R wave in aVL lead: an outstanding ECG index in hypertension
Pierre-Yves Courand1, Sophie Jenck, Giampiero Bricca
1aCardiology Department, European Society of Hypertension Excellence center, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon bGénomique Fonctionnelle de l'Hypertension artérielle, Université Claude Bernard Lyon1, Villeurbanne cHôpital Nord-Ouest, Villefranche-sur-Saône, France *Pierre-Yves Courand and Sophie Jenck contributed equally to the writing of this article.
Insights
The voltage of the R wave in lead aVL (RaVL) predicts all-cause and cardiovascular death in hypertensive individuals. Higher RaVL voltages indicate increased mortality risk, even when other ECG criteria are normal.
Area of Science:
- Cardiology
- Clinical Electrophysiology
- Hypertension Research
Background:
- Left ventricular hypertrophy (LVH) is linked to cardiovascular events.
- The voltage of the R wave in lead aVL (RaVL) correlates strongly with LVH and cardiovascular outcomes.
- Existing ECG criteria for LVH may not fully capture cardiovascular risk.
Purpose of the Study:
- To investigate if RaVL voltage is an independent predictor of all-cause and cardiovascular death in hypertensive individuals.
- To determine optimal RaVL voltage cutoffs for mortality risk stratification.
Main Methods:
- Prospective cohort study of 589 hypertensive individuals.
- Analysis of baseline clinical, biological, and ECG variables.
- 10-year follow-up for mortality outcomes.
- Multivariate adjusted Cox regression models were used.
Main Results:
- 95 deaths (53 cardiovascular) observed over 10 years.
- Optimal RaVL cutoffs: 0.8 mV (all-cause) and 0.6 mV (cardiovascular).
- RaVL > 0.8 mV associated with 2.04x all-cause death risk (HR: 2.04, 95% CI: 1.30-3.22).
- RaVL > 0.6 mV associated with 2.89x cardiovascular death risk (HR: 2.89, 95% CI: 1.47-5.68).
- Each 0.1 mV increment in RaVL increased all-cause death risk by 1.07 times and cardiovascular death risk by 1.13 times.
- RaVL remained a significant predictor even when other LVH indices were absent.
Conclusions:
- RaVL voltage is a significant independent predictor of mortality in hypertensive patients.
- RaVL provides valuable risk stratification for hypertensive individuals.
- These findings support the utility of RaVL in identifying high-risk patients beyond traditional ECG markers.
Objectives:
The voltage of R wave in lead aVL (RaVL) seems to be more tightly correlated with left ventricular mass and cardiovascular events than any other ECG criterium of left ventricular hypertrophy. We hypothesized that RaVL could be an independent predictor of all-cause and cardiovascular death in hypertensive individuals.
Methods:
The baseline clinical and biological variables as well as ECG recordings were analyzed in a prospective cohort of 589 hypertensive individuals.
Results:
After 10 years of follow-up, we observed 95 deaths of which 53 had a cardiovascular cause. The optimal RaVL voltages to predict all-cause and cardiovascular mortality were 0.8 and 0.6 mV, respectively. In a multivariate adjusted Cox model, having an RaVL voltage superior to these cutoffs was associated with increased risks of all-cause death [hazard ratio: 2.04, 95% confidence interval (CI): (1.30-3.22)] and of cardiovascular death [hazard ratio: 2.89, 95% CI: (1.47-5.68)]. In the whole cohort and with the same adjusted Cox regression model, each 0.1 mV increment would increase the risk of all-cause death by 1.07 times [95% CI: (1.02-1.12)] and that of cardiovascular death by 1.13 times [95% CI: (1.06-1.20)]. After excluding in turn patients with positive Sokolow index, Cornell voltage, or Cornell product, the results remained statistically significant, meaning that RaVL was still able to pick-up high-risk patients when other classical and more sophisticated indices were not observable.
Conclusion:
The present results strengthen previous reports that demonstrated a strong role of RaVL voltage in risk stratification in hypertension.
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