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European Heart Journal Advance Access published online on November 5, 2009
European Heart Journal, doi:10.1093/eurheartj/ehp443
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org
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Electrocardiographic amplitudes: a new risk factor for sudden death in hypertrophic cardiomyopathy

Ingegerd Östman-Smith1,*, Aase Wisten2, Eva Nylander3, Ewa-Lena Bratt1, Anne de-Wahl Granelli1, Abderrahim Oulhaj4 and Erik Ljungström5

1 Division of Paediatrics, Department of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Queen Silvia Childrens Hospital, SE-416 85 Gothenburg, Sweden
2 Department of Internal Medicine, Sunderby Hospital, Luleå, Sweden
3 Department of Clinical Physiology/CVM, Faculty of Health Science, Linköping University, Sweden
4 OPTIMA, Department of Physiology, Anatomy and Genetics, University of Oxford, UK
5 Department of Cardiology, University Hospital, Lund University, Sweden

Received 29 May 2008; revised 15 July 2009; accepted 29 September 2009 * Corresponding author. Tel: +46 31 3434512, Fax: +46 31 3435947, Email: ingegerd.ostman-smith{at}pediat.gu.se

Aims: Assessment of ECG-features as predictors of sudden death in adults with hypertrophic cardiomyopathy (HCM).

Methods and results: ECG-amplitude sums were measured in 44 normals, 34 athletes, a hospital-cohort of 87 HCM-patients, and 29 HCM-patients with sudden death or cardiac arrest (HCM-CA). HCM-patients with sudden death or cardiac arrest had substantially higher ECG-amplitudes than the HCM-cohort for limb-lead and 12-lead QRS-amplitude sums, and amplitude–duration products (P = 0.00003–P = 0.000002). Separation of HCM-CA from the HCM-cohort is obtained by limb-lead QRS-amplitude sum ≥7.7 mV (odds ratio 18.8, sensitivity 87%, negative predictive value (NPV) 94%, P < 0.0001), 12-lead amplitude–duration product ≥2.2 mV s (odds ratio 31.0, sensitivity 92%, NPV 97%, P < 0.0001), and limb-lead amplitude–duration product ≥0.70 mV s (odds ratio 31.5, sensitivity 93%, NPV 96%, P < 0.0001). Sensitivity in HCM-patients <40 years is 90, 100, and 100% for those ECG-variables, respectively. Qualitative analysis showed correlation with cardiac arrest for pathological T-wave-inversion (P = 0.0003), ST-depression (P = 0.0010), and dominant S-wave in V4 (P = 0.0048). A risk score is proposed; a score ≥6 gives a sensitivity of 85% but a higher positive predictive value than above measures. Optimal separation between HCM-CA <40 years and athletes is obtained by a risk score ≥6 (odds ratio 345, sensitivity 85%, specificity 100%, P < 0.0001).

Conclusion: Twelve-lead ECG is a powerful instrument for risk-stratification in HCM.

Key Words: Hypertrophic cardiomyopathy • Sudden death • Electrocardiogram • Screening • Athletes • Gender


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