Diagnostic Value Of Electrocardiogram Peguero Index In Patients With Hypertrophic Cardiomyopathy

Background:Hypertrophic cardiomyopathy（HCM）is one of the main causes of sudden death in adolescents and athletes.Early diagnosis,risk assessment and prevention of sudden death are very important.At present,the diagnosis of this disease mainly depends on echocardiography,as we well-known,echocardiography is not so convenient to act as routine examination,but electrocardiogram（ECG）is wildly used as the vehicle for early detection of HCM.In patients with HCM,more than 90%of patients have ECG alterations which could be presented earlier than clinical symptoms and ultrasonographic manifestations.At the same time,ECG reflects the three-dimensional comprehensive vector of the heart,which could be helpful to find blind spots in that imaging examination might not find.Therefore,electrocardiogram as a screening method for hypertrophic cardiomyopathy is very valuable.However,the classical electrocardiographic diagnostic indicators including Sokolow-Lyon voltage,Conell voltage and Conell product to diagnose left ventricular hypertrophy have high specificity（about 90%）but poor sensitivity（<50%）.In2017,Peguero et al.proposed to add the S-wave amplitude（S_D）of the deepest S-wave leads and the S-wave amplitude(S_V4)of the V4 leads,i.e.S_D+S_V4.Left ventricular hypertrophy is indicated in males（>2.8 mv）and females（>2.3 mv）.This index can improve the sensitivity of diagnosis of left ventricular hypertrophy and maintain high specificity.However,the diagnostic and screening value of this index for hypertrophic cardiomyopathy is still unclear,at present,there are few such studies at home and abroad.Objective:To explore the diagnostic value of left ventricular hypertrophic ECG voltage index including Peguero index in patients with hypertrophic cardiomyopathy,and to analyze the correlation between ECG voltage index and systolic and diastolic function,so as to find the best ECG diagnostic index for early screening of HCM.Methods:This study included 221 patients with hypertrophic cardiomyopathy diagnosed in outpatient or inpatient department of the First Affiliated Hospital of Fujian Medical University,and 201 patients without hypertrophy diagnosed by color Doppler echocardiography in the same period.The diagnosis of hypertrophic cardiomyopathy conforms to the diagnostic criteria in the Guidelines for the Diagnosis and Treatment of Adult Hypertrophic Cardiomyopathy in China in 2017.The age range is 18-89 years,with an average age of 62.38±13.78 years.There are156 males and 65 females.The patients without cardiac hypertrophy were defined as non-diagnostic hypertrophic cardiomyopathy by color Doppler echocardiography,and left ventricular mass index was<115g/m² for males and<95g/m² for females,ranging from 22 to 89 years old,with an average age of 60.53±13.59 years,including 131 males and 70 females.Excluding other cardiomyopathies（e.g.dilated cardiomyopathy,restrictive cardiomyopathy,arrhythmogenic right ventricular cardiomyopathy,viral cardiomyopathy,secondary cardiomyopathy such as myocardial amyloidosis）,congenital heart disease,valvular heart disease,coronary heart disease after myocardial infarction,right ventricular hypertrophy,left and right bundle branch block,pre-excitation syndrome,ventricular rhythm,pacemaker implantation patients.Obesity,emphysema,pericardial effusion,pleural effusion and pneumothorax were excluded.Age,sex,blood pressure and body mass index were recorded.All patients underwent routine 12-lead ECG and color Doppler echocardiography,and the ECG voltage(including Sokolow-Lyon voltage,Conell voltage,Conell product,Lewis voltage,S_D+S_V44 voltage and S_D voltage)and color Doppler echocardiographic parameters（including interventricular septum thickness,left ventricular posterior wall thickness,LVEF,E/e’）were obtained.The sensitivity and specificity of different electrocardiogram indices for the diagnosis of hypertrophic cardiomyopathy were calculated,and the correlation between the indices and cardiac systolic and diastolic function was analyzed.Results:（1）.Compared with the Non-myocardial hypertrophy group,the proportion of coronary heart disease in HCM group was higher（P<0.001）.The electrocardiogram voltage（including Sokolow-Lyon voltage,Conell voltage,Conell product,Lewis voltage,Peguero voltage,S_D voltage）and color Doppler ultrasound parameters（including IVST,LVPWT,LVMI,LAD and E/e’）were significantly higher than those in the Non-myocardial hypertrophy group while the LVEF is lower（P<0.001）.（2）The area under the curve of ECG voltage indices（including Sokolow-Lyon voltage,Conell voltage,Conell product,Lewis voltage,Peguero voltage and SD voltage）for diagnosing HCM ranged from 0.71 to 0.85（P<0.001）.The sensitivity of the new index Peguero voltage was the best（71%）,the specificity of each index was high（88.6%-99%）.（3）Grouped studies based on gender showed that among male subjects,Sokolow-Lyon voltage（71.2%）was the most sensitive,followed by Peguero voltage（66.7%）.Peguero voltage（81.5%）was the most sensitive in female subjects,followed by Sokolow-Lyon voltage（63.1%）.（4）A grouping study based on age showed that the diagnostic sensitivity of Sokolow-Lyon voltage was similar in HCM patients aged<65 years and over 65years（67.8%vs 68%,P>0.05）,while that of Peguero voltage in<65 years was higher than that in<65 years（76.9%vs 64%,P<0.05）.（5）The age,BMI,Sokolow-Lyon voltage and Lewis voltage of HCM with HT group were higher than those of HCM without HT group（P<0.05）.The diagnostic sensitivity of Sokolow-Lyon voltage in HCM patients with hypertension was higher than that in HCM patients without hypertension（76.8%vs 58.7%,P<0.05）,the diagnostic sensitivity of Peguero voltage were high in both groups（69.6%vs 72.5%,P>0.05）.（6）According to whether it is apical hypertrophic cardiomyopathy（AHCM）,the Peguero voltage,Conell voltage,Conell product,S_D,IVST and LVMI in AHCM group were lower than those in non-AHCM group（P<0.05）.Sokolow-Lyon voltage had no significant difference in diagnostic sensitivity between AHCM group and non-AHCM group（77.4%vs 64.9%,P>0.05）.Peguero voltage was significantly lower in AHCM group than in non-AHCM group（45.3%vs 79.2%,P<0.001）.（7）According to the grouping study of obstructive hypertrophic cardiomyopathy,the Peguero voltage,Conell voltage,Conell product,S_D,IVST,LVPWT,LVMI and E/e’of obstructive HCM group were higher than those of non-obstructive HCM group（P<0.05）.The diagnostic sensitivity of Sokolow-Lyon voltage in patients with obstructive HCM was lower than that of non-obstructive HCM（54.5%vs 71.2%,P<0.05）.The diagnostic sensitivity of Peguero voltage was good between the two groups（81.8%vs68.4%P>0.05）.（8）The diagnostic sensitivity of HCM was greatly improved by combining the Sokolow-Lyon voltage with the Puguero voltage,it can reach more than 90%in the general population,men and women,and the specificity was about 80%.In different subgroups,the sensitivity of combined voltage was also more than 84%,which was significantly higher than that of single Sokolow-Lyon voltage or Peguero voltage.（9）In HCM group,E/e’and LVEF were used as dependent variables,age,sex,BMI,Sokolow-Lyon voltage,Peguero voltage,IVST,LVPWT,hypertension,diabetes mellitus,coronary heart disease,dyslipidemia and obstructive HCM were included as independent variables in regression equation.The results showed that Peguero voltage（beta=0.189,P<0.05）,LVPWT(beta=0.355,P<Obstructive HCM（beta=0.268,P<0.001）,age（beta=0.277,P<0.001）were independently correlated with E/e’.Peguero voltage（beta=-0.204,P=0.009）,age（beta=-0.169,P=0.023）,coronary heart disease（beta=0.203,P=0.005）were independently correlated with LVEF.Conclusion:Peguero voltage,a new electrocardiographic indicator,has high diagnostic value in HCM patients.It not only has good specificity（88.6%）but also shows high sensitivity（71%）.Especially in female and obstructive HCM subjects,the sensitivity can reach more than 80%,but its diagnostic sensitivity in apical hypertrophic cardiomyopathy is poor（45.3%）.Sokolow-Lyon voltage has high diagnostic value in HCM patients,with sensitivity 67.9%and specificity 93%.The diagnostic sensitivity of HCM was further greatly improved by combining the Sokolow-Lyon voltage with the Puguero voltage.Peguero voltage was positively correlated with E/e’,an index of left ventricular diastolic function,and negatively correlated with LVEF,an index of systolic function.