LETTERS FROM READERS
Echocardiography, subclinical cardiac damage and indexing method

Ecocardiografía, daño cardíaco subclínico y método de indexación

  • FRANK ALEXANDER BUSTAMANTE MAYURI, 1  ORCID logo 
  • 1  Medicine student at Universidad Privada San Juan Bautista, Ica, Perú , Ica, Peru

Rev Argent Cardiol 2025;93:314-315. https://doi.org/10.7775/rac.v93.i4.20919

Correspondence: Frank A. Bustamante Mayuri. E-mail: frank.bustamante@upsjb.edu.pe


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I read with great interest the article published by Travetto and Argento entitled Detection of subclinical cardiac damage by echocardiography in a hypertensive population with a high prevalence of obesity: discrepancies observed according to the indexing method used, (1) which highlights the clinical relevance of using height-based allometric indices to detect target organ damage in hypertensive patients who are overweight or obese. The purpose of this letter is to point out certain limitations identified in the study, which could help improve future research of this kind.

The study's findings, which show a significant underestimation of left ventricular hypertrophy (LVH) and left atrial enlargement (LAE) when using body surface area-based indexing (BSAI), are particularly relevant in the context of a population where obesity is highly prevalent. The fact that up to 38% of patients were reclassified when using allometric height-based indexing (AHI) highlights the potential clinical impact of this methodological choice on cardiovascular risk assessment. However, despite the results obtained, the study has some important limitations.

As this is a single-center, cross-sectional study without long-term follow-up, it is not possible to establish causal relationships or evaluate the prognostic value of the different indexing methods. This contrasts with studies such as that by Chirinos et al., (2) where AHI not only improved LVH detection but also showed a greater predictive value for cardiovascular events over time. Similarly, De Simone et al. (3) identified that left ventricular mass indexed to height2.7 was associated with a higher population-attributable risk of events in the Strong Heart Study, which included a long-term follow-up.

Furthermore, the results were not validated in other populations or in different clinical contexts. This issue has been addressed by Liao et al., (4) who, in a large, diverse cohort, concluded that AHI offered greater diagnostic accuracy, particularly in overweight or obese women. Kuznetsova et al. (5), meanwhile,

analyzed the discrepancies between BSAI and AHI according to the degree of obesity in a multinational cohort, and found results similar to those reported by Travetto et al., but with broader validation.

For all these reasons, I believe that future research should apply multicenter and longitudinal designs with external validation, evaluate the reproducibility of measurements, and incorporate technologies that allow for the automatic calculation of allometric formulas in echocardiographic equipments.

I congratulate the authors for rising awareness of this issue and agree that it is urgent to incorporate AHI as standard clinical practice in hypertensive patients who are overweight or obese.

Sincerely,

Ethical considerations

Not applicable.

Conflicts of interest

None declared.

(See authors' conflict of interests forms on the web).

 
 
 

REFERENCES

1. Travetto CM, Argento L V. Detection of subclinical cardiac target organ damage by echocardiography in a population of hypertensive patients with a high prevalence of obesity: discrepancies observed depending on the indexing method used. Rev Argent Cardiol 2025;93:6-14. https://doi.org/10.7775/rac.v93.i1.20850
2. Chirinos JA, Segers P, De Buyzere ML, Kronmal RA, Raja MW, De Bacquer D, et al. Left ventricular mass: Allometric scaling, normative values, effect of obesity, and prognostic performance. Hypertension. 2010;56:91-8. https://doi.org/10.1161/HYPERTENSIONAHA.110.150250
3. de Simone G, Daniels SR, Devereux RB, Meyer RA, Roman MJ, de Divitiis O, et al. Left ventricular mass and body size in normotensive children and adults: Assessment of allometric relations and impact of overweight. J Am Coll Cardiol 1992;20:1251-60. https://doi.org/10.1016/0735-1097(92)90385-Z
4. Liao Y, Cooper RS, Mcgee DL, Mensah GA, Ghali JK. The Relative Effects of Left Ventricular Hypertrophy, Coronary Artery Disease, and Ventricular Dysfunction on Survival Among Black Adults. JAMA: The Journal of the American Medical Association. 1995;273:1592-7. https://doi.org/10.1001/jama.1995.03520440046035
5. KKuznetsova T, Haddad F, Tikhonoff V, Kloch-Badelek M, Ryabikov A, > Knez J, et al. Impact and pitfalls of scaling of left ventric> ular and atrial structure in population-based studies. J Hypertens > 2016;34:1186-94. https://doi.org/10.1097/HJH.0000000000000922

 
 

AUTHORS’ REPLY

 

We thank the reader for his interest in our study and acknowledge that it has certain limitations that should be considered when interpreting the results. However, we believe that the reported findings have fulfilled the

objectives for which the study was proposed, raising awareness of this problem, which is of increasing interest and importance in clinical practice, not only in the field of Cardiology but also in other specialties, in which indexing structures to body surface area is not appropriate for addressing the phenomenon under study in overweight and obese subjects.

Sincerely,

,
Carolina Travetto, Laura Argento MTSAC
 
 

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