Rafla et al.
, Int J Cardiovasc Res 2018, 7:6
DOI: 10.4172324-8602.1000396
Research Article
Validation of Cornell Product as a
Method of Assessing Left
Ventricular Hypertrophy
Samir Rafla1, Tarek Elzawawy1, Omar Ismail Elbahy2, Amr Kamal
Mohamed1 and Ali Elshourbagy2
1Cardiology and angiology Department, Faculty of Medicine, Alexandria
University, Egypt
2Cardiology unit, medical research institute Alexandria University, Egypt
*Corresponding author: Samir Rafla, Cardiology and angiology Department,
Faculty of Medicine, Alexandria University, Egypt, E-mail: smrafla@yahoo.com
Received: 12 November 2018 Processed Date: 22 November 2018 Published:
29 November 2018
Abstract
Background: LV diastolic dysfunction (DD) and diastolic HF is
a major and widely spreaded health proplem and it’s
associated with higher cardiovascular morbidity and all-cause
mortality, ECG –LVH is studied as an early predictor of LV
diastolic dysfunction.
Methods: diastolic dysfunction is evaluated in 100 patients
with Cornell product (CP) criteria >2440 mm.ms with complete
evaluation of diastolic function via mitral inflow velocities (mitral
E velocity, A velocity and E/A ratio ), tissue Doppler
imaging(septal and lateral annular velocity, E/E’ ratio),
deceleration time, isovolumic relaxation time, left atrial
Enlargement, left ventricular mass index.
Results: Among the 100 patients (59% female and 41%
males ), 14% presented with normal diastolic function, while
86% had diastolic dysfunction with different grades, with
increasing values of CP with more progression of the diastolic
dysfunction severity, in concern to the echocardiographic
parameters there were progressively higher values of LVEDD,
PWD, IVSD, LVMI, E/A ratio, E/E’ ratio and LAVI with
advancement of diastolic dysfunction ; while there were inverse
relation between the diastolic dysfunction severity and (E-
velocity, a-velocity, lateral E’ velocity and DT).
The IVRT shows higher values with mild degree of diastolic
dysfunction then with progression of diastolic dysfunction there
were progressive reduction in IVRT values, while there were no
significant difference in concern of LVESD and septal E’
velocity between normal population and different grades of
diastolic dysfunction.
Conclusions: CP LVH is a strong predictor of presence of
Diastolic dysfunction and with higher degrees of diastolic
dysfunction; the CP LVH was higher indicating good predictor
for the severity of diastolic dysfunction.
Keywords: Cornell product; left Ventricular hypertrophy;
Diastolic dysfunction; Heart failure; Echocardiography
Abbreviations: DD: Diastolic Dysfunction; LVEF: Left
Ventricular Ejection Fraction; DHF: Diastolic Heart Failure; LAV:
left Atrial Volume; LVH: Left Ventricular Hypertrophy; HFPEF:
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International Journal of
Cardiovascular Research
A SCITECHNOL JOURNAL
Heart Failure with Preserved Ejection Fraction; TTE:
Transthoracic Echo; CP: Cornell Product; CV: Cornell Voltage;
LAVI: Left Atrial Volume Index
Introduction
Diastolic dysfunction and consequently diastolic heart failure is a
major public health problem, it accounts for more than 1 million
hospitalizations per year in the United States [1-3]. Epidemiologic data
obtained within the past 20 years, since the concept of heart failure
with normal LVEF was introduced, show that its prevalence is
30%-74% (median 45%) [4-6]. Population-based studies showed that
at least 40%-50% of all patients with heart failure have a normal or
near normal LVEF and that DHF is most common among patients
older than 75 years. Identifying patients with asymptomatic diastolic
dysfunction may allow the implementation of non-pharmacological or
pharmacological interventions aiming at reversing heart functional
and structural abnormalities, thus delaying the onset of symptomatic
HF.
The onset of HFpEF is preceded by diastolic abnormalities such as
slowing in relaxation and alterations in the filling pressures and
structure of the left ventricle (LV)-left ventricular hypertrophy (LVH),
and increased left atrial volume (LAV). Thus, it is important to detect
these abnormalities in a preclinical phase [7]. Hypertension is major
risks for HF development [8,9]..Mechanisms by which LVH can
negatively influence diastolic function and contribute to development
of HFpEF are thought to include abnormal LV relaxation and passive
stiffness associated with increased LV mass [10-12]. Increased ECG
LVH by Cornell product is an independent predictor of diastolic
dysfunction [13] and an effective predictor of increased LV mass
[14-17]. Therefore, the aim of this study was to correlates the
persistence of Cornell product ECG LVH at with echocardiographic
LV diastolic function to show the availability of using Cornell product
as a powerful indictor for diastolic dysfunction.
Methods
Study population
One hundred patients who underwent ECG for different causes at
Alexandria main university Hospital- were selected according to the
presence of ECG-LVH Cornell product with a cut-of value for the
Cornell product equal 2440 mm.ms or more. Transthoracic
echocardiography (TTE) was done for all patients and they undergone
evaluation of diastolic function. Subjects were excluded if they met any
of the following criteria: LV ejection fraction <40%; age less than 18
year; having ECG criteria that does not meet the Cornell product;
hypertrophic cardiomyopathy; pericardial constriction; congenital
heart diseases; acute pulmonary embolism, right or left bundle branch
block; atrial or ventricular arrhythmia .
Electrocardiography
Standard 12-lead ECGs were recorded by skilled ECG technicians at
25 mm/s and 1 mV/cm according to standard American Heart
Association recommendations [18]. Patient's results were interpreted
blindly from TTE results. All subjects whose ECG demonstrated sinus
Citation: Rafla S, Elzawawy T, Elbahy OI, Mohamed AK, Elshourbagy A (2018) Validation of Cornell Product as a Method of Assessing Left Ventricular
Hypertrophy. Int J Cardiovasc Res 7:6.

doi: 10.4172324-8602.1000396

rhythm and meeting the Cornell product-LVH with a cut-of value higher with advancement of DD; mean QRS was 96 ± 12.6ms, 100 ±
2440 mm.ms were included in the study. If more than one ECG was 12.6ms, 100 ± 0.0ms for grade I, II and III respectively.
available, the ECG closest in time to TTE was selected for analysis.
ECG measurements included QRS duration, heart rate, Cornell voltage Without With DD
ECG data Mean ± SD. DD (n=86) tp
criteria and Cornell product. (n=14)
LVH was calculated using sex-specific Cornell product (CP) criteria:
82.50 ±
[sum of the R wave in aVL plus the S wave in V3, plus 8 mm in HR
12.14
81.45 ± 14.56 0.800
women] × QRS duration; as well as Cornell Voltage (CV) criteria: sum
of the R wave in aVL plus the S wave in V3 [19,20]. All ECG variables QRS width
88.57 ±
98.14 ± 11.73 0.001
10.27
were recorded by a physician independent of ECG or TTE
interpretation. 26.86 ±
CV 26.85 ± 4.31 0.995
4.20
Echocardiography CP 2650 ± 198 2953 ± 492 <0.001
Confirmation of LVH in all patients included in the study was done
DD: Diastolic Dysfunction; HR: Heart Rate; CV: Cornell Voltage; CP: Cornell
via Echocardiography by calculation of left ventricular mass index. All Product
subjects underwent Full echocardiographic study and assessment of
P: P value for student t-test comparing between the two studied groups
diastolic dysfunction was done using several echocardiography
Statistically significant at p ≤ 0.05
parameters; mitral inflow velocities (mitral E velocity, A velocity and
E/A ratio), tissue Doppler imaging (septal and lateral annular velocity,
E/E’ ratio), deceleration time, is volumetric relaxation time, left atrial Table 1: Comparison between the two groups according to ECG data
Enlargement according to standard guidelines [21-23]. Using (n=100).
standardized principles, each subject’s diastolic function was graded as
normal, abnormal relaxation (Stage I), pseudo normal (Stage II), and Compared with patients without DD, whose mean CP was 2650 ±
restrictive (Stage III) [21-23]. 198 mm.ms and mean QRS was 88 ± 10.2ms. While there was no
significant difference between both groups concerning Cornell voltage
criteria and heart rate. Table 1-4
Statistical Analyses
According to echocardiographic findings patients with DD had
All statistical analyses were performed using SPSS, version 19.0
more abnormal IVSD, PW, LAVI, lateral Eʹ, E/Eʹ; they also had higher
(SPSS Inc., Chicago, IL, USA) with a 2-tailed P<0.05 considered
indexed LV mass. There was no difference in LV ejection fraction or
statistically significant. Data are presented as mean ± SD for
LV internal diastolic and systolic dimension between groups, E-
continuous variables and as percentages for categorical variables. Chi-
velocity , A-velocity , E/A ratio, septal e’ velocity , DT and IVRT . With
square tests and independent t-tests were used for comparison of
detailed comparison of different grades of DD there were significant
categorical and continuous variables, respectively.
difference between the different groups concerning all
Echocardiographic parameters except LV internal systolic dimension
Results and septal E’ velocity .Table 3-4

Study group Discussion

One hundred patients selected according to their Cornell product
values, of which 86 (86%) had DD diagnosed by TTE. Characteristics
of all subjects and the comparison between those with and without DD
revealed no statistical difference between the two groups as regards
sex, age, weight, height, BMI, and BSA.
There was no significant between subjects without DD and those
with DD according to demographic data but patients with DD had
higher prevalence of hypertension compared to those with normal
diastolic function, while there was no difference between both groups
according to the other predisposing factor of diastolic dysfunction as
smoking, diabetes, ischemic heart disease and valvular heart disease.
ECG data for patients with diastolic dysfunction and with normal
diastolic function are in table, those with diastolic dysfunction had a
higher values for Cornell product mean CP was 2953 ± 492 mm·ms for
the whole group and with detailed analysis of different grades of DD
the mean CP was higher with advancement of DD; mean CP was, 2833
± 459 mm.ms, 3080 ± 485 mm.ms, 3550 ± 636 mm.ms for grade I, II
and III respectively.
While the mean QRS duration was 98 ± 11.7 for the whole group
and with detailed analysis of different grades of DD the mean QRS was
CP LVH and DD
The study showed that ECG LVH by CP is strongly associated with
the presence of echocardiographic DD in patients with a preserved
ejection fraction. The other significant ECG parameter of DD was QRS
duration. These findings suggest that increased CP LVH can identify
patients in need of further cardiovascular evaluation of possible
underlying DD.
This goes with the result of a recent cohort study to show whether
ECG CP- LVH is associated with LV diastolic dysfunction (DD) of
patients who underwent both cardiac computed topographic
angiography and transthoracic echocardiography (TTE) with complete
evaluation of diastolic function, The presence of DD was determined
via evaluation of mitral inflow velocities, tissue Doppler imaging,
deceleration time, is volumetric relaxation time, pulmonary venous
systolic: diastolic ratio, and left atrial enlargement.
The study concluded that Cornell product ECG LVH is a powerful
predictor of the presence of diastolic dysfunction [24]. Also, Krepp et
al [25]. In his a cross-sectional analysis of patients who underwent
ECG, echocardiography and coronary CT angiography found a strong

Volume 7 • Issue 6 • 1000396 • Page 2 of 5 •

Citation: Rafla S, Elzawawy T, Elbahy OI, Mohamed AK, Elshourbagy A (2018) Validation of Cornell Product as a Method of Assessing Left Ventricular
Hypertrophy. Int J Cardiovasc Res 7:6.

doi: 10.4172324-8602.1000396

association between Cornell product LVH and diastolic dysfunction from LIFE have demonstrated that incident HF is significantly related
after adjustment for potential risk factors when Cornell product LVH to changing levels of both ECG LVH and echocardiographic LVH
exceeded the 75th percentile value of 1595mm_ms Previous studies [25,26].

Grade of D.D Fp
ECG data Mean ± SD
None I II III
(n=14) (n=48) (n=36) (n=2)

HR 82 ± 12.1 83 ± 14.9 79 ± 13.9 77 ± 17.6 0.580

QRS width 87 ± 9.9 96 ± 12.6 100 ± 12.6 100 ± 0.0 <0.004

CV 26.8 ± 4.2 26.8 ± 4.6 26.5 ± 3.8 31.5 ± 0.7 0.480

CP 2608 ± 202 2833 ± 459 3080 ± 485 3550 ± 636 <0.001

P: p value for F-ANOVA test comparing between the studied groups

Statistically significant at p ≤ 0.05

Table 2: Relation between grade of D.D and ECG data (n=100).

And In an analysis of the large subset of the overall LIFE study
population without a history of previous HF [25]. Greater regression of
Cornell product LVH was strongly associated with a reduced incidence
of HF hospitalizations, independent of other potential HF risk factors.
Further examination of the subset of the LIFE study population that
also underwent echocardiography demonstrated that both ECG and
echocardiographic LVH independently contributed to the increased
risk of developing new HF. These findings suggested that the
relationship between changing levels of ECG LVH and HF risk might
be mediated at least in part by differences in LV systolic and/or
diastolic function [26].
This goes with what Kim SJ. et al [27] in a prospective observational
study to compare the prognostic significance of commonly used ECG
criteria for LVH (Sokolow-Lyon voltage (SV) or voltage-duration
product (SP) and Cornell voltage (CV) or voltage-duration product
(CP) criteria, and to investigate the association between
echocardiographic LV mass index (LVMI) and ECG-LVH criteria in
ESRD patients, who consecutively started maintenance hemodialysis,
Found that The product of QRS voltage and duration is helpful in
identifying the presence of LVH and predicting cardiovascular
mortality in incident HD patients [27].
Joji Ishikawa et al. studied levels of Cornell Voltage and Cornell
Product for predicting cardiovascular and stroke mortality and
morbidity. They concluded that Cardiovascular and stroke risks may
be elevated at lower levels of CV and CP in Japanese subjects,
especially females [28].
Study limitation
The study revealed the relationship between CP LVH and presence
of mild and moderate degrees of diastolic dysfunction but may not be
applicable to patients with severe diastolic dysfunction because of the
small number of population in the group with restrictive filling pattern
which can be targeted later on in different studies.
We did not calculate other methods of assessing LVH as Sokolow-
Lyon index or Romhilt-Estes point score system.

Echo parameters Without DD With DD

(n=14) (n=86) tp
Mean ± SD.

LVEDD 47 ± 6.7 45.8 ± 4.74 0.522

LVESD 29.8 ± 3.7 29.8 ± 3.8 0.990

LVMI 94 ± 14 117 ± 17 <0.001

EF 64.7 ± 5.8 62.5 ± 7.9 0.318

LVSD 11.7 ± 2.57 13.7 ± 1.36 0.014

PW 11.2 ± 2.4 13.2 ± 1.2 0.010

E-VEL 75.6 ± 15.7 70.2 ± 21.3 0.3

A-VEL 74.3 ± 15.6 82.4 ± 25.2 0.2

P: p value for student t-test comparing between the two studied groups

Volume 7 • Issue 6 • 1000396 • Page 3 of 5 •

Citation: Rafla S, Elzawawy T, Elbahy OI, Mohamed AK, Elshourbagy A (2018) Validation of Cornell Product as a Method of Assessing Left Ventricular
Hypertrophy. Int J Cardiovasc Res 7:6.

doi: 10.4172324-8602.1000396

Statistically significant at p ≤ 0.05. LVSD=LV septal diameter

Table 3: Comparison between the two groups according to Echo parameters.

Grade of D.D Fp
Echo parameters Mean ± SD
None I II III
(n=14) (n=48) (n=36) (n=2)

LVEDD 47 ± 6.7 44 ± 4.54 47 ± 4.59 51 ± 1.98 0.034

LVESD 29.8 ± 3.7 29.7 ± 4.3 30 ± 3.16 28.5 ± 2.1 0.949

LVMI 94 ± 14 110± 11.85 123± 17.22 164 ± 4.95 <0.001

EF 64.7 ± 5.8 60.7 ± 8.7 64± 6 72 ± 4 0.031

IVSD 11.7 ± 2.57 13.7 ± 1.13 13.6 ± 1.61 15 ± 1.41 <0.001

PW 11 ± 2.4 13 ± 1.21 13 ± 1.22 14 ± 0.71 <0.001

E–VEL 75.6 ± 15.7 61.8 ± 17.8 80.8 ± 21.5 80 ± 7 <0.001

A–VEL 74 ± 15.6 86 ± 21 79 ± 28.4 38 ± 3.5 <0.02

E/A 1.08 ± 0.36 0.72 ± 0.13 1.06 ± 0.36 2 ± 0.01 <0.001

Septal E'–V 8.7 ± 1.57 6.9 ± 8.80 5.4 ± 1.14 5.4 ± 0.07 0.386

Lateral E'–V 12.3 ± 2.50 7.5 ± 1.52 7.4 ± 1.54 6.0 ± 0.21 <0.001

E/E' 7.7 ± 0.78 9.7 ± 3.42 12.7 ± 3.04 14.5 ± 0.71 <0.001

LAVI 21.8 ± 6.27 24.2 ± 8.64 35.6 ± 13.2 48 ± 14.14 <0.001

DT 244 ± 35.57 253 ± 39.37 182 ± 21.23 136 ± 30.41 <0.001

IVRT 116 ± 35.76 129 ± 28.96 103 ± 23.21 48 ± 5.66 <0.001

P: p value for F-ANOVA test comparing between the studied groups

Statistically significant at p ≤ 0.05

Table 4: Comparison between the populations in different grades of DD according to Echo parameters

Conclusion guidelines for the evaluation and management of heart failure) :

Our study shows that increased value of Cornell product LVH
voltage criteria is strongly correlated to diastolic dysfunction and the
Cornell product LVH is better and more significant predictor for
diastolic dysfunction than Cornell voltage criteria of LVH, The study
also showed that the QRS duration is also highly correlated to diastolic
dysfunction and may be the cause for significance of the Cornell
product LVH criteria over the Cornell voltage criteria as a predictor of
diastolic dysfunction.
We found also that of the echocardiographic parameters of diastolic
dysfunction the E/A ratio, deceleration time and left atrial volume
index were significant parameters of abnormal diastolic function.
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Hypertrophy. Int J Cardiovasc Res 7:6.
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