community-based cohort. LVH was defined as LV mass index > 95 g/m2 for females and > 115 g/m2 for males according to echocardiography. The area under the receiver operator characteristic (ROC) curve to detect LVH was 0.55 (95% confidence interval [CI], 0.50-0.61) in Sokolow-Lyon criteria and 0.53 (0.47-0.59) in the Cornell voltage criteria. After addition of N-terminal-proBNP levels to the model, the corresponding areas under the ROC were 0.63 (0.58-0.69) and 0.64 (0.59-0.69), respectively. P values for the comparison in areas under the ROC for models with and without N-terminal-proBNP levels were < 0.001. These data suggest that addition of N-terminal-proBNP levels to ECG criteria could significantly improve the diagnostic accuracy of LVH in general populations.

Keyword

Hypertrophy; Left Ventricular; Electrocardiography; Natriuretic Peptides

MeSH Terms

Adult
Cohort Studies
*Electrocardiography
Female
Humans
Hypertrophy, Left Ventricular/blood/*diagnosis
Male
Middle Aged
Natriuretic Peptide, Brain/*blood
Peptide Fragments/*blood
ROC Curve
Natriuretic Peptide, Brain
Peptide Fragments

Figure

• 

  Fig. 1 Receiver operating characteristic (ROC) curves for the combination of N-terminal pro-B-type natriuretic peptide (NT-proBNP) level and electrocardiography (ECG) criteria compared with ECG criteria alone for the detection of left ventricular hypertrophy.

Reference

1. Kannel WB, Gordon T, Offutt D. Left ventricular hypertrophy by electrocardiogram. Prevalence, incidence, and mortality in the Framingham study. Ann Intern Med. 1969; 71:89–105.

2. Kannel WB, Gordon T, Castelli WP, Margolis JR. Electrocardiographic left ventricular hypertrophy and risk of coronary heart disease. The Framingham study. Ann Intern Med. 1970; 72:813–822.

3. Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Gattobigio R, Zampi I, Porcellati C. Prognostic value of a new electrocardiographic method for diagnosis of left ventricular hypertrophy in essential hypertension. J Am Coll Cardiol. 1998; 31:383–390.

4. Sundström J, Lind L, Arnlöv J, Zethelius B, Andrén B, Lithell HO. Echocardiographic and electrocardiographic diagnoses of left ventricular hypertrophy predict mortality independently of each other in a population of elderly men. Circulation. 2001; 103:2346–2351.

5. Sever PS, Dahlöf B, Poulter NR, Wedel H, Beevers G, Caulfield M, Collins R, Kjeldsen SE, Kristinsson A, McInnes GT, et al. ASCOT investigators. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet. 2003; 361:1149–1158.

6. Woythaler JN, Singer SL, Kwan OL, Meltzer RS, Reubner B, Bommer W, DeMaria A. Accuracy of echocardiography versus electrocardiography in detecting left ventricular hypertrophy: comparison with postmortem mass measurements. J Am Coll Cardiol. 1983; 2:305–311.

7. Soeki T, Kishimoto I, Okumura H, Tokudome T, Horio T, Mori K, Kangawa K. C-type natriuretic peptide, a novel antifibrotic and antihypertrophic agent, prevents cardiac remodeling after myocardial infarction. J Am Coll Cardiol. 2005; 45:608–616.

8. Choi SY, Lee JE, Jang EH, Kim MO, Baek H, Ki CS, Park SW, Kim DJ, Huh WS, Oh HY, et al. Association between changes in N-terminal pro-brain natriuretic peptide levels and changes in left ventricular mass index in stable hemodialysis patients. Nephron Clin Pract. 2008; 110:c93–c100.

9. Wang AY, Lam CW, Wang M, Chan IH, Lui SF, Zhang Y, Sanderson JE. Diagnostic potential of serum biomarkers for left ventricular abnormalities in chronic peritoneal dialysis patients. Nephrol Dial Transplant. 2009; 24:1962–1969.

10. Luchner A, Burnett JC Jr, Jougasaki M, Hense HW, Heid IM, Muders F, Riegger GA, Schunkert H. Evaluation of brain natriuretic peptide as marker of left ventricular dysfunction and hypertrophy in the population. J Hypertens. 2000; 18:1121–1128.

11. Vasan RS, Benjamin EJ, Larson MG, Leip EP, Wang TJ, Wilson PW, Levy D. Plasma natriuretic peptides for community screening for left ventricular hypertrophy and systolic dysfunction: the Framingham heart study. JAMA. 2002; 288:1252–1259.

12. Ahn MS, Kim JY, Youn YJ, Kim SY, Koh SB, Lee K, Yoo BS, Lee SH, Yoon J, Park JK, et al. Cardiovascular parameters correlated with metabolic syndrome in a rural community cohort of Korea: the ARIRANG study. J Korean Med Sci. 2010; 25:1045–1052.

13. Koh SB, Park JK, Yoon JH, Chang SJ, Oh SS, Kim JY, Ryu SY, Kim KS, Lee TY, You JS. Preliminary report: a serious link between adiponectin levels and metabolic syndrome in a Korean nondiabetic population. Metabolism. 2010; 59:333–337.

14. Koh SB, Yoon J, Kim JY, Yoo BS, Lee SH, Park JK, Choe KH. Relationships between serum adiponectin with metabolic syndrome and components of metabolic syndrome in non-diabetic Koreans: ARIRANG study. Yonsei Med J. 2011; 52:234–241.

15. Lee JH, Kim JY, Kim KM, Lee JW, Youn YJ, Ahn MS, Yoo BS, Lee SH, Yoon J, Choe KH, et al. A prospective study of epicardial adipose tissue and incident metabolic syndrome: the ARIRANG study. J Korean Med Sci. 2013; 28:1762–1767.

16. Kim JY, Ahn SV, Yoon JH, Koh SB, Yoon J, Yoo BS, Lee SH, Park JK, Choe KH, Guallar E. Prospective study of serum adiponectin and incident metabolic syndrome: the ARIRANG study. Diabetes Care. 2013; 36:1547–1553.

17. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, et al. Chamber Quantification Writing Group. American Society of Echocardiographys Guidelines and Standards Committee. European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiographys Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005; 18:1440–1463.

18. Dumesnil JG, Paulin C, Pibarot P, Coulombe D, Arsenault M. Mitral annulus velocities by Doppler tissue imaging: practical implications with regard to preload alterations, sample position, and normal values. J Am Soc Echocardiogr. 2002; 15:1226–1231.

19. Sohn DW, Chai IH, Lee DJ, Kim HC, Kim HS, Oh BH, Lee MM, Park YB, Choi YS, Seo JD, et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol. 1997; 30:474–480.

20. Sokolow M, Lyon TP. The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads. Am Heart J. 1949; 37:161–186.

21. Casale PN, Devereux RB, Alonso DR, Campo E, Kligfield P. Improved sex-specific criteria of left ventricular hypertrophy for clinical and computer interpretation of electrocardiograms: validation with autopsy findings. Circulation. 1987; 75:565–572.

22. Karl J, Borgya A, Gallusser A, Huber E, Krueger K, Rollinger W, Schenk J. Development of a novel, N-terminal-proBNP (NT-proBNP) assay with a low detection limit. Scand J Clin Lab Invest Suppl. 1999; 230:177–181.

23. Jissho S, Shimada K, Taguchi H, Yoshida K, Fukuda S, Tanaka H, Yoshikawa J, Yoshiyama M, Ishii M, Goto Y. Impact of electrocardiographic left ventricular hypertrophy on the occurrence of cardiovascular events in elderly hypertensive patients. - The Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Circ J. 2010; 74:938–945.

24. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003; 289:2560–2572.

25. Pewsner D, Jüni P, Egger M, Battaglia M, Sundström J, Bachmann LM. Accuracy of electrocardiography in diagnosis of left ventricular hypertrophy in arterial hypertension: systematic review. BMJ. 2007; 335:711.

26. Park JK, Shin JH, Kim SH, Lim YH, Kim KS, Kim SG, Kim JH, Lim HG, Shin J. A comparison of cornell and sokolow-lyon electrocardiographic criteria for left ventricular hypertrophy in korean patients. Korean Circ J. 2012; 42:606–613.

27. Frey N, Olson EN. Cardiac hypertrophy: the good, the bad, and the ugly. Annu Rev Physiol. 2003; 65:45–79.

28. Paradis P, Dali-Youcef N, Paradis FW, Thibault G, Nemer M. Overexpression of angiotensin II type I receptor in cardiomyocytes induces cardiac hypertrophy and remodeling. Proc Natl Acad Sci U S A. 2000; 97:931–936.

29. Kaye D, Esler M. Sympathetic neuronal regulation of the heart in aging and heart failure. Cardiovasc Res. 2005; 66:256–264.

30. Rizvi MA, Katwa L, Spadone DP, Myers PR. The effects of endothelin-1 on collagen type I and type III synthesis in cultured porcine coronary artery vascular smooth muscle cells. J Mol Cell Cardiol. 1996; 28:243–252.

31. Goetze JP, Mogelvang R, Maage L, Scharling H, Schnohr P, Sogaard P, Rehfeld JF, Jensen JS. Plasma pro-B-type natriuretic peptide in the general population: screening for left ventricular hypertrophy and systolic dysfunction. Eur Heart J. 2006; 27:3004–3010.

32. Martinez-Rumayor AA, de Lemos JA, Rohatgi AK, Ayers CR, Powell-Wiley TM, Lakoski SG, Berry JD, Khera A, Das SR. Addition of highly sensitive troponin T and N-terminal pro-B-type natriuretic peptide to electrocardiography for detection of left ventricular hypertrophy: results from the Dallas Heart Study. Hypertension. 2013; 61:105–111.

33. Wong CY, O'Moore-Sullivan T, Leano R, Byrne N, Beller E, Marwick TH. Alterations of left ventricular myocardial characteristics associated with obesity. Circulation. 2004; 110:3081–3087.

34. Hinderliter AL, Light KC, Willis PW 4th. Racial differences in left ventricular structure in healthy young adults. Am J Cardiol. 1992; 69:1196–1199.

35. Harshfield GA, Koelsch DW, Pulliam DA, Alpert BS, Richey PA, Becker JA. Racial differences in the age-related increase in left ventricular mass in youths. Hypertension. 1994; 24:747–751.

36. Daimon M, Watanabe H, Abe Y, Hirata K, Hozumi T, Ishii K, Ito H, Iwakura K, Izumi C, Matsuzaki M, et al. Normal values of echocardiographic parameters in relation to age in a healthy Japanese population: the JAMP study. Circ J. 2008; 72:1859–1866.

37. Wong CY, O'Moore-Sullivan T, Leano R, Byrne N, Beller E, Marwick TH. Alterations of left ventricular myocardial characteristics associated with obesity. Circulation. 2004; 110:3081–3087.

38. Hinderliter AL, Light KC, Willis PW 4th. Racial differences in left ventricular structure in healthy young adults. Am J Cardiol. 1992; 69:1196–1199.

39. Harshfield GA, Koelsch DW, Pulliam DA, Alpert BS, Richey PA, Becker JA. Racial differences in the age-related increase in left ventricular mass in youths. Hypertension. 1994; 24:747–751.

40. Daimon M, Watanabe H, Abe Y, Hirata K, Hozumi T, Ishii K, Ito H, Iwakura K, Izumi C, Matsuzaki M, et al. Normal values of echocardiographic parameters in relation to age in a healthy Japanese population: the JAMP study. Circ J. 2008; 72:1859–1866.