ECG Criteria for Left Ventricular Hypertrophy in Hypertensive Black Africans: Insights from the coArtHA Trial

Background: Electrocardiographic (ECG) criteria for detecting left ventricular hypertrophy (LVH) have largely been derived from non-African populations. Their diagnostic performance in Black African adults with untreated hypertension remains uncertain.

Objective: To evaluate the diagnostic performance of established ECG-LVH criteria compared with echocardiographically assessed left ventricular mass index (LVMI) in Black African adults with untreated, uncomplicated hypertension enrolled in the coArtHA trial.

Methods: In this subanalysis, we included 1,125 participants from rural Tanzania and Lesotho who underwent baseline 12-lead ECG and focused transthoracic echocardiography (fTTE). LVH was defined as LVMI > 95 g/m² in women, and >115 g/m² in men. Diagnostic performance of multiple ECG-LVH criteria was assessed using correlation analyses, sensitivity and specificity estimates, receiver-operating characteristic (ROC) analysis, including calculation of the area under the ROC curve (AUROC), and precision-recall curves (PRC).

Results: Echocardiographic LVH was present in 56 (5%) participants. Across continuous ECG indices, Cornell voltage product adjusted by +0.8 mV in women showed the strongest association with LVMI (Spearman’s rho = 0.37, p < 0.001). Among evaluated criteria, Cornell voltage product-based measures demonstrated the most consistent diagnostic performance across evaluated metrics, with an AUROC of approximately 0.76. Using established cut-off values, this criterion yielded a sensitivity of 64% and a specificity of 80%, whereas voltage-only criteria, including Multi-Ethnic Study of Atherosclerosis (MESA)- and Sokolow–Lyon-based indices, showed limited accuracy in this setting. Exploratory analyses of alternative cut-off values demonstrated the expected sensitivity–specificity trade-offs.

Conclusions: In this cohort of hypertensive Black African adults, ECG criteria showed a moderate association with LVMI by echocardiography. Among established ECG criteria, Cornell voltage product-based measures demonstrated the most consistent diagnostic performance. Diagnostic characteristics were strongly influenced by cut-off selection and clinical context, underscoring the need for population-specific evaluation and external validation of ECG criteria for LVH in African settings.

Trial registration: Clinicaltrials.gov NCT04129840. Registered on October 17, 2019 (https://www.clinicaltrials.gov/).