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on June 1, 2004

A more recent version of this article appeared on July 1, 2004

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Submitted on March 4, 2004
Revised on March 16, 2004

Electrocardiographic Strain Pattern and Prediction of Cardiovascular Morbidity and Mortality in Hypertensive Patients

Peter M. Okin^*; Richard B. Devereux; Markku S. Nieminen; Sverker Jern; Lasse Oikarinen; Matti Viitasalo; Lauri Toivonen; Sverre E. Kjeldsen; Stevo Julius; Steven Snapinn; Björn Dahlöf; for the LIFE Study Investigators

From the Greenberg Division of Cardiology (P.M.O., R.B.D.), Weill Medical College of Cornell University, New York, NY; the Division of Cardiology (M.S.N., L.O., M.V., L.T.), Department of Medicine, Helsinki University Central Hospital, Finland; Sahlgrenska University Hospital/Östra (S.J., B.D.), Göteborg, Sweden; Ullevål University Hospital (S.E.K.), Oslo, Norway; University of Michigan Medical Center (S.J.), Ann Arbor; and Merck Research Laboratories (S.S.), West Point, Pa.

^* To whom correspondence should be addressed. E-mail: pokin{at}mail.med.cornell.edu.

Abstract--The ECG strain pattern of lateral ST depression and T-wave inversion is a marker for left ventricular hypertrophy (LVH) and adverse prognosis in population studies. However, whether ECG strain is an independent predictor of cardiovascular (CV) morbidity and mortality in the setting of aggressive antihypertensive therapy is unclear. ECGs were examined at study baseline in 8854 hypertensive patients with ECG LVH who were treated in a blinded manner with atenolol- or losartan-based regimens. Strain was defined by the presence of a downsloping convex ST segment with an inverted asymmetrical T wave opposite to the QRS axis in leads V₅ and/or V₆ and was present in 971 patients (11.0%). The Losartan Intervention For Endpoint reduction in hypertension (LIFE) study composite end point of CV death or nonfatal myocardial infarction or stroke occurred in 1035 patients (11.7%). In Cox analyses adjusting only for treatment effect, ECG strain was a significant predictor of CV death (hazard ratio [HR] 2.26, 95% confidence interval [CI] 1.78 to 2.86), fatal/nonfatal myocardial infarction (HR 2.16, 95% CI 1.67 to 2.80), fatal/nonfatal stroke (HR 1.76, 95% CI 1.39 to 2.21), and the composite CV end point (HR 1.99, 95% CI 1.70 to 2.33). After further adjusting for standard CV risk factors, baseline blood pressure, and severity of ECG LVH, ECG strain remained a significant predictor of CV mortality (HR 1.53, 95% CI 1.18 to 2.00), myocardial infarction (HR 1.55, 95% CI 1.16 to 2.06), and the composite CV end point (HR 1.33, 95% CI 1.11 to 1.59). Thus, ECG strain is a marker of increased CV risk in hypertensive patients in the setting of aggressive blood pressure lowering, independent of baseline severity of ECG LVH.

Key words: coronary disease • electrocardiography • hypertension

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