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Updated: Apr 11, 2026
Real-Time Cardiac Mapping with a Noninvasive Imageless Electrocardiographic Imaging System
Published on: April 11, 2025
ECG abnormalities are strongly associated with CVD outcomes in low-risk individuals using the PREVENT risk equation
Mouhammad J Alawad1, Elsayed Z Soliman2,3, Todd M Brown4
1Weill Cornell Medicine, Department of Medicine, New York, NY.
Insights
Resting electrocardiogram (ECG) abnormalities are linked to increased cardiovascular disease (CVD) risk, even in low-risk individuals. Incorporating ECGs into risk assessments may improve identification of those needing preventive strategies.
Area of Science:
- Cardiology
- Preventive Medicine
- Medical Diagnostics
Background:
- Resting electrocardiograms (ECGs) are not standard for cardiovascular disease (CVD) risk assessment.
- Emerging evidence suggests ECGs may play a role in CVD risk stratification.
Purpose of the Study:
- To evaluate the association between ECG abnormalities and incident CVD events.
- To assess ECG findings in relation to the 2023 Predicting Risk of Cardiovascular Disease Events (PREVENT) equations.
Main Methods:
- Analysis of the REasons for Geographic And Racial Differences in Stroke (REGARDS) prospective cohort.
- Classification of baseline ECGs (2003-2007) using Minnesota Code (MC) into normal, minor abnormality, or major abnormality.
- Follow-up for incident CVD events through December 31, 2021.
Main Results:
- Among 19,173 participants, 47.0% had normal ECGs, 44.0% had minor abnormalities, and 9.0% had major abnormalities.
- Incident CVD occurred in 12.4% (normal ECG), 17.0% (minor abnormality), and 25.4% (major abnormality).
- Adjusted hazard ratios for CVD were 1.19 for minor and 1.53 for major ECG abnormalities compared to normal ECGs. Notably, in the low-risk (<7.5% PREVENT) group, major ECG abnormalities (present in 5.0%) were associated with an adjusted HR of 1.87 for CVD.
Conclusions:
- ECG abnormalities correlate with CVD event risk across all PREVENT risk strata.
- A significant number of individuals classified as low-risk by PREVENT equations exhibit ECG abnormalities, indicating elevated risk.
- Integrating ECG evaluation, particularly for major abnormalities, into risk assessment tools like PREVENT may enhance cardiovascular risk discrimination and identify candidates for intensified primary prevention.
Background:
Resting electrocardiogram (ECG) is not currently recommended as part of cardiovascular disease (CVD) risk assessment, although accumulating evidence suggests a potential role.
Objective:
To examine the association between ECG abnormalities and incident CVD events as assessed by the 2023 Predicting Risk of Cardiovascular Disease Events (PREVENT) equations.
Design:
Secondary data analysis from the REasons for Geographic And Racial Differences in Stroke (REGARDS) prospective cohort, including study participants without a baseline CVD.
Exposure:
ECG abnormalities were classified by Minnesota Code (MC) as normal, any minor, or major abnormality at baseline (2003-2007).
Outcome:
Participants were followed for expert adjudicated incident CVD events through December 31, 2021.
Results:
Among 19,173 participants (mean age at baseline of 63.7 years; 57.8% were female). According to the PREVENT risk equations, 39.4% were classified as <7.5% 10-year risk CVD risk, 44.6% as 7.5-20% risk, and 16.0% as >20% risk. Overall, 47.0% had normal ECG, 44.0% had any minor abnormality, and 9.0% had any major abnormality. During follow-up, CVD events occurred in 12.4% of participants with normal ECG, 17.0% of those with any minor abnormality, and 25.4% of those with any major abnormality. Compared to those without ECG abnormality, the adjusted HR for incident CVD were 1.19 (95% CI 1.10-1.29) for any minor abnormality, and 1.53 (1.36-1.72) for any major ECG abnormality. In the <7.5% risk group, 43.6% had at least one ECG abnormality; in this risk group compared to those without ECG abnormality, the HR for incident CVD associated with any major ECG abnormality, present in 5.0% of the <7.5% risk group, was 1.87 (95% CI 1.34-2.62), The HR for any minor ECG abnormalities, present in 38.6% was 1.13 (95% CI 0.93 - 1.37).
Conclusion:
ECG abnormalities were associated with risk of CVD events across PREVENT risk groups. A substantial proportion of low-risk participants (according to the PREVENT equation) had ECG abnormalities and associated elevated risk. This supports the potential for using ECG to identify a subgroup of low-risk patients who may benefit from more aggressive primary prevention especially with major ECG abnormalities. Addition of electrocardiographic evaluation to the PREVENT risk equations may improves cardiovascular risk discrimination.
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