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Electrocardiographic Left Ventricular Hypertrophy Among Gambian Diabetes

Mellitus Patients

Article  in  Ghana Medical Journal · April 2015

DOI: 10.4314/gmj.v49i1.4

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March 2015 Volume 49, Number 1 GHANA MEDICAL JOURNAL

ELECTROCARDIOGRAPHIC LEFT VENTRICULAR HYPERTROPHY

AMONG GAMBIAN DIABETES MELLITUS PATIENTS
 
M. JOBE¹, A. KANE¹, J. C. JONES2, S. PESSINABA¹, B. C. NKUM3, S. ABDOU BA1, and O. A.
NYAN²
¹Service de Cardiologie, CHU Aristide Le Dantec, Dakar, Senegal, ²Department of Medicine and Therapeu-
tics, School of Medicine and Allied Health Sciences, University of The Gambia, Edward Francis Small Teach-
ing Hospital, Banjul, The Gambia, 3Department of Medicine, School of Medical Sciences, Kwame Nkrumah
University of Science and Technology, Kumasi, Ghana

DOI: http://dx.doi.org/10.4314/gmj.v49i1.4
 
Corresponding Author: Dr. M. Jobe E-mail: [email protected]
Conflict of Interest: None declared
 
SUMMARY INTRODUCTION
Background: The global prevalence of diabetes and its The global prevalence of diabetes mellitus (DM) con-
complications is increasing worldwide. Its role in coro- tinues to rise at an alarming rate.1 It is acknowledged as
nary heart disease has been linked with the presence of a principal risk factor for cardiovascular morbidity and
left ventricular hypertrophy (LVH). The present study mortality and has a heavy impact on the global health
aims to determine the prevalence of electrocardio- expenditure due to both its short and long term compli-
graphic left ventricular hypertrophy (ECG-LVH) in cations.2 DM is closely linked to coronary events3 and
adult diabetic subjects, its epidemiological and clinical left ventricular hypertrophy (LVH) in DM patients has
correlates. been widely implicated4,5 and therefore considered as a
Methods: A descriptive cross-sectional study involv- treatment target5, as associated cardiovascular risks
ing 534 patients was conducted at the Edward Francis become normal with full regression of LVH.6 Insulin
Small Teaching Hospital (formerly Royal Victoria resistance and associated abnormal glucose metabolism
Teaching Hospital), The Gambia. Four hundred and have been implicated in many reports as a possible
forty patients were included using a standard question- pathophysiological mechanism of LVH. This therefore
naire. Anthropometry, laboratory investigations and highlights the need for the early detection of LVH in
electrocardiogram were carried out. We used the Lew- DM in order to institute a timely effective interven-
is, Cornell, and Sokolow-Lyon Voltage criteria to de- tion.7
fine ECG-LVH. MinitabTM statistical software version
13.20 was used for analysis. Electrocardiogram remains a cheap, useful and a wide-
Results: 146 (35.2%) patients had ECG-LVH using all ly available tool to determine LVH.8 This paper aims to
3 criteria and this prevalence was higher among wom- determine the prevalence of electrocardiographic left
en being 116 (79.5%). A generally high prevalence of ventricular hypertrophy (ECG-LVH) among adult
overweight (155/37.4%) and obesity (119/28.6%) was Gambian DM patients and also to determine its associ-
observed among study participants, and both clinic-day ated clinical factors.
systolic and diastolic blood pressure (BP) were signifi-
cantly higher in those with ECG-LVH. Poor diabetes METHODS
control was observed in both groups. This study was conducted at the Edward Francis Small
Conclusion: There was a high prevalence of ECG- Teaching Hospital (EFSTH) in Banjul, The Gambia
LVH and it is especially so with combining multiple during routine clinic visits (on every Monday and
criteria, hence the need for screening. Clinic-day hy- Wednesday) from the 6th November, 2008 to the 4th
pertension was associated with ECG-LVH hence the January 2009 between the hours of 8am and 2pm.
need for diagnosing and aggressive treatment of hyper-
tension in patients with diabetes mellitus. Study Population: All patients with a confirmed diag-
nosis of DM and who attend the medical out-patient
Keywords: Diabetes mellitus, ECG-LVH, The Gam- department, EFSTH for routine care were eligible for
bia, voltage criteria inclusion into the study. Pregnant women and those
who did not consent for inclusion were excluded.

19
March 2015 M. Jobe et al ECG-LVH in Gambian diabetic patients

Subjects less than 25 years of age and those with bun- Blood and urine samples: Venous blood samples were
dle branch block were excluded from the present anal- collected and analysed using a COBAS INTEGRA
ysis. 400 plus analyser (Roche Diagnostics GmbH) at the
EFSTH laboratories for total cholesterol, high density
Study design: cross-sectional study. lipoprotein cholesterol (HDL-cholesterol), low density
lipoprotein cholesterol (LDL-cholesterol), triglycer-
Questionnaire: a trained research field assistant in a ides, creatinine, fructosamine, albumin and uric acid
language understood by the study participant adminis- levels. Blood glucose was determined using a portable
tered a standard questionnaire designed for the purpose glucometer (Accu-Chek). Urine sample was also col-
of the study. The questionnaire was divided into 3 sec- lected and urine dipstick was done for glucose and pro-
tions. Section A included items on demographic de- tein.
tails like age, sex, address, ethnicity, religion, educa-
tional level, smoking status as well as background de- Electrocardiography: The study participants had a
tails about the participant’s DM. Occupations were standard surface 12-lead ECG recorded with the patient
coded as manual if involving mainly unskilled labour; lying supine and relaxed on a flat surface (using a Car-
as trades for occupations mainly involving skilled dioline Delta 1 EKG Machine). The machine was regu-
manual labour; or as non-manual. The rest were coded larly checked to ensure that it was in a proper working
as others. Section B covered information about the condition. After explaining the procedure to the patient,
usual medical care the patient receives (including activ- the ECG leads were placed according to standard prac-
ities at clinic visits, medications prescribed) and also tice. The paper speed was set at 25mm/s whilst the
evidence of diabetic foot (or feet) complication(s). Sec- voltage set at 10mm/mV. The ECG recordings were
tion C involved carrying out basic anthropometric sent to Aristide Le Dantec Teaching Hospital, in Da-
measurements, blood pressure (BP) measurements, kar, Senegal and analysed by a group of cardiology
urine dipstick, and venous blood sampling for serum residents, supervised by an electrophysiologist with
biochemistry and also obtaining a standard 12-lead many years of experience using a specially designed
surface ECG. protocol. The various parameters studied included the
rhythm, heart rate, PR interval, presence of significant
Blood pressure: Blood pressure and pulse rate were Q wave, LVH (using Lewis, Cornell, and Sokolow-
recorded with an Omron 705IT machine (Omron, Kyo- Lyon voltage criteria) and ST-T changes.
to, Japan) with the participant in a seated position using
the subject’s left arm positioned at heart level. The BP ECG-LVH was defined according to standard criteria
was taken first when the patient enters the consulting using the mean of 3 consecutive QRS values as fol-
room and after five minutes. Two measurements were lows: Lewis voltage as (R wave in lead 1-R wave in
done at each time and the mean of the two readings lead 3)+(S wave in lead 3-S wave in lead 1)≥1.7mV
9
was recorded. Cornell voltage as S wave in V3+ R wave in
aVL≥2.0mV in women and 2.8mV in men10 Sokolow-
Anthropometry: Height was measured without foot- Lyon Voltage as S wave in V1+R wave in V5 or
wear or headwear with the subject standing fully erect V6≥3.5mV 11
on a flat surface, with heels, buttock and shoulders flat
to the height meter, and the subject looking straight Data Management
ahead using a daily calibrated stadiometer (Leicester The data of each participant was collected on a ques-
height measure, Seca 214, Birmingham, UK). Meas- tionnaire which was then entered into Microsoft Excel
urement was done to the nearest 0.5cm. Weight was 2007 by double entry. The data was cross-checked and
measured with the subject wearing light clothing with all inconsistencies were corrected. The data was then
no footwear using a digital scale (Tanita Corporation, transferred to and analyzed using MinitabTM statistical
Tokyo, Japan). The value was recorded to the nearest software version 13.20. The characteristics of patients
0.1kg. Waist circumference measured at the level of with ECG-LVH and those without it were compared
the upper margin of the iliac crest, was measured to the using two-sample t-test for continuous variables and
nearest centimeter with a flexible tape. Body mass in- Chi-square test for categorical variables. P-values of
dex (BMI) was defined as weight (kg)/height (m).2 We less than 0.05 were considered to be of statistical sig-
used a new generation foot-to-foot bioimpedence de- nificance.
vice (Tanita TBF300GS, Tanita Corporation) to meas-
ure fat percent, fat mass, total body water (TBW) with Ethical Consideration
the subject standing erect in bare feet on the bioim- The School of Medicine and Allied Health Sciences,
pedence analyzer. University of the Gambia Research and Publication
Committee approved the study protocol.

20
 March 2015 Volume 49, Number 1 GHANA MEDICAL JOURNAL

An informed consent was obtained from each of the As shown in Table 2, there was no significant differ-
study participants after explanation and careful consid- ence in the age of patients with or without ECG-LVH
eration by the participant signing or thumbs printing a both at the time of diagnosis of diabetes and also at the
written consent form. time of the study.

RESULTS Hypertension was more prevalent among subjects with

A total of 534 patients (171 males and 363 females) ECG-LVH but this was not statistically significant.
took part in the study, of whom 440 (131 males and However, clinic-day systolic and diastolic BPs were
309 females) had a standard surface ECG. Of those significantly more elevated among patients with ECG-
who had an ECG, 415 (121 males and 294 females) LVH.
met criteria for inclusion in this analysis. The majority
of participants, 80.3% were between the ages of 40 and Two hundred and seventy-four (66%) of patients were
69; The actual age distribution according to age groups either overweight (155/37.4%) or obese (119/28.6%).
(25-39, 40-54, 55-69 and ≥ 70 years) was 49 (11.8%), We found a significant difference between the sexes as
175 (42.2%), 158 (38.1%) and 33 (7.9%) respectively. 48 (39.7%) and 9 (7.4%) of males were respectively
overweight and obese compared to 107 (36.4%) and
The prevalence of ECG-LVH according to the different 110 (37.4%) of females (P<0.001); indeed the distribu-
criteria used is shown in Table 1. The highest preva- tion of subjects by BMI (<18.5, 18.5-24.9, 25-29.9 and
lence was recorded with the Cornell voltage criteria. ≥30) was 9 (2.2%), 132 (31.8%), 155 (37.3%) and 119
With the Lewis but especially the Cornell voltage crite- (28.7%) respectively.
ria, where the number of females diagnosed was signif-
icantly higher than that of males. However, this large However, as shown in Table 3 there was no significant
difference was not observed with the Sokolow-Lyon statistical difference between BMIs of subjects with or
criteria. without ECG-LVH. Serum creatinine and lipid profile
were similar in both groups. However, serum albumin
Table 1 Prevalence of LVH in diabetic patients accord- level was significantly lower among patients with
ing to different ECG criteria ECG-LVH. In this cohort, fructosamine levels were
ECG Criteria Male Female Total P- high in both groups.
N= 121 N= 294 N=415 value
Lewis 9 (7.4%) 35 (11.9%) 44 (10.6%) 0.179 Table 3 Metabolic features of diabetic patients by
Cornell 13 (10.7%) 89 (30.3%) 102 <0.001
(24.6%)
ECG-LVH
Sokolow-Lyon 15 (12.4%) 38 (12.9%) 53 (12.8%) 0.883 Variable ECG-LVH No ECG-LVH P
N=146 N=269 value
Combined 30 (24.8%) 116 146 0.004
criteria (39.5%) (35.2%) Fructosamine 375 377 0.877
(µmol/L) (363-389) (368.7-385.3)
Serum creatinine 69.1 71.4 0.433
One hundred and forty-six (35.2%) patients met one or (µmol/L) (66.6-71.6) (69.7-73.1)
more of the three standard criteria that we have used to Serum albumin (g/L) 38.9 40.1 0.033
define ECG-LVH, of whom 116 (79.5%) were females. (38.4-39.4) (39.8-40.4)
Total cholesterol 5.3 5.2 0.560
Among the female population studied, 116 (39.5%) had (mmol/L) (5.2-5.4) (5.1-5.3)
ECG-LVH compared to 30 (24.8%) of males. Serum triglycerides 1.3 1.3 0.644
(mmol/L) (1.25-1.35) (1.23-1.32)
Table 2 Clinical characteristics of diabetic patients by HDL-cholesterol 0.87 0.86 0.720
ECG-LV (mmol/L) (0.85-0.89) (0.85-0.88)
Results are shown as mean and 95% CI
Variable ECG-LVH No ECG- P value
N=146 LVH
N=269 DISCUSSION
Age (years) 52.9±11.1 53.1±11.5 0.910 The prevalence of ECG-LVH using all three standard
Age at diagnosis (years) 48.1±10.9 47.2±12.0 0.488
Sex
criteria (Lewis, Cornell and Sokolow-Lyon Voltage) in
Female 116 (79.5%) 178 (66.2%) 0.004 this study was high (35.2%). The prevalence was high-
Height (cm) 161.9±6.9 162.7±8.8 0.352 er in females compared to males using either all or any
Weight (Kg) 73.3±13.9 72.4±15.2 0.564 of the aforementioned criteria. Using the individual
BMI (kg/m²) 28.0±5.2 27.4±6.1 0.352 criteria, the prevalence of ECG-LVH was highest with
History of hypertension 97 (66.4%) 152 (56.5%) 0.056
Systolic BP(mmHg) 137.5±22.5 129.8±21.3 0.001
the Cornell voltage criteria (26.8%) and lowest with the
Diastolic BP(mmHg) 80.3±12 76.5±9.5 < 0.001 Lewis voltage criteria (10.6%).
BMI- body mass index, BP- blood pressure

21
March 2015 M. Jobe et al ECG-LVH in Gambian diabetic patients

It has been demonstrated from previous studies that Women with DM have been shown to have a higher
ECG has a lower sensitivity compared to echocardiog- cardiovascular morbidity and mortality than their male
raphy in determining LVH.12 Generally, black individ- counterparts.23, 24, 25 Therefore the higher prevalence of
uals have greater precordial QRS voltages than whites females with LVH and obesity in this cohort is worry-
and many of the LVH criteria have higher sensitivity in ing and needs attention.
detecting LVH in blacks and lower specificity com-
pared with whites.13,14 However, many of the criteria We advocate for the early detection and aggressive
proposed like the Araoye for African blacks are yet to treatment of LVH to prevent potentially life-
be validated and so far have offered no comparative threatening consequences. Many antihypertensive
advantage over the standard criteria.15 agents have been recommended for the treatment of
LVH. However, agents with intrinsic sympathomimetic
Additionally many factors might limit the accuracy of properties or with direct vasodilatory effects (e.g. hy-
ECG in determining LVH including age, body habitus, dralazine and minoxidil) must be avoided.26 The most
obesity and chronic lung diseases. Hence many au- effective agents in reducing left ventricular mass are
thors advocate the use of echocardiography to deter- angiotensin II receptor blockers, angiotensin-
mine LVH. However, the availability of echocardiog- converting enzyme inhibitor, calcium channel blockers
raphy is still limited and not feasible in many places and diuretics.27 Bauml and Underwood recommend
especially in our sub-region. Besides the unavailability that treatment should consist of an angiotensin II recep-
of technical expertise to operate echocardiography in tor blocker or an angiotensin-converting enzyme inhib-
many places, high costs further limits its usage. The itor 28 which have additional renoprotective effect as
present study compared different voltage criteria and well as reversing LVH. However, these agents are less
showed the superiority of using more than one criterion efficacious in blacks according to the investigators of
to determine ECG-LVH. This is advocated by many Studies of Left Ventricular Dysfunction (SOLVED) 29
authors and has been demonstrated in various stud- but who have been shown to benefit from treatment
ies.16,17,18 with diuretic agents.26

We found in the present study that both systolic and CONCLUSION

diastolic BP were significantly higher in those with We found a higher prevalence using multiple criteria to
ECG-LVH which is consistent with the findings by determine ECG-LVH and this prevalence was higher
Desai et al19, There is therefore the need for a more among females and associated with high clinic-BP.
aggressive BP control. Niiranen et al found home Therefore, screening, aggressive treatment for ECG-
measured blood pressure values to be more strongly LVH and associated high BP should be instituted in the
associated with ECG-LVH.20 In the Cascale Monferra- standard care of DM patients.
to study however, the prevalence of hypertension was
high and systolic BP were raised in both groups (i.e. ACKNOWLEDGEMENTS
those with ECG-LVH and those without) but with no We would like to thank all the patients who took part in
statistical difference. 6 the study and the staff of the medical outpatient de-
partment of the Edward Francis Small Teaching Hospi-
There is paucity of data regarding the relationship be- tal. We would like to extend our heartfelt gratitude to
tween low serum albumin level and LVH in DM pa- Mr. Eliman Jobe of the Edward Francis Small Teach-
tients which we found in our study. This needs evalua- ing Hospital Laboratories and to Ms Musu Bojang for
tion with further studies as low serum albumin has their special contributions to the realisation this work.
been strongly linked to cardiovascular events in a pre-
vious study.21
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