Left ventricular hypertrophy in hypertension: Is the electrocardiogram enough for risk stratification?

2 Although the assessment of LV mass (LVM) by transthoracic ECHO represents the reference imaging tool for its established diagnostic accuracy in identifying LVH in hypertensive patients and improving CV risk stratification, the availability and the costs of this technique do not allow its routinary use in clinical practice. [...]we read with great interest and attention the study by Park et al. 3 aimed to investigate the value of LVH, phenotyped by ECG and ECHO criteria, in predicting the composite of major CV events including heart failure, myocardial infarction, peripheral artery disease, ischemic stroke, stroke, end stage renal disease (MACEs) or death among 1743 participants to Korean Hypertension Cohort study over a median 10-year follow-up period. [...]a retrospective, population-based cohort study of older individuals without overt CV disease, documented that ECHO, but not ECG markers of LVH predicted the long-term risk of composite coronary events, heart failure, stroke, or death from any cause. 8 In this complex scenario, the translational implications of Park's study 3 supporting the indication to perform the echocardiogram only in patients with normal ECG, in consideration of its marginal additional prognostic value in patients with ECG-LVH, need some considerations. [...]the adoption of ECHO thresholds recommended by international guidelines (derived primarily from cohorts of Caucasian ethnicity) may have led to significant misclassification of LVH in a such sample of Asian hypertensive patients. 9 Third, the diagnosis of ECHO-LVH was exclusively made by indexing LVM by body surface area without performing a sensitivity analysis based on the indexation for height2.7 more appropriate in identifying LVH in overweight and obese individuals in which ECG criteria are less performing. 10 Fourth, factors associated with diagnostic discrepancy between ECG- and ECHO-LVH criteria have not been addressed, as well as gender-related differences in the association between LVH and outcome. 11 Last but not least, it is worth noting that beyond mere identification of LVH, ECHO provides a variety of useful information (i.e., LV function, valve disease, left atrial, and aortic root dimensions) for the clinical management both in hypertensive patients with and without ECG-LVH.