Digitized validation of ECG criteria for left ventricular hypertrophy: an elite athlete CMR study
Authors: Van Diepen M A , Daems J J N , Van Hattum J C , Verwijs S M , Boekholdt S M , Planken R N , Van Randen A , Boonstra M J , Van Der Zwaard S , Moen M H , Kors J A , Postema P G , Bijsterveld N R , Asselbergs F W , Jorstad H T 
Published: June 2024

Abstract

Background
In current athletes’ electrocardiography (ECG) guidelines, the presence of ECG findings meeting left ventricular hypertrophy (LVH) criteria is interpreted as normal variation. However, this is largely based on echocardiographic studies in men. The efficacy of LVH criteria, in both sexes, obtained by advanced ECG analysis tools validated against cardiac magnetic resonance imaging (CMR) remains largely unknown.

Purpose
To evaluate diagnostic accuracy of ECG-LVH criteria in detecting CMR-defined LVH among elite athletes, with a specific focus on sex differences and potential correlations between ECG-LVH criteria measurements and myocardial mass and thickness.

Methods
We analysed 12-lead ECG and CMR data in 251 healthy, elite athletes (43% female, median age 25 [interquartile range: 22-30]) from the ELITE cohort. ECG-LVH criteria (Sokolow-Lyon, Cornell, Peguero Lo-Presti, Modified sum of 12 leads voltages and product, Romhilt-Estes points) were quantified using a digitized modular ECG analysis system. Our primary metric of interest was area under he curve (AUC) for each criterion as predictor for LVH on CMR. CMR-LVH was defined as exceeding population sex-specific 95th percentile thresholds for indexed left ventricular mass (LVM) and maximum wall thickness (LVWTmax). Furthermore, we examined correlations (Pearson's r, multivariate regression) between voltages/points within each criterion and LVM or LVWTmax.

Results
Female athletes (n=107) showed higher AUCs for ECG-LVH criteria in detecting LVM compared to male athletes (n=144) (average 0.66; 95% confidence interval [CI]: 0.53-0.79 vs. 0.52; 95% CI: 0.33-0.70, respectively). Notably, Sokolow-Lyon (0.74; 95%CI: 0.63-0.85) and Peguero Lo-Presti criteria (0.71; 95%CI: 0.59-0.83) had acceptable performance in female athletes in identifying increased LVM and performed better than in male athletes (0.50; 95%CI 0.34-0.66; p=0.011, and 0.48; 95%CI 0.32-0.63; p=0.015, respectively). In both sexes, ECG-LVH criteria showed similarly poor discriminating ability in detecting increased LVWTmax (average AUCs 0.58; 95%CI: 0.35-0.80 for females; 0.53; 95%CI: 0.41-0.64 for males). ECG-LVH criteria voltages were more strongly correlated with LVM in female athletes than in males with the Modified 12-lead voltage product showing the strongest correlation in both (r = 0.45 vs. 0.17; p=0.020, respectively [Figure 2]). Multivariate regression analysis identified this criterion as a predictor of LVM after adjusting for sex, endurance sports participation and heart rate (p&lt;0.001).

Conclusion
ECG-LVH criteria, even with digitized QRS voltage analysis, demonstrate limited efficacy in predicting CMR-derived maximum wall thickness beyond conventional LVH thresholds. We found clear sex differences, as several criteria, particularly Sokolow-Lyon, demonstrated acceptable performance in detecting increased LVM in female athletes. Our findings highlight the need for sex-specific ECG criteria in elite athletes. ROC curves. Correlation analysis.