We read with interest the commendable work by Roberts et al published in the September 2015 issue of the AJC . In their study cohort, the investigators used 12-lead ECG in patients with syphilitic aortic aneurysms to measure the presence of left ventricular (LV) hypertrophy. The study findings illustrate that syphilis does not directly affect the heart/myocardium and is primarily a disease of the thoracic aorta and its branches, using a diagnostic cut-point of total 12-lead QRS voltage >175 mm for diagnosing LV hypertrophy. In the light of these findings, we found the suggestion very compelling that the literary community should move away from the term “cardiovascular syphilis” and move toward the suggested nomenclature like “syphilitic aortitis” or “vascular syphilis.”

The 12-lead QRS voltage criteria for diagnosing LV hypertrophy were first proposed by Roberts and his research group and have been subsequently validated in several other studies. Although not perfect, this remains a quite reliable method for predicting LV hypertrophy. More recently, Angeli et al reported a further enhanced sensitivity of total 12-lead QRS voltage when used along with body mass index for predicting LV hypertrophy in patients with systemic hypertension. Furthermore, this approach has been found superior to the most other traditional diagnostic criteria for LV hypertrophy including Romhilt-Estes point score, Sokolow-Lyon, Cornell voltages, and Perugia score. While measuring the total QRS voltage, the output of the limb lead electrodes (bipolar plus unipolar leads) is repeated because leads I, II, III, and R, L, F essentially use the same 3 electrodes thus leading to some redundancy in this measurement. In one of the previous works conducted by the senior author of this letter, the total QRS voltage minus the R, L, and F voltage with a cut-off value of 110 mm offered a better sensitivity (73%) and specificity (72%) in predicting LV hypertrophy compared with total QRS voltage criteria.

We wonder if the use of 9-lead QRS voltage (precordial leads and I, II, III) instead of 12-lead QRS voltage may even be superior in terms of diagnostic accuracy for LV hypertrophy even in patients with syphilitic aortitis. Thus, there may be perhaps a potential avenue for a sub-study using the patient data presented in the present study by Roberts et al that may consequently further enhance the value of these study findings.