Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

ECG and CT for the detection of left atrial enlargement in hypertensive individuals—a population-based study

Hypertension Research volume 45, pages 1382–1391 (2022)Cite this article

A Comment to this article was published on 09 June 2022

Abstract

Left atrial enlargement (LAE) is associated with hypertension and an increased risk of cardiovascular morbidity and mortality. Guidelines for hypertension recommend LAE evaluation. We aimed to estimate the agreement of LAE as assessed by 12-lead electrocardiogram (ECG) and cardiac computed tomography (CT) in both the general population and hypertensive individuals. Cardiac CT and ECG were used to evaluate the presence of LAE in participants in the Copenhagen General Population Study. LAE, is defined as an LA volume above the 97.5% upper confidence limit by cardiac CT, as compared with multiple ECG criteria for LAE. A total of 3507 participants (47% males, age: 60 ± 10 years) were included. The prevalence of CT-defined LAE was 5.9% in the total population and 8.7% in participants with hypertension. In hypertensive individuals, LAE was identified by CT or by ECG in 31% with only a 4% overlap. ECG signs for anatomical LAE by CT had high negative predictive values between 93 and 96% but low sensitivity and positive predictive values. Specificity ranged from 27 to 93%. P-wave duration >120 ms was the best performing criterion, with a sensitivity of 48%, a specificity of 78%, and the highest area under the curve (0.66). We found a discrepancy in LAE prevalence when participants were assessed by CT and ECG, indicating that the two diagnostic modalities reflect different phenotypes of left atrial alterations. The diagnostic performance of ECG criteria for identifying anatomical LAE was poor.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

Data cannot be shared for ethical/privacy reasons.

References

  1. Bombelli M, Facchetti R, Cuspidi C, Villa P, Dozio D, Brambilla G, et al. Prognostic significance of left atrial enlargement in a general population: results of the PAMELA study. Hypertension 2014;64:1205–11.

    Article  CAS  Google Scholar 

  2. Benjamin EJ, D’Agostino RB, Belanger AJ, Wolf PA, Levy D. Left atrial size and the risk of stroke and death. The Framingham Heart Study. Circulation 1995;92:835–41.

    Article  CAS  Google Scholar 

  3. Vaziri SM, Larson MG, Benjamin EJ, Levy D. Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study. Circulation 1994;89:724–30.

    Article  CAS  Google Scholar 

  4. Mahabadi AA, Geisel MH, Lehmann N, Lammerding C, Kalsch H, Bauer M, et al. Association of computed tomography-derived left atrial size with major cardiovascular events in the general population: the Heinz Nixdorf Recall Study. Int. J. Cardiol. 2014;174:318–23.

    Article  Google Scholar 

  5. Nielsen JB, Kuhl JT, Pietersen A, Graff C, Lind B, Struijk JJ, et al. P-wave duration and the risk of atrial fibrillation: results from the Copenhagen ECG Study. Heart Rhythm 2015;12:1887–95.

    Article  Google Scholar 

  6. Ahmad MI, Mujtaba M, Anees MA, Li Y, Soliman EZ. Interrelation between electrocardiographic left atrial abnormality, left ventricular hypertrophy, and mortality in participants with hypertension. Am. J. Cardiol. 2019;124:886–91.

    Article  Google Scholar 

  7. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J. Hypertens. 2018;36:1953–2041.

    Article  CAS  Google Scholar 

  8. Abhayaratna WP, Seward JB, Appleton CP, Douglas PS, Oh JK, Tajik AJ, et al. Left atrial size: physiologic determinants and clinical applications. J. Am. Coll. Cardiol. 2006;47:2357–63.

    Article  Google Scholar 

  9. Yokota A, Kabutoya T, Hoshide S. Automatically assessed P-wave predicts cardiac events independently of left atrial enlargement in patients with cardiovascular risks: The Japan Morning Surge-Home Blood Pressure Study. J. Clin. Hypertens. 2021;23:301–8.

  10. Chirife R, Feitosa GS, Frankl WS. Electrocardiographic detection of left atrial enlargement. Correlation of P wave with left atrial dimension by echocardiography. Br. Heart J. 1975;37:1281–5.

    Article  CAS  Google Scholar 

  11. Lee KS, Appleton CP, Lester SJ, Adam TJ, Hurst RT, Moreno CA, et al. Relation of electrocardiographic criteria for left atrial enlargement to two-dimensional echocardiographic left atrial volume measurements. Am. J. Cardiol. 2007;99:113–8.

    Article  Google Scholar 

  12. Waggoner AD, Adyanthaya AV, Quinones MA, Alexander JK. Left atrial enlargement Echocardiographic assessment of electrocardiographic criteria. Circulation. 1976;54:553–7.

    Article  CAS  Google Scholar 

  13. Birkbeck JP, Wilson DB, Hall MA, Meyers DG. P-wave morphology correlation with left atrial volumes assessed by 2-dimensional echocardiography. J. Electrocardiol. 2006;39:225–9.

    Article  Google Scholar 

  14. Kircher B, Abbott JA, Pau S, Gould RG, Himelman RB, Higgins CB, et al. Left atrial volume determination by biplane two-dimensional echocardiography: validation by cine computed tomography. Am. Heart J. 1991;121:864–71.

    Article  CAS  Google Scholar 

  15. Kuhl JT, Lonborg J, Fuchs A, Andersen MJ, Vejlstrup N, Kelbaek H, et al. Assessment of left atrial volume and function: a comparative study between echocardiography, magnetic resonance imaging and multi slice computed tomography. Int. J. Cardiovasc. Imaging 2012;28:1061–71.

    Article  Google Scholar 

  16. Fuchs A, Mejdahl MR, Kuhl JT, Stisen ZR, Nilsson EJ, Kober LV, et al. Normal values of left ventricular mass and cardiac chamber volumes assessed by 320-detector computed tomography angiography in the Copenhagen General Population Study. Eur. Heart J. Cardiovasc. Imaging 2016;17:1009–17.

    Article  Google Scholar 

  17. Ariyarajah V, Frisella ME, Spodick DH. Reevaluation of the criterion for interatrial block. Am. J. Cardiol. 2006;98:936–7.

    Article  Google Scholar 

  18. Soliman EZ, Prineas RJ, Case LD, Zhang ZM, Goff DC Jr. Ethnic distribution of ECG predictors of atrial fibrillation and its impact on understanding the ethnic distribution of ischemic stroke in the Atherosclerosis Risk in Communities (ARIC) study. Stroke 2009;40:1204–11.

    Article  Google Scholar 

  19. Perosio AM, Suarez LD, Torino A, Llera JJ, Ballester A, Roisinblit JM. Reassessment of electrovectorcardiographic signs of left atrial enlargement. Clin. Cardiol. 1982;5:640–6.

    Article  CAS  Google Scholar 

  20. Hazen MS, Marwick TH, Underwood DA. Diagnostic accuracy of the resting electrocardiogram in detection and estimation of left atrial enlargement: an echocardiographic correlation in 551 patients. Am. Heart J. 1991;122:823–8.

    Article  CAS  Google Scholar 

  21. Munuswamy K, Alpert MA, Martin RH, Whiting RB, Mechlin NJ. Sensitivity and specificity of commonly used electrocardiographic criteria for left atrial enlargement determined by M-mode echocardiography. Am. J. Cardiol. 1984;53:829–32.

    Article  CAS  Google Scholar 

  22. Truong QA, Charipar EM, Ptaszek LM, Taylor C, Fontes JD, Kriegel M, et al. Usefulness of electrocardiographic parameters as compared with computed tomography measures of left atrial volume enlargement: from the ROMICAT trial. J. Electrocardiol. 2011;44:257–64.

    Article  Google Scholar 

  23. Simek CL, Feldman MD, Haber HL, Wu CC, Jayaweera AR, Kaul S. Relationship between left ventricular wall thickness and left atrial size: comparison with other measures of diastolic function. J. Am. Soc. Echocardiogr.1995;8:37–47.

    Article  CAS  Google Scholar 

  24. Mehta S, Charbonneau F, Fitchett DH, Marpole DG, Patton R, Sniderman AD. The clinical consequences of a stiff left atrium. Am. Heart J. 1991;122:1184–91.

    Article  CAS  Google Scholar 

  25. Kabutoya T, Hoshide S, Kario K. Advances and challenges in the electrocardiographic diagnosis of left ventricular hypertrophy in hypertensive individuals. Am. J. Hypertens. 2020;33:819–21.

    Article  Google Scholar 

  26. Pritchett AM, Mahoney DW, Jacobsen SJ, Rodeheffer RJ, Karon BL, Redfield MM. Diastolic dysfunction and left atrial volume: a population-based study. J. Am. Coll. Cardiol. 2005;45:87–92.

    Article  Google Scholar 

  27. Kuhl JT, Nielsen JB, Stisen ZR, Fuchs A, Sigvardsen PE, Graff C, et al. Left ventricular hypertrophy identified by cardiac computed tomography and ECG in hypertensive individuals: a population-based study. J. Hypertens. 2019;37:739–46.

    Article  Google Scholar 

  28. Tsao CW, Josephson ME, Hauser TH, O’Halloran TD, Agarwal A, Manning WJ, et al. Accuracy of electrocardiographic criteria for atrial enlargement: validation with cardiovascular magnetic resonance. J. Cardiovasc. Magn. Reson. 2008;10:7.

    Article  Google Scholar 

Download references

Acknowledgements

The authors wish to thank the chief radiographer Kim Madsen, Department of Radiology, and his staff of radiographers and nurses for outstanding technical and logistical support. There are no relationships with the industry.

Author information

Authors and Affiliations

  1. Department of Cardiology, Rigshospitalet, DK-2100, Copenhagen, Denmark

    Emma Julia Petronella Nilsson, Jørgen Tobias Kühl, Jonas Bille Nielsen, Andreas Fuchs, Andreas Dehlbæk Knudsen, Per Ejlstrup Sigvardsen, Lars Køber & Klaus Fuglsang Kofoed

  2. Department of Health Science and Technology, Aalborg University, DK-9220, Aalborg, Denmark

    Claus Graff

  3. Department of Clinical Biochemistry, Herlev Hospital, DK-2730, Herlev, Denmark

    Børge Nordestgaard

  4. Department of Radiology, Rigshospitalet, DK-2100, Copenhagen, Denmark

    Klaus Fuglsang Kofoed

Authors
  1. Emma Julia Petronella Nilsson
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jørgen Tobias Kühl
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jonas Bille Nielsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andreas Fuchs
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Andreas Dehlbæk Knudsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Per Ejlstrup Sigvardsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Claus Graff
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Lars Køber
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Børge Nordestgaard
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Klaus Fuglsang Kofoed
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Emma Julia Petronella Nilsson.

Ethics declarations

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nilsson, E.J.P., Kühl, J.T., Nielsen, J.B. et al. ECG and CT for the detection of left atrial enlargement in hypertensive individuals—a population-based study. Hypertens Res 45, 1382–1391 (2022). https://doi.org/10.1038/s41440-022-00918-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41440-022-00918-z

Keywords

Search

Advanced search

Quick links