• Users Online: 74
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 55-60

Relationship between ECG QRS voltage and left ventricular functions in patients with heart failure attending federal Medical Centre Nguru, Northeastern Nigeria


1 Department of Internal Medicine, Federal Medical Centre Nguru, Yobe State, Nigeria
2 Department of Medicine, College of Medical Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria
3 Department of Internal Medicine, Usman Danfodio University, Sokoto, Nigeria

Date of Submission30-Sep-2019
Date of Decision13-Dec-2019
Date of Acceptance09-Jan-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Musa Mohammed Baba
Department of Internal Medicine, Federal Medical Centre, P. M. B 02, Nguru, Yobe State
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njc.njc_22_19

Rights and Permissions
  Abstract 


Introduction: Heart failure (HF) is a clinical syndrome characterized by typical symptoms (e.g., breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, and peripheral edema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. Electrocardiogram (ECG) is a widely available tool; it is relatively inexpensive and simple to perform; and it yields an instant result. A normal ECG makes systolic dysfunction unlikely and is rare in patients with suspected heart failure. Low ECG voltage has been reported as a marker of the severity of HF and is a risk factor for adverse outcomes in patients with systolic HF at 1 year. However, the relationship between ECG QRS voltage and left ventricular function in patients with heart failure has not been evaluated. Therefore, the objective of this study is to determine the relationship between electrocardiographic QRS voltage and left ventricular function.
Methodology: This was a prospective cross-sectional study conducted among inpatients with HF in the medical ward of the hospital.
Results: Three hundred and sixty patients were recruited for the study, of which 19 had incomplete data and were excluded in the analysis. The remaining 341 subjects were analyzed comprising 215 female and 126 male with a mean age of 47.54 ± 18.85 years. Majority of patients with normal or high QRS voltage had HF with preserved ejection fraction (HFpEF), while those with low QRS voltage had HF with reduced ejection fraction (HFrEF). On the other hand, patients with high QRS voltage had impaired relaxation pattern of diastolic dysfunction, while those with low QRS voltage had a restrictive pattern of diastolic dysfunction. There was a positive and significant correlation between the QRS voltage and ejection fraction, fractional shortening, isovolumic left ventricular relaxation time, and left ventricular deceleration time, while a negative but not significant correlation was observed between electrocardiographic QRS voltage and transmitral E/A ratio. Majority of patients with normal QRS voltage had normal left ventricular geometry, while those with high QRS voltage predominantly had concentric left ventricular hypertrophy and those with low QRS voltage had eccentric left ventricular hypertrophy. Patients with concentric left ventricular hypertrophy had predominantly HFpEF and impaired relaxation pattern of diastolic dysfunction, while those with eccentric left ventricular hypertrophy had HFrEF and restrictive pattern of diastolic dysfunction.
Conclusion: HF patients with high QRS voltage had preserved left ventricular systolic function, impaired relaxation pattern of left ventricular diastolic dysfunction, and concentric left ventricular hypertrophy. While those with low QRS voltage predominantly had reduced left ventricular systolic function, restrictive pattern of left ventricular diastolic dysfunction, and eccentric left ventricular hypertrophy.

Keywords: ECG, left ventricular function, QRS voltage


How to cite this article:
Baba MM, Buba F, Talle MA, Umar H, Abdul H. Relationship between ECG QRS voltage and left ventricular functions in patients with heart failure attending federal Medical Centre Nguru, Northeastern Nigeria. Nig J Cardiol 2020;17:55-60

How to cite this URL:
Baba MM, Buba F, Talle MA, Umar H, Abdul H. Relationship between ECG QRS voltage and left ventricular functions in patients with heart failure attending federal Medical Centre Nguru, Northeastern Nigeria. Nig J Cardiol [serial online] 2020 [cited 2020 Aug 12];17:55-60. Available from: http://www.nigjcardiol.org/text.asp?2020/17/1/55/288646




  Introduction Top


Heart failure (HF) is a clinical syndrome characterized by typical symptoms (e.g., breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g., elevated jugular venous pressure, pulmonary crackles, and peripheral edema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.[1] The American College of Cardiology and American Heart Association guidelines on HF classified the progression of heart disease into four stages as follows: Stage A – patients are at high risk for HF but have no structural heart disease or symptoms of HF, Stage B – patients have structural heart disease but have no symptoms of HF, Stage C – patients have structural heart disease and have symptoms of HF, and Stage D – patients have refractory HF requiring specialized interventions.[2] Similarly, the New York Heart Association classified HF into four functional classes based on the relationship between dyspnea and the amount of effort required to provoke this symptom as follows: Class I patients have no limitation of physical activity, Class II patients have slight limitation of physical activity, Class III patients have marked limitation of physical activity, and Class IV patients have symptoms even at rest and are unable to carry on any physical activity without discomfort.[3] HF has also been classified according to the ejection fraction, natriuretic peptide levels, and the presence of structural heart disease and diastolic dysfunction into three subtypes, namely HF with reduced ejection fraction (HFrEF) with left ventricular ejection fraction of <40%, HF with preserved ejection fraction (HFpEF) with left ventricular ejection fraction of >50%, and HF mid-range ejection fraction (HFmrEF) with left ventricular ejection fraction of 40–49.[1] HF has emerged as the most common primary diagnosis for patients admitted to hospital with suspected cardiac disease in Africa.[4]

Electrocardiogram (ECG) is a widely available tool; it is relatively inexpensive and simple to perform, and it yields an instant result. A normal ECG makes systolic dysfunction unlikely and is rare in patients with suspected HF.[5] Low ECG voltage has been reported as a marker of the severity of HF and is a risk factor for adverse outcomes in patients with systolic HF at 1 year.[6] The mechanism of the ECG QRS voltage attenuation in HF is thought to be a combination of reduced ability of the myocardium to generate force that will transmit to the surface and impact of peripheral edema, with different proportions of these two influences in different patients depending on the extent of changes in the heart and the peripheral edema.[7],[8],[9],[10] However, the relationship between ECG QRS voltage and left ventricular function in patients with HF has not been evaluated. Therefore, the objective of this study is to determine the relationship between electrocardiographic QRS voltage and left ventricular function.


  Methodology Top


This was a prospective cross-sectional study conducted among in patients with HF in the medical ward of the hospital after obtaining an ethical approval from the Ethics and Research Committee of the hospital as well as verbal consent from the patients or their relatives.

Inclusion criteria

The inclusion criteria for the study were adults with HF symptoms that met the Framingham diagnostic criteria.[11]

Exclusion criteria

Patients excluded from the study were those with HF symptoms that did not meet the Framingham diagnostic criteria or patient with HF symptoms <18 years. Other exclusion criteria included patients with hypothyroidism, pericardial effusion, pleural effusion, chronic obstructive airway disease, pneumothorax, hypothermia, and morbidly obsessed patients.

All patients had detailed medical history and examination; the diagnosis of HF was based on the Framingham diagnostic criteria.[11] Serum electrolytes, fasting blood glucose, lipid profile, electrocardiography, and echocardiography were done to all patients. Electrocardiographic diagnosis of high QRS voltage is based on the Sokolow–Lyon criteria for the diagnosis left ventricular hypertrophy,[12] while low QRS voltage is defined as nadir-to-peak QRS complex voltage <0.5 mV (<5 mm) in all limb leads and <1.0 mV (<<<<10 mm) in all precordial leads.[13] Echocardiographic measurements were done according to the standard guidelines.[14],[15] Left ventricular mass index (LVMI) and left ventricular relative wall thickness (RWT) were used to define the left ventricular geometry. The normal LVMI and RWT vary for age and sex; for females, normal LVMI and RWT are 43–95 g/m2 and 0.22–0.42, respectively. While for males, normal LVMI and RWT are 49–115 g/m2 and 0.24–0.42, respectively. Normal left ventricular geometry is defined as normal LVMI and normal RWT. Concentric hypertrophy is defined as increased LVMI and RWT. Eccentric left ventricular hypertrophy is defined as increased LVMI with normal RWT, and concentric remodeling is defined as normal LVMI with increased RWT.[14],[15] All patients were placed on the same anti-heart failure regiments except otherwise contraindicated (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, aldosterone antagonist, carvedilol, and loop diuretics either furosemide or Torsemide. Digoxin was added to patients with arrhythmias or those with poor systolic function. Amiodarone was however prescribed to patients with refractory atrial fibrillation). Antiplatelet (aspirin or clopidogrel) and warfarin were prescribed to patients with dilated cardiac chamber with hypokinesia and those with rheumatic heart disease in atrial fibrillation, respectively, as part of HF management protocol.[1]

Data analysis

Statistical analysis was done using SPSS version 21.0 (SPSS, IBM). Chicago, Illinoi. Data were presented as mean ± standard deviation for continuous variables, while categorical variables were expressed as frequencies and proportion. Student's t-test was used to compare mean values of continuous variables, while Fisher's exact or Chi-square tests were used where necessary to compare categorical variables. Spearman correlation coefficient was used to determine the relationship between continuous variable, and P < 0.05 was considered statistically significant.


  Results Top


Three hundred and sixty patients were recruited for the study, out of which 19 had incomplete data and were excluded in the analysis. The remaining 341 patients were analyzed comprising 215 females and 126 males with a mean age of 47.54 ± 18.85 years. [Table 1] shows the demographic and clinical characteristics of the study population. The mean body mass index and heart rate of the studied population were 26.27 ± 4.73 kg/m2 and 104.43 ± 18.09 beats/min, respectively, and their mean systolic and diastolic blood pressure were 128.03 ± 24.95 mmHg and 79.05 ± 14.30 mmHg, respectively, while their mean QRS voltage was 29.78 ± 9.98. Three hundred and twenty (93.84%) patients had normal QRS voltage duration, while 15 (6.16%) had prolonged QRS voltage duration. One hundred and thirty-one (38.4%) had progressive hypertensive heart disease, 62 (18.2%) were hypertensive diabetics, 80 (23.5%) had peripartum cardiomyopathy, 39 (11.4%) had idiopathic dilated cardiomyopathy, 24 (7.0%) had rheumatic heart disease, while 5 (1.5%) had a myocardial infarction. [Table 2] shows the mean QRS voltage of patients with various categories of left ventricular systolic function. The analysis of QRS voltage revealed that 127 patients had normal QRS voltage, of these 64 (50.4%) had HFpEF, 54 (42.5%) had HFrEF, and 9 (7.1%) had HFmrEF. High QRS voltage was observed in 134 patients, among these, 110 (82.1%) had HFpEF, 18 (13.4%) had HFrEF, and 6 (4.5%) had HFmrEF. Eighty patients had low QRS voltage, of these 12 (15.0%) had HFpEF, 62 (77.5%) had HFrEF, and 6 (7.5%) had HFmrEF. [Table 3] shows the QRS voltage distribution among patients with various categories of HF.
Table 1: Demographic and clinical characteristics of the study population

Click here to view
Table 2: Mean QRS voltage among patients with various categories of heart failure

Click here to view
Table 3: QRS voltage distribution among patients with various categories of heart failure

Click here to view


Among the 127 patients with normal QRS voltage, 27 (21.3%) had normal left ventricular diastolic function, 40 (31.5%) had impaired relaxation pattern of left ventricular diastolic dysfunction, and 60 (47.2%) had a restrictive pattern of left ventricular diastolic dysfunction. Among the 134 patients with high QRS voltage, 14 (10.4%) had a normal left ventricular diastolic function, 114 (85.1%) had impaired relaxation pattern of left ventricular diastolic dysfunction, and 6 (4.5%) had a restrictive pattern of left ventricular diastolic dysfunction. Of the eighty patients with low QRS voltage, 7 (8.7%) had a normal left ventricular diastolic function, 3 (3.8%) had impaired relaxation pattern of left ventricular diastolic dysfunction, and 70 (87.5%) had restrictive pattern of left ventricular diastolic dysfunction. [Table 4] shows the distribution of QRS voltage among patients with various categories of left ventricular diastolic functions.
Table 4: QRS voltage distribution among patients with various categories of left ventricular diastolic functions

Click here to view


There was a positive and significant correlation between electrocardiographic QRS voltage and parameters of left ventricular systolic function, i.e. ejection fraction and fractional shortening (r = 0.484, P ≤ 0.001 and r = 0.452, P ≤ 001, respectively). On the other hand, there was a significant but negative correlation between left ventricular internal diameter and electrocardiographic QRS voltage (r = −0.308, P ≤ 0.001). Similarly, there was a positive and significant correlation between electrocardiographic QRS voltage and parameters of left ventricular diastolic function, i.e. isovolumic relaxation time (IVRT) and left ventricular deceleration time (DCT) (r = 0.626, P ≤ 0.001 and r = 0.360, P ≤ 0.001, respectively). However, a negative but not significant correlation was observed between electrocardiographic QRS voltage and transmitral E/A ratio (r = −0.064, P = 0.242). [Table 5] shows the correlation between electrocardiographic QRS voltage and left ventricular internal diameter, left ventricular ejection fraction, left ventricular fractional shortening, left ventricular isovolumic relaxation time, left ventricular DCT, and the ratio of early transmitral left ventricular filling flow velocity to late atrial contraction of left ventricular filling flow velocity (E/A ratio). [Table 6] shows the mean QRS voltage of patients with various categories of left ventricular geometry. Majority of patients with normal QRS voltage (77, 60.6%) had normal left ventricular geometry, while those with high QRS voltage predominantly had concentric left ventricular hypertrophy (118, 88.0%) and those with low QRS voltage (73, 91.3%) had eccentric left ventricular hypertrophy. [Table 7] shows the QRS voltage distribution among patients with various categories of left ventricular geometry.
Table 5: Correlation between electrocardiographic QRS voltage and left ventricular internal diameter in diastole, ejection fraction, fractional shortening, isovolumic relaxation time, deceleration time, and mitral E/A ratio

Click here to view
Table 6: Mean QRS voltage among patients with various categories of left ventricular geometry

Click here to view
Table 7: QRS voltage distribution among patients with various categories of left ventricular geometry

Click here to view


Eighty-six patients had normal left ventricular geometry, of which 45 (52.3%) had HFpEF, 32 (37.2%) had HF with reduced ejection fraction, and 9 (10.5%) had HFmrEF. One hundred and forty two-patients had concentric left ventricular hypertrophy, of these 112 (78.9%) had HFpEF, 23 (16.2%) had HF with reduced ejection fraction, and 7 (4.9%) had HFmrEF. Similarly, 104 had eccentric left ventricular hypertrophy, of these 23 (22.1%) had HFpEF, 77 (74.0%) had HF with reduced ejection fraction, and 4 (3.8%) HFmrEF. [Table 8] shows the distribution of left ventricular systolic function among patients with various categories of left ventricular geometry. Among the patients with normal left ventricular geometry, 16 (18.6%) had a normal left ventricular diastolic function, 21 (24.4%) had impaired relaxation patterns of diastolic dysfunction, and 49 (57.0%) had a restrictive pattern of diastolic dysfunction. Concentric left ventricular hypertrophy was observed in 142 patients. Among the patients with concentric left ventricular geometry, 20 (14.1%) had a normal left ventricular diastolic function, 115 (81.0%) had impaired relaxation pattern of left ventricular diastolic dysfunction, and 7 (4.9%) had a restrictive pattern of diastolic dysfunction. While among those with eccentric left ventricular hypertrophy, 12 (11.5%) had a normal left ventricular diastolic function, 13 (12.5%) had impaired relaxation pattern of left ventricular diastolic dysfunction, and 79 (76.0%) had a restrictive pattern of left ventricular diastolic dysfunction. [Table 9] shows the distribution of diastolic dysfunction in patients with various categories of left ventricular geometry.
Table 8: Distribution of left ventricular systolic function among patients with various categories of left ventricular geometry

Click here to view
Table 9: Distribution of diastolic functions among patients with various categories of left ventricular geometry

Click here to view



  Discussion Top


HF is a major public health problem worldwide. Available data suggest that the morbidity due to HF is significant in many parts of the world. In this cross-sectional study, female subjects constitute a substantial proportion of patients admitted with HF; this perhaps may be due to peripartum cardiomyopathy among the female subjects as it a purely disease of women. Progressive hypertensive heart disease was the most common cause of HF, while cardiomyopathies were the second particularly peripartum type. Rheumatic heart disease and myocardial infarction were the third and fourth causes of HF. These suggest that hypertension remained the major cause of HF among our patients.

High QRS voltage was observed predominantly among patients with progressive hypertensive heart disease and hypertensive diabetics compared to those with peripartum cardiomyopathy and idiopathic dilated cardiomyopathy, suggesting that hypertension and/or diabetes could be responsible for the left ventricular hypertrophy, as it was previously described.[16],[17],[18] In this study, we found that patients with high QRS voltage predominantly had HFpEF and impaired relaxation pattern of diastolic dysfunction. On the other hand, those with low QRS voltage had HF with reduced ejection fraction and restrictive pattern of diastolic dysfunction. We also observed a positive and significant correlation between QRS voltage and left ventricular ejection fraction, fractional shortening, IVRT and DCT and negative correlation between QRS voltage and trans-mitral flow (E/A ratio). These findings suggest that myocardial hypertrophy enhances contractility, increases QRS voltage and impaired ventricular compliance during diastole often occurs as a compensatory phenomenon that eventually becomes maladaptive, and evolves toward progressive left ventricular dysfunction and HF similar to what was previously described by other researchers.[7],[8],[9],[10],[19]

In this study, we found that peripartum cardiomyopathy and idiopathic dilated cardiomyopathy were associated with chamber dilatation, reduced myocardial contractility, reduced left ventricular systolic function, and low QRS voltage, a finding previously described by Pearson et al.[20] We also found that the majority of patients with concentric left ventricular hypertrophy had HFpEF, impaired relaxation pattern of left ventricular diastolic dysfunction, and high QRS voltage, similar to the previous report by Gupta et al.[21] Eccentric left ventricular hypertrophy results from the combination of volume and pressure overload.[22] While on the other hand, restrictive diastolic dysfunction is associated with chamber dilatation and increased left ventricular end-diastolic pressure.[23] In this study, we observed that patients with eccentric left ventricular hypertrophy had heart failure with reduced ejection fraction, restrictive pattern of diastolic dysfunction, and low QRS voltage findings in keeping with previous studies.[22],[23]


  Conclusion Top


Our findings is this study revealed that HF patients with high QRS voltage had predominantly preserved left ventricular systolic function, impaired relaxation pattern of left ventricular diastolic dysfunction, and concentric left ventricular hypertrophy, while those with low QRS voltage predominantly had reduced left ventricular systolic function, restrictive pattern of left ventricular diastolic dysfunction, and eccentric left ventricular hypertrophy.

Limitation of this study

  1. Lack of tissue Doppler study to isolate those with Grade 2 (pseudonormalized) diastolic dysfunction
  2. Lack of pulmonary venous flow study of left atrial filling to isolate those patients with Grade 2 (pseudonormalized) diastolic dysfunction.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016;18:891-975.  Back to cited text no. 1
    
2.
Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol 2009;53:e1-90.  Back to cited text no. 2
    
3.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr., Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013;128:1810-52.  Back to cited text no. 3
    
4.
Damasceno A, Cotter G, Dzudie A, Sliwa K, Mayosi BM. Heart failure in Sub-Saharan Africa: Time for action. J Am Coll Cardiol 2007;50:1688-93.  Back to cited text no. 4
    
5.
Khan NK, Goode KM, Cleland JG, Rigby AS, Freemantle N, Eastaugh J, et al. Prevalence of ECG abnormalities in an international survey of patients with suspected or confirmed heart failure at death or discharge. Eur J Heart Fail 2007;9:491-501.  Back to cited text no. 5
    
6.
Kamath SA, Meo Neto Jde P, Canham RM, Uddin F, Toto KH, Nelson LL, et al. Low voltage on the electrocardiogram is a marker of disease severity and a risk factor for adverse outcomes in patients with heart failure due to systolic dysfunction. Am Heart J 2006;152:355-61.  Back to cited text no. 6
    
7.
Madias JE, Agarwal H, Win M, Medepalli L. Effect of weight loss in congestive heart failure from idiopathic dilated cardiomyopathy on electrocardiographic QRS voltage. Am J Cardiol 2002;89:86-8.  Back to cited text no. 7
    
8.
Madias JE, Song J, White CM, Kalus JS, Kluger J. Response of the ECG to short-term diuresis in patients with heart failure. Ann Noninvasive Electrocardiol 2005;10:288-96.  Back to cited text no. 8
    
9.
Madias JE. Standard electrocardiographic and signal-averaged electrocardiographic changes in congestive heart failure. Congest Heart Fail 2005;11:266-71.  Back to cited text no. 9
    
10.
Madias JE. Mechanism of attenuation of the QRS voltage in heart failure: A hypothesis. Europace 2009;11:995-1000.  Back to cited text no. 10
    
11.
McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: The Framingham study. N Engl J Med 1971;285:1441-6.  Back to cited text no. 11
    
12.
Sokolow M, Lyon TP. The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads. Am Heart J 1949;37:161-86.  Back to cited text no. 12
    
13.
Eisenberg MJ, de Romeral LM, Heidenreich PA, Schiller NB, Evans GT Jr. The diagnosis of pericardial effusion and cardiac tamponade by 12-lead ECG. A technology assessment. Chest 1996;110:318-24.  Back to cited text no. 13
    
14.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015;16:233-70.  Back to cited text no. 14
    
15.
Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2016;29:277-314.  Back to cited text no. 15
    
16.
Frohlich ED, Apstein C, Chobanian AV, Devereux RB, Dustan HP, Dzau V, et al. The heart in hypertension. N Engl J Med 1992;327:998-1008.  Back to cited text no. 16
    
17.
Palmieri V, Bella JN, Arnett DK, Liu JE, Oberman A, Schuck MY, et al. Effect of type 2 diabetes mellitus on left ventricular geometry and systolic function in hypertensive subjects: Hypertension Genetic Epidemiology Network (HyperGEN) study. Circulation 2001;103:102-7.  Back to cited text no. 17
    
18.
Kannel WB. Hypertension, hypertrophy, and the occurrence of cardiovascular disease. Am J Med Sci 1991;302:199-204.  Back to cited text no. 18
    
19.
Heinzel FR, Hohendanner F, Jin G, Sedej S, Edelmann F. Myocardial hypertrophy and its role in heart failure with preserved ejection fraction. J Appl Physiol (1985) 2015;119:1233-42.  Back to cited text no. 19
    
20.
Pearson GD, Veille JC, Rahimtoola S, Hsia J, Oakley CM, Hosenpud JD, et al. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. JAMA 2000;283:1183-8.  Back to cited text no. 20
    
21.
Gupta DK, Shah AM, Castagno D, Takeuchi M, Loehr LR, Fox ER, et al. Heart failure with preserved ejection fraction in African Americans: The ARIC (Atherosclerosis Risk in Communities) Study. JACC Heart Fail 2013;1:156-63.  Back to cited text no. 21
    
22.
Messerli FH, Sundgaard-Riise K, Ventura HO, Dunn FG, Oigman W, Frohlich ED. Clinical and hemodynamic determinants of left ventricular dimensions. Arch Intern Med 1984;144:477-81.  Back to cited text no. 22
    
23.
Masutani S, Little WC, Hasegawa H, Cheng HJ, Cheng CP. Restrictive left ventricular filling pattern does not result from increased left atrial pressure alone. Circulation 2008;117:1550-4.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methodology
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed169    
    Printed3    
    Emailed0    
    PDF Downloaded16    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]