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R wave in aVL lead: an outstanding ECG index in hypertension

Courand, Pierre-Yvesa,b,c,*; Jenck, Sophiea,*; Bricca, Giampierob,c; Milon, Huguesa; Lantelme, Pierrea,b,c

doi: 10.1097/HJH.0000000000000181

Objectives: The voltage of R wave in lead aVL (RaVL) seems to be more tightly correlated with left ventricular mass and cardiovascular events than any other ECG criterium of left ventricular hypertrophy. We hypothesized that RaVL could be an independent predictor of all-cause and cardiovascular death in hypertensive individuals.

Methods: The baseline clinical and biological variables as well as ECG recordings were analyzed in a prospective cohort of 589 hypertensive individuals.

Results: After 10 years of follow-up, we observed 95 deaths of which 53 had a cardiovascular cause. The optimal RaVL voltages to predict all-cause and cardiovascular mortality were 0.8 and 0.6 mV, respectively. In a multivariate adjusted Cox model, having an RaVL voltage superior to these cutoffs was associated with increased risks of all-cause death [hazard ratio: 2.04, 95% confidence interval (CI): (1.30–3.22)] and of cardiovascular death [hazard ratio: 2.89, 95% CI: (1.47–5.68)]. In the whole cohort and with the same adjusted Cox regression model, each 0.1 mV increment would increase the risk of all-cause death by 1.07 times [95% CI: (1.02–1.12)] and that of cardiovascular death by 1.13 times [95% CI: (1.06–1.20)]. After excluding in turn patients with positive Sokolow index, Cornell voltage, or Cornell product, the results remained statistically significant, meaning that RaVL was still able to pick-up high-risk patients when other classical and more sophisticated indices were not observable.

Conclusion: The present results strengthen previous reports that demonstrated a strong role of RaVL voltage in risk stratification in hypertension.

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aCardiology Department, European Society of Hypertension Excellence center, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon

bGénomique Fonctionnelle de l’Hypertension artérielle, Université Claude Bernard Lyon1, Villeurbanne

cHôpital Nord-Ouest, Villefranche-sur-Saône, France

*Pierre-Yves Courand and Sophie Jenck contributed equally to the writing of this article.

Correspondence to Pierre-Yves Courand, MD, MSc, Cardiology Department, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, F-69004 Lyon, France. Tel: +33 472 071 667; fax: +33 472 071 674; e-mail:

Abbreviations: BP, blood pressure; BPM, beats per minute; CépiDC, Centre d’Epidémiologie sur les Causes Médicales de Décès; CI, confidence interval; CVD, cardiovascular diseases; INSEE, Institut National de la Statistique et des Etudes Economiques; LVM, left ventricular mass; LVH, left ventricular hypertrophy; MDRD, Modification of Diet in Renal Disease formula; RaVL, R wave in lead aVL; ROC, receiver-operating characteristic; TTE, transthoracic echocardiography

Received 5 November, 2013

Revised 11 January, 2014

Accepted 18 February, 2014

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© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins