Correlations Between Novel Adiposity Indices and Electrocardiographic Evidence of Left Ventricular Hypertrophy in Individuals with Arterial Hypertension

Academic Edi o : And eas
P. Kaloge opoulos
Recei ed: 3 Ap il 2025
Re ised: 16 May 2025
Accep ed: 26 May 2025
Published: 2 June 2025
Ci a ion: Ge aci, G.; Fe a a, P.;
Pallo i, F.; Le Moli, R.; Calab ese, V.;
Pa e nò, V.; Zanoli, L.; Giammanco, A.;
Bella ia, A.; Na o, L.; e al.
Co ela ions Be ween No el Adiposi y
Indices and Elec oca diog aphic
E idence o Le Ven icula
Hype ophy in Indi iduals wi h
A e ial Hype ension. J. Pe s. Med.
2025,15, 229. h ps://doi.o g/
10.3390/jpm15060229
Copy igh : © 2025 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license
(h ps://c ea i ecommons.o g/
licenses/by/4.0/).
A icle
Co ela ions Be ween No el Adiposi y Indices and
Elec oca diog aphic E idence o Le Ven icula Hype ophy
in Indi iduals wi h A e ial Hype ension
Giulio Ge aci 1,2,† , Pie o Fe a a 3,4,† , F ancesco Pallo i 1,2,* , Rosa io Le Moli 1, Vincenzo Calab ese 1,
Valen ina Pa e nò2, Luca Zanoli 5, An onina Giammanco 6, Alessand a Bella ia 6, Liliana Na o 7,
Alessand a So ce 8, Luigi La Via 9, Jacob Geo ge 10 , Ricca do Polosa 1,5,11 , Giuseppe Mulè8,12
and Ca e ina Ca ollo 8,12
1Depa men o Medicine and Su ge y, “Ko e” Uni e si y o Enna, 94100 Enna, I aly;
[email p o ec ed] (G.G.); osa io.lemoli@uniko e.i (R.L.M.); incenzo.calab ese@uniko e.i (V.C.);
[email p o ec ed] (R.P.)
2UOC In e nal Medicine, Hospi al Umbe o I, ASP Enna, 94100 Enna, I aly
3Cen e o Public Heal h Resea ch, Uni e si y o Milan–Bicocca, 20900 Monza, I aly
4Labo a o y o Public Heal h, IRCCS Is i u o Auxologico I aliano, 20149 Milan, I aly
5Depa men o Clinical and Expe imen al Medicine, Uni e si y o Ca ania, 95131 Ca ania, I aly;
[email p o ec ed]
6Uni o In e nal Medicine, Depa men o Heal h P omo ion, Mo he and Child Ca e, In e nal Medicine and
Medical Special ies, Uni e si y o Pale mo, 90133 Pale mo, I aly; [email p o ec ed] (A.G.);
[email p o ec ed] (A.B.)
7
UOC In e nal Medicine, Hospi al “S. Elias”, ASP Cal anisse a, 93100 Cal anisse a, I aly; [email p o ec ed]
8Uni o Neph ology, Depa men o Heal h P omo ion, Mo he and Child Ca e, In e nal Medicine and
Medical Special ies, Uni e si y o Pale mo, 90133 Pale mo, I aly; alessand a.so ce@communi y.unipa.i (A.S.);
[email p o ec ed] (G.M.); [email p o ec ed] (C.C.)
9Depa men o Anes hesia and In ensi e Ca e 1, Uni e si y Hospi al Policlinico “G. Rodolico-San Ma co”,
95131 Ca ania, I aly; [email p o ec ed]
10
School o Medicine, Uni e si y o Dundee, Ninewells Hospi al, Dundee DD1 9SY, UK; [email p o ec ed]
11 Cen e o Excellence o he Accele a ion o HA m Reduc ion (CoEHAR), Uni e si y o Ca ania,
95131 Ca ania, I aly
12 Eu opean Socie y o Hype ension Excellence Cen e , Chai o Neph ology, Uni e si y o Pale mo,
90133 Pale mo, I aly
*Co espondence: ancesco.pallo i@uniko e.i
†These au ho s con ibu ed equally o his wo k.
Abs ac : Backg ound/Objec i es: Obesi y is a key d i e o ca dio ascula disease (CVD),
wi h cen al adiposi y di ec ly in ol ed in ad e se ca diac emodeling. Body mass index
(BMI) is limi ed in cap u ing a dis ibu ion and associa ed ca dio ascula isk. No el
an h opome ic indices, including A Body Shape Index (ABSI) and Body Roundness Index
(BRI), may o e g ea e clinical alue, bu hei ela ionship wi h elec oca diog aphic
ma ke s o le en icula hype ophy (LVH) emains unde explo ed. This s udy aims o
assess he co ela ion be ween no el adiposi y indices (ABSI and BRI) and elec oca dio-
g aphic e idence o LVH, as measu ed by he Sokolow-Lyon Index (SLI), in indi iduals
wi h a e ial hype ension. Me hods: 274 hype ensi e pa ien s we e ec ui ed, and BMI,
ABSI, and BRI we e calcula ed. LVH was assessed ia SLI on 12-lead ECG. Pa icipan s
we e s a i ied by he SLI (
≤
35 mm s. >35 mm) o s a is ical analyses. Resul s: Pa ien s
wi h a lowe SLI showed signi ican ly highe alues o ABSI and BRI compa ed o hose
in highe SLI g oup, wi hou di e ences in BMI. In he en i e popula ion, SLI was signi i-
can ly and in e sely co ela ed wi h bo h ABSI ( =
−
0.296, p< 0.001) and BRI ( =
−
0.238,
p< 0.01), bu no wi h BMI. Mul i a ia e eg ession analysis con i med ABSI (p= 0.013) and
BRI (p= 0.038) as independen p edic o s o SLI, e en a e adjus ing o age, blood p essu e,
enal unc ion, and me abolic pa ame e s. Conclusions: ABSI and BRI a e in e sely and in-
dependen ly associa ed wi h ECG-de i ed SLI in hype ensi e indi iduals, sugges ing ha
J. Pe s. Med. 2025,15, 229 h ps://doi.o g/10.3390/jpm15060229
J. Pe s. Med. 2025,15, 229 2 o 11
cen al adiposi y may a enua e ECG ol ages and obscu e LVH de ec ion. Inco po a ing
no el adiposi y indices in o ECG in e p e a ion may enhance diagnos ic accu acy and isk
s a i ica ion in obese and hype ensi e popula ions. Longi udinal s udies a e needed o
alida e hese indings and e ine clinical algo i hms.
Keywo ds: hype ension; obesi y; ca dio ascula isk; Sokolow-Lyon index; le en icula
hype ophy; a body shape index; body oundness index; elec oca diog aphy
1. In oduc ion
Obesi y is a ch onic, mul i ac o ial disease ha has eached epidemic p opo ions
globally, posing a majo challenge o public heal h sys ems. Acco ding o he Wo ld Heal h
O ganiza ion (WHO), o e 2.5 billion adul s we e o e weigh and mo e han 890 million
obese in 2022. Obesi y is s ongly associa ed wi h inc eased ca dio ascula mo bidi y
and mo ali y, wi h cen al adiposi y in pa icula con ibu ing o ad e se s uc u al and
unc ional ca diac emodeling [1,2].
The pa hophysiology unde lying obesi y- ela ed como bidi ies is complex [
3
–
5
]. Ex-
cessi e sec e es bioac i e molecules—such as adipokines, cy okines, and ho mones— ha
dis up me abolic balance and ad e sely a ec ca dio ascula and enal unc ion. Cen al
o isce al obesi y, cha ac e ized by excessi e a deposi ion in he abdominal egion, is
associa ed wi h me abolic synd ome and ype 2 diabe es, bo h o which inc ease ca dio as-
cula isk [
6
]. The ele a ed elease o ee a y acids om isce al adipose issue p omo es
lipo oxici y, which impai s myoca dial unc ion and exace ba ing hea ailu e. Hepa ic
s ea osis, also common in obesi y, con ibu es o dyslipidemia and sys emic in lamma ion,
u he agg a a ing ca dio ascula ou comes [7].
Hype ension, a majo de e minan o ca dio ascula mo bidi y in obesi y, a ises
om in e ela ed mechanisms. Excessi e adiposi y ac i a es he sympa he ic ne ous
sys em ac i a ion and dis up s he enin-angio ensin-aldos e one sys em (RAAS), caus-
ing asocons ic ion and sodium e en ion, which ele a e blood p essu e. Addi ionally,
mechanical comp ession o he kidneys by adipose issue esul s in pa enchymal damage,
impai ing sodium exc e ion, u he exace ba ing hype ension. Toge he , obesi y-induced
hype ension and endo helial dys unc ion accele a e a he oscle osis, inc easing he isk o
myoca dial in a c ion, s oke, and pe iphe al a e y disease [5,8,9].
A c i ical mani es a ion o obesi y- ela ed ca dio ascula damage is le en icula
hype ophy (LVH), as a consequence o inc eased ca diac wo kload, ele a ed ci cula ing
blood olume, and neu oho monal ac i a ion ha lead o ca diac s uc u al emodeling.
LVH—which is also highly p e alen in hype ensi e indi iduals— ep esen s a key in e -
media e pheno ype o a ge o gan damage and is associa ed wi h poo ca dio ascula
ou comes. O e ime, hese changes p edispose indi iduals o hea ailu e, which is a
majo con ibu o o hea ailu e hospi aliza ions [10,11].
Elec oca diog aphy (ECG), despi e i s ela i ely low sensi i i y and lowe ca dio-
ascula p edic i e alue compa ed o echoca diog aphy o ca diac magne ic esonance,
emains a i s -line ool o diagnosing LVH in ou ine clinical se ings due o i s accessibili y
and cos -e ec i eness [
12
]. O e ime, se e al ECG-based c i e ia and sco es ha e been
de eloped and alida ed o LVH de ec ion. Among hem, he Sokolow-Lyon c i e ion,
in pa icula , is in luenced by adiposi y h ough a educ ion o elec oca diog aphic ol -
ages [
13
]. The low ECG sensi i i y in de ec ing LVH pe sis s e en a e ECG pa ame e s a e
co ec ed o he body mass index (BMI), ye his co ec ion does no subs an ially imp o e
he diagnos ic sensi i i y o speci ic ECG c i e ia o LVH.
J. Pe s. Med. 2025,15, 229 3 o 11
BMI, he mos commonly used measu e o obesi y, is limi ed in i s abili y o cap u e a
dis ibu ion and is only modes ly co ela ed wi h ca dio ascula isk and LVH. Mo eo e ,
ecen insigh s om he Lance Diabe es & Endoc inology Commission highligh ha
adi ional measu es like body mass index (BMI) may no adequa ely cap u e indi idual
heal h isks associa ed wi h obesi y, unde sco ing he impo ance o comp ehensi e as-
sessmen s beyond BMI o be e unde s and and add ess he mul i ace ed heal h impac s
o obesi y [
14
]. As such, eliance on BMI may obscu e he ela ionship be ween adipos-
i y and subclinical ca diac damage. To add ess hese limi a ions, no el an h opome ic
indices—such as A Body Shape Index (ABSI) and Body Roundness Index (BRI)—ha e
been p oposed. These indices inco po a e wais ci cum e ence and body shape, po en ially
p o iding a mo e accu a e ep esen a ion o cen al obesi y and i s ca dio ascula con-
sequences [
15
–
18
]. Despi e eme ging e idence suppo ing he u ili y o ABSI and BRI in
p edic ing ca dio ascula ou comes, hei ela ionship wi h elec oca diog aphic ma ke s
o LVH emains unde explo ed.
The e o e, he aim o ou s udy is o analyze he ela ionships be ween no el an h o-
pome ic adiposi y indices (ABSI and BRI) and le en icula hype ophy (LVH) assessed
by ECG using he Sokolow-Lyon index (SLI) in indi iduals wi h a e ial hype ension.
2. Ma e ials and Me hods
2.1. S udy Popula ion
This s udy included hype ensi e indi iduals consecu i ely ec ui ed om he Eu-
opean Cen e o Excellence o he Eu opean Socie y o Hype ension a he Uni e si y
o Pale mo, be ween 1 Feb ua y 2024 and 30 Sep embe 2024. Hype ension was de ined
based on a p io clinical diagnosis and/o cu en use o an ihype ensi e medica ion, in
line wi h he 2023 ESH Guidelines.
Pa ien s mee ing he ollowing c i e ia we e excluded om his esea ch:
−class III obesi y (BMI ≥40 kg/m2) o unde weigh (BMI < 20 kg/m2),
−seconda y hype ension ( eno ascula , endoc ine, o malignan ),
−end-s age enal disease equi ing enal eplacemen he apy,
−hea ailu e (NYHA class IV),
−his o y o p esence o pleu al/pe ica dial e usion,
−his o y o COPD, in e s i ial lung disease, hy oid diso de s, o s o age diseases,
−clinical signs o anasa ca o cachexia,
−majo non-ca dio ascula como bidi ies signi ican ly a ec ing heal h s a us.
Exclusions we e de e mined ia de ailed his o y, clinical documen a ion e iew, and
ou pa ien e alua ion. Seconda y o ms o hype ension we e excluded h ough Duplex-
Dopple enal ul asound, se um elec oly es, plasma enin ac i i y, and aldos e one concen-
a ion. The s udy was app o ed by he local e hics commi ee and conduc ed in acco dance
wi h he Decla a ion o Helsinki.
2.2. S udy Design
A comp ehensi e medical his o y, a e iew o clinical eco ds, and a physical exami-
na ion we e conduc ed o all pa icipan s. Cu en smoke s we e de ined as indi iduals
epo ing egula ciga e e use wi hin he pas yea . Blood p essu e was measu ed using a
alida ed oscillome ic de ice (Mic oli e Wa chBP O ice, Widnau, Swi ze land) [
19
], and
he inal BP alue was calcula ed as he mean o h ee consecu i e eadings ob ained du ing
a single o ice isi , ollowing 5 min o es , in acco dance wi h he 2023 ESH guidelines [
20
].
All pa ien s unde wen an h opome ic e alua ion o adiposi y indices and elec oca -
diog aphic e alua ion. Rou ine labo a o y es s included comple e blood coun , se um
c ea inine, as ing glucose, u ic acid le els, and lipid p o ile. Analyses we e pe o med
J. Pe s. Med. 2025,15, 229 4 o 11
using s anda dized me hods on an au oma ed analyse (Boeh inge Mannheim o he
Hi achi 911 sys em, Mannheim, Ge many) as desc ibed elsewhe e [
21
]. Se um u ic acid
was measu ed using he u icase/pe oxidase me hod. Low-densi y lipop o ein choles e ol
(LDL-C) was calcula ed using he F iedewald o mula. The es ima ed glome ula il a ion
a e (eGFR) was de i ed using he Ch onic Kidney Disease Epidemiology Collabo a ion
(CKD-EPI) equa ion [22].
2.3. An h opome ic Indices o Adiposi y
Body weigh , heigh , and wais ci cum e ence (WC) we e measu ed by a physi-
cian and used o calcula e he body su ace a ea (BSA), BMI, ABSI, and BRI using
s anda dized o mulas. BSA was calcula ed acco ding o he DuBois o mula, as
BSA = 0.007184
×
Weigh 0.425
×
Heigh 0.725 [
23
]. BMI was calcula ed as
BMI = Weigh /Heigh 2. ABSI, as p oposed by K akaue e al. [
24
], was compu ed as
ABSI = WC/(BMI 2/3
×
H 1/2), wi h WC in me e s. BRI was de i ed om WC and heigh
in me e s, beginning wi h he calcula ion o eccen ici y (
ε
), ep esen ing he deg ee o
ci cula i y o an ellipse ( om 0 o a pe ec ci cle o 1 o a e ical line), as p e iously de-
sc ibed by Thomas e al. [
25
]. Values close o 1 a e ypical o indi iduals wi h a longi udinal
body shape, whe eas highe alues indica e a mo e ounded body shape [25].
2.4. Sokolow Lyon Index (SLI)
S anda d 12-lead ECG was pe o med in all subjec s as pa o no mal clinical p ac ice,
acco ding o in e na ional guidelines ecommenda ions [
20
], and he Sokolow-Lyon index
was calcula ed as ECG sign o LVH. Among he elec oca diog aphic c i e ia used o
diagnosing LVH, he Sokolow-Lyon index was chosen since i is widely used due o
i s simplici y and ep oducibili y. B ie ly, i is calcula ed by summing he ampli ude o
he S wa e in lead V1 and he R wa e in lead V5 o V6 (whiche e is g ea e ). A cu -
o
alue > 35 mm
is conside ed indica i e o LVH. Al hough cha ac e ized by ela i ely
low sensi i i y, he index possesses high speci ici y, making i pa icula ly aluable in
epidemiological se ings and popula ion-based s udies.
2.5. S a is ical Analysis
Analysis was pe o med on he en i e s udy popula ion and subsequen ly s a i ied
in o wo g oups based on he SLI alue (SLI
≤
o >35 mm). Con inuous a iables we e
epo ed as mean
±
s anda d de ia ion (SD) o median and in e qua ile ange (IQR),
acco ding o hei dis ibu ion assessed using he Kolmogo o -Smi no es . The la e
we e also log- ans o med o pa ame ic analyses. Ca ego ical a iables we e p esen ed as
coun s and/o pe cen ages. Compa isons be ween g oups we e pe o med using S uden ’s
- es o con inuous a iables and Chi-squa e es (
χ2
) o ca ego ical a iables, applying
Ya es’ co ec ion o Fishe ’s exac when app op ia e. Fo compa isons in ol ing mo e
han wo g oups, one-way ANOVA wi h Holm-Sidak pos -hoc es was used o con inu-
ous a iables, and
χ2
es o ca ego ical a iables. Associa ions be ween a iables we e
assessed using simple linea eg ession and Pea son co ela ion coe icien s. These anal-
yses we e conduc ed in he o e all coho and wi hin SLI subg oups (
SLI ≤o >35 mm
).
Di e ences in Pea son co ela ion coe icien s be ween g oups we e es ed using Fishe ’s
- o-z ans o ma ion. Mul i a ia e linea eg ession was conduc ed using SLI as he de-
penden a iable. A backwa d s epwise app oach was used, including co a ia es ha
we e signi ican in uni a ia e analysis. Independen a iables included: age, sex, smoking
s a us, eGFR, sys olic (SBP) and dias olic blood p essu e (DBP), ABSI (o , al e na i ely, BRI),
BMI (o , al e na i ely, WC), as ing glucose, LDL-c, high-densi y lipop o ein choles e ol
(HDL-c). Resul s we e epo ed using bo h uns anda dized (B) and s anda dized eg ession
J. Pe s. Med. 2025,15, 229 5 o 11
coe icien s (
β
). A p- alue < 0.05 was conside ed s a is ically signi ican . Analyses we e
pe o med using SPSS so wa e, e sion 21.0 (IBM Co po a ion, New Yo k, NY, USA). code.
3. Resul s
A o al o 274 indi iduals wi h a e ial hype ension we e included in he inal anal-
ysis. Pa icipan s we e s a i ied in o wo g oups based on he median SLI alue: sub-
g oup I wi h SLI
≤
35 mm (n= 253) and subg oup II wi h SLI > 35 mm (n = 21). The
main demog aphic, an h opome ic, me abolic, and ECG cha ac e is ics o he o e all
s udy popula ion and he wo subg oups s a i ied by SLI a e p esen ed in Table 1. The
wo g oups o pa ien s did no di e signi ican ly in he use o ca dio ascula and an idia-
be ic d ugs (all p> 0.05). Simila ly, no di e ences in smoking habi , diabe es, o enal unc-
ion (assessed as
eGFR < 60 mL/min/1.73 m2
) we e obse ed be ween he wo g oups (all
p> 0.05).
Table 1. Demog aphic, an h opome ic, and me abolic cha ac e is ics o he o e all s udy popula ion
and o he g oups di ided by he median alue o he Sokolow-Lyon Index.
To al Coho
(n = 274)
SLI ≤35 mm
(n = 253)
SLI > 35 mm
(n = 21) p-Value
Age (yea s) 52 ±15 54 ±15 45 ±14 <0.001
Male gende , n (%) 154 (56.2) 137 (54.2) 17 (80.9) <0.001
Smoke, n (%) 94 (34.3) 89 (35.2) 5 (23.8) 0.685
Clinical pa ame e s
Diabe es, n (%) 72 (26.3) 68 (26.9) 4 (19) 0.485
eGFR < 60 mL/min/1.73 m2, n (%) 60 (21.9) 57 (22.5) 3 (14.3) 0.310
Sokolo -Lyon Index (mm) 22 ±7 21 ±5 38 ±4 <0.001
Clinic sys olic BP (mmHg) 135 ±17 134 ±16 139 ±20 0.214
Clinic dias olic BP (mmHg) 81 ±12 81 ±12 88 ±14 0.007
Clinic mean BP (mmHg) 99 ±13 99 ±12 105 ±15 0.030
Clinic pulse p essu e (mmHg) 53 ±13 53 ±13 51 ±12 0.453
Clinic hea a e (bea s) 75 ±8 75 ±8 74 ±7 0.650
Biochemical pa ame e s
Fas ing Glucose (mg/dL)
100.5
±30.4
103.7
±30.8 93.7 ±23.4 0.148
U ic Acid (mg/dL) 6.13 ±4.41 6.16 ±4.58 5.86 ±1.09 0.771
To al choles e ol (mg/dL) 189 ±41 189 ±41 196 ±48 0.432
LDL-c (mg/dL) 122 ±33 121 ±32 125 ±42 0.574
HDL-c (mg/dL) 49 ±12 49 ±12 57 ±17 0.003
T iglyce ides (mg/dL) 111 (81–149) 111 (82–152) 107 (68–133) 0.771
Se um C ea inine (mg/dL) 1.04 ±0.61 1.03 ±0.59 1.19 ±0.73 0.253
eGFR (mL/min/1.73 m2)83.7 ±26.7 82.8 ±25.7 94.9 ±35.4 0.046
An h opome ic pa ame e s
Weigh (Kg) 79.3 ±17.3 79.5 ±17.8 77.3 ±10.6 0.575
Heigh (cm) 166 ±10 166 ±10 168 ±9 0.335
BSA (m2)1.86 ±0.21 1.86 ±0.21 1.87 ±0.16 0.870
BMI (Kg/m2)28.7 ±5.6 28.9 ±5.8 27.4 ±2.6 0.240
WC (cm) 99 ±15 99 ±16 91 ±8 0.016
BRI 5.51 ±2.37 5.61 ±2.42 4.29 ±1.19 0.014
ABSI 0.81 ±0.05 0.81 ±0.05 0.78 ±0.03 0.008
BMI ≥30 kg/m2, n (%) 78 (28.5) 83 (32.8) 5 (24.0) 0.436
SLI: Sokolo -Lyon Index eGFR: es ima ed Glome ula Fil a ion Ra e; BP: Blood P essu e; LDL-c: Low Densi y
Lipop o ein Choles e ol; HDL-c: High Densi y Lipop o ein Choles e ol; BSA: Body Su ace A ea; BMI: Body Mass
Index; WC: wais ci cum e ence; BRI: Body Roundness Index; ABSI: A Body Shape Index.
As shown in Figu e 1, pa ien s wi h a lowe SLI had signi ican ly highe alues o
ABSI and BRI compa ed o hose in he highe SLI g oup, al hough he wo g oups o
pa ien s did no signi ican ly di e in BMI alues.

J. Pe s. Med. 2025,15, 229 6 o 11
J.Pe s.Med.2025,15,xFORPEERREVIEW5o 12


smokings a us,eGFR,sys olic(SBP)anddias olicbloodp essu e(DBP),ABSI(o ,
al e na i ely,BRI),BMI(o ,al e na i ely,WC), as ingglucose,LDL-c,high-densi y
lipop o eincholes e ol(HDL-c).Resul swe e epo edusingbo huns anda dized(B)and
s anda dized eg essioncoefficien s(β).Ap- alue<0.05wasconside eds a is ically
signi ican .Analyseswe epe o medusingSPSSso wa e, e sion21.0(IBM
Co po a ion,NewYo k,NY,USA).code.
3.Resul s
A o alo 274indi idualswi ha e ialhype ensionwe eincludedin he inal
analysis.Pa icipan swe es a i iedin o wog oupsbasedon hemedianSLI alue:
subg oupIwi hSLI≤35mm(n=253)andsubg oupIIwi hSLI>35mm(n=21).The
maindemog aphic,an h opome ic,me abolic,andECGcha ac e is icso  heo e all
s udypopula ionand he wosubg oupss a i iedbySLIa ep esen edinTable1.The
wog oupso pa ien sdidno diffe signi ican lyin heuseo ca dio ascula and
an idiabe icd ugs(allp>0.05).Simila ly,nodiffe encesinsmokinghabi ,diabe es,o 
enal unc ion(assessedaseGFR<60mL/min/1.73m
2
)we eobse edbe ween he wo
g oups(allp>0.05).
AsshowninFigu e1,pa ien swi halowe SLIhadsigni ican lyhighe  alueso 
ABSIandBRIcompa ed o hosein hehighe SLIg oup,al hough he wog oupso 
pa ien sdidno signi ican lydiffe inBMI alues.
Theuni a ia eco ela ionsbe weenSLI,an h opome icadiposi yindices,ando he 
clinical a iablesin heo e alls udypopula iona ep esen edinTable2.SLIwas
signi ican lyandin e selyco ela edwi hABSI( :−0.296;p<0.001),andsimila  esul s
we eob ainedwi hBRI( :−0.238;p<0.001).Incon as ,nos a is icallysigni ican 
co ela ionwasobse edbe weenSLIandBMI.Thediffe encein hes eng ho 
co ela ionbe weenSLIandABSI(o BRI) e susSLIandBMIwass a is icallysigni ican 
(p=0.05),asassessedusingFishe ’s - o-z ans o ma ion.
Whenwepe o med hemul i a ia elinea  eg essionanalysiswi has epwise
app oachbyconside ingSLIas hedependen  a iable,SLIwasindependen lyassocia ed
wi hABSI,e ena e adjus men  o allo he co a ia es,includingBMIo al e na i ely
CV(p=0.013).Asimila independen associa ionwasobse edwhenBRI eplacedABSI
in hemodel(p=0.038)(Table3).

Figu e1.Mean alueso ABSIandBRIin he wog oupso pa ien sdi idedbySLI(≤o >35mm).
Figu e 1. Mean alues o ABSI and BRI in he wo g oups o pa ien s di ided by SLI (
≤
o >35 mm).
The uni a ia e co ela ions be ween SLI, an h opome ic adiposi y indices, and o he
clinical a iables in he o e all s udy popula ion a e p esen ed in Table 2. SLI was signi i-
can ly and in e sely co ela ed wi h ABSI ( :
−
0.296; p< 0.001), and simila esul s we e
ob ained wi h BRI ( :
−
0.238; p< 0.001). In con as , no s a is ically signi ican co ela ion
was obse ed be ween SLI and BMI. The di e ence in he s eng h o co ela ion be ween
SLI and ABSI (o BRI) e sus SLI and BMI was s a is ically signi ican (p= 0.05), as assessed
using Fishe ’s - o-z ans o ma ion.
Table 2. Uni a ia e co ela ions be ween he Sokolow-Lyon Index, an h opome ic adiposi y indices,
and o he a iables in he o e all s udy popula ion.
SLI ABSI BRI BMI WC
Age (yea s) −0.308 *** 0.337 *** 0.139 * 0.003 NS 0.076 NS
Heigh (cm) 0.201 *** −0.502 *** −0.357 *** −0.035 NS −0.043 NS
Weigh (Kg) 0.012 NS 0.088 NS 0.531 *** 0.837 *** 0.758 ***
Fas ing glucose (mg/dL) −0.144 * 0.160 * 0.152 * 0.151 * 0.160 *
U ic Acid (mg/dL) 0.142 * 0.005 NS 0.025 NS 0.160 * 0.183 **
To al Choles e ol (mg/dL) −0.039 NS 0.041 NS 0.014 NS 0.028 NS 0.014 NS
LDL-c (mg/dL) −0.103 NS 0.037 NS 0.019 NS −0.003 NS 0.002 NS
HDL-c (mg/dL) 0.050 NS 0.034 NS −0.062 NS −0.132 * −0.130 *
HDL-c (mmol/L) 0.100 NS −0.006 NS −0.100 NS −0.140 * −0.151 *
T iglyce ides (mg/dL) −0.036 NS −0.043 NS 0.110 NS 0.304 *** 0.239 ***
Se um C ea inine (mg/dL) 0.174 ** −0.026 NS 0.030 NS 0.004 NS 0.016 NS
eGFR (mL/min/1.73 m2)−0.014 NS −0.151 * −0.061 NS 0.019 NS −0.008 NS
Clinical Sys olic BP (mmHg) 0.197 *** −0.034 NS −0.065 NS −0.068 NS −0.053 NS
Clinical Dias olic BP (mmHg) 0.260 *** −0.160 * −0.163 * −0.098 NS −0.095 NS
Clinical Mean BP (mmHg) 0.255 *** −0.120 * −0.134 * −0.093 NS −0.085 NS
Clinical Pulse P essu e (mmHg) 0.003 NS 0.120 * 0.079 NS 0.008 NS 0.025 NS
Clinical Hea Ra e (bea s/min) 0.134 * −0.144 * −0.110 NS −0.089 NS −0.105 NS
SLI (mm) 1 −0.296 *** −0.238 *** −0.123 * −0.182 **
BMI (kg/m2)−0.121 NS 0.458 *** 0.876 *** 1 0.934 ***
WC (cm) −0.182 ** 0.688 *** 0.917 *** 0.934 *** 1
ABSI −0.296 *** 1 0.761 *** 0.458 *** 0.688 ***
BRI −0.238 *** 0.761 *** 1 0.876 *** 0.917 ***
SLI: Sokolo -Lyon Index; ABSI: A Body Shape Index; BRI: Body Roundness Index; BMI: Body Mass Index; WC:
Wais Ci cum e ence; LDL-c: Low Densi y Lipop o ein Choles e ol; HDL-c: High Densi y Lipop o ein Choles e ol;
eGFR: es ima ed Glome ula Fil a ion Ra e; BP: Blood P essu e. * p< 0.05; ** p
≤
0.01; *** p
≤
0.001; NS wi h
p> 0.05.
When we pe o med he mul i a ia e linea eg ession analysis wi h a s epwise ap-
p oach by conside ing SLI as he dependen a iable, SLI was independen ly associa ed
wi h ABSI, e en a e adjus men o all o he co a ia es, including BMI o al e na i ely
J. Pe s. Med. 2025,15, 229 7 o 11
CV (p= 0.013). A simila independen associa ion was obse ed when BRI eplaced ABSI
in he model (p= 0.038) (Table 3).
Table 3. Mul i a ia e linea eg ession analysis conduc ed in he o e all popula ion, conside ing
Sokolow-Lyon Index (SLI) as he dependen a iable and including ABSI along wi h o he co a ia es
in he model (see s a is ical sec ion).
Reg ession Coe icien s
Non S anda dized
S anda dized
B SE β p
Model (R2= 0.217)
Age −0.187 0.033 −0.390 −5.61 <0.001
eGFR −0.073 0.019 −0.254 −3.80 0.005
ABSI −31.694 9.290 −0.197 −3.41 0.013
Sys olic blood p essu e 0.083 0.025 0.179 3.31 0.016
eGFR: es ima ed Glome ula Fil a ion Ra e; SE: S anda d E o ; ABSI: A Body Shape Index.
4. Discussion
This s udy explo ed he associa ion be ween no el an h opome ic indices o
adiposi y—ABSI and BRI—and elec oca diog aphic signs o LVH, as measu ed by he
SLI, in a coho o hype ensi e pa ien s. Ou esul s e eal a signi ican and independen
in e se associa ion o bo h ABSI and BRI wi h SLI, e en a e adjus ing o con en ional
con ounde s such as BMI, blood p essu e, and enal unc ion. A key obse a ion is he
s ong co ela ion be ween hese no el adiposi y indices and adi ional measu es such as
BMI and WC in hype ensi e indi iduals. S ong linea co ela ions we e no ed be ween
ABSI (o BRI) and BMI (o WC) ac oss he en i e s udy popula ion.
These indings a e consis en wi h p e ious s udies: K akaue e al. epo ed sig-
ni ican co ela ions be ween ABSI, BMI, and WC in he gene al popula ion [
24
], while
Thomas e al. ound simila associa ions o BRI wi h con en ional obesi y indices [
25
].
Despi e hese ela ionships, BMI was no signi ican ly co ela ed wi h SLI, highligh ing i s
limi a ions in cap u ing he complexi y o obesi y- ela ed ca dio ascula isk. This suppo s
exis ing e idence ha BMI does no adequa ely e lec a dis ibu ion o i s ca diome abolic
consequences, pa icula ly in he con ex o cen al adiposi y [14,26].
In con as , ABSI and BRI—designed o e lec body shape and abdominal a
(Figu e S1)—showed s onge associa ions wi h ma ke s o subclinical ca diac emod-
eling, suppo ing hei po en ial alue in ca dio ascula isk assessmen [
18
,
27
–
29
]. The
in e se co ela ion be ween ABSI and SLI may appea pa adoxical, gi en he known asso-
cia ion be ween adiposi y and inc eased e en icula mass. Howe e , his disc epancy
may be explained by he physical and elec ical in e e ence o adipose issue, which can
a enua e ECG ol age ansmission [
30
]. Excess uncal o isce al a may educe he
su ace ol ages eco ded by ECG, pa icula ly in he leads used o calcula e he SLI [
31
,
32
].
Mo eo e , he independen associa ion be ween ABSI and SLI emained signi ican in
mul i a ia e analysis, e en a e adjus ing o BMI, eGFR, blood p essu e, and o he ele-
an clinical a iables. Subs i u ing ABSI wi h BRI yielded compa able esul s, ein o cing
hei po en ial as modi ie s o ECG in e p e a ion in obese pa ien s. Al hough ou model
explained only a mode a e p opo ion o a iance in SLI alues (R
2
= 0.217), his inding
unde sco es he clinical ele ance o hese indices. Fu u e esea ch should include ROC
analyses o u he e alua e hei diagnos ic pe o mance and assess whe he hey p o ide
inc emen al alue beyond adi ional obesi y me ics.
Al hough ECG c i e ia o LVH ha e been p oposed wi h co ec ion ac o s o BMI,
hese adjus men s ha e gene ally yielded only modes imp o emen s in diagnos ic pe -
J. Pe s. Med. 2025,15, 229 8 o 11
o mance. Cu en ECG c i e ia o LVH, including BMI-adjus ed h esholds, ha e shown
only modes imp o emen s in diagnos ic accu acy. Ou indings sugges ha inco po a -
ing ABSI and BRI—indices ha be e e lec a dis ibu ion—could enhance ECG-based
de ec ion o LVH in cen ally obese hype ensi e pa ien s. By accoun ing o he ol age-
a enua ing e ec s o adiposi y, hese indices may help educe alse nega i es and imp o e
isk s a i ica ion when in eg a ed in o ECG in e p e a ion algo i hms [28,33].
In e es ingly, we also obse ed ha pa ien s wi h lowe SLI alues had signi ican ly
highe ABSI, BRI, BMI, and WC—ma ke s o cen al adiposi y—compa ed o hose wi h
highe SLI alues. This suppo s he hypo hesis ha inc eased adipose issue may obscu e
he elec oca diog aphic de ec ion o LVH, a he han indica ing a uly lowe p e alence
o ca diac emodeling [
31
,
34
]. Ou indings ha e impo an clinical implica ions. The SLI
emains one o he mos widely used ECG c i e ia o LVH de ec ion due o i s simplici y and
cos -e ec i eness [
13
]. Howe e , i s accu acy in indi iduals wi h ele a ed cen al adiposi y
may be comp omised. In ligh o he global obesi y epidemic and he ising p e alence o
cen al obesi y among hype ensi e pa ien s, ou s udy suppo s he need o econside
how adiposi y in luences ECG-based LVH diagnosis. Inco po a ing no el indices such as
ABSI and BRI in o ECG in e p e a ion algo i hms may imp o e isk s a i ica ion and help
a oid alse-nega i e esul s in his high- isk popula ion.
Fu he suppo ing he physiological plausibili y o hese indings, a la ge u al Chi-
nese s udy epo ed ha BRI posi i ely co ela ed wi h echoca diog aphic le en icula
mass index (LVMI) and p edic ed LVH [
35
]. This ein o ces he idea ha ABSI and BRI
no only e lec ue s uc u al ca diac changes bu may also in e e e wi h ECG-based
de ec ion o hose changes.
Se e al limi a ions should be acknowledged. Fi s , al hough SLI is commonly used, i
has limi ed sensi i i y and may be subop imal compa ed o imaging-based assessmen s
o LVH, such as echoca diog aphy o ca diac magne ic esonance. No ably, he diagnos ic
accu acy o echoca diog aphic c i e ia can also a y depending on como bid condi ions,
pa icula ly ch onic kidney disease [
36
]. Second, LVH was assessed solely using SLI; o he
ECG-based c i e ia (e.g., Co nell ol age o Romhil -Es es sco es) o imaging modali ies
such as echoca diog aphy we e no sys ema ically collec ed, which may limi he comp e-
hensi eness o LVH de ec ion. Fu u e s udies should explo e and compa e he diagnos ic
pe o mance o al e na i e ECG-based indices, especially in obese and cen ally obese
popula ions. Thi d, ou sample, al hough well-cha ac e ized, was ela i ely small and
de i ed om a single cen e , po en ially limi ing gene alizabili y. Fou h, body composi ion
was assessed using an h opome ic o mulas a he han di ec imaging o bioimpedance
echniques, which migh p o ide mo e accu a e measu es o isce al and subcu aneous
a . Finally, we did no analyze sex- and age- ela ed di e ences in a dis ibu ion and ECG
ol ages sepa a ely, which could ha e p o ided addi ional insigh s. Addi ionally, he lack
o de ailed da a on indi idual pha macological ea men s limi ed ou abili y o e alua e
hei speci ic e ec s, as pa ien s we e only ca ego ized as ecei ing he apy o no . This
he apeu ic he e ogenei y may ha e con ibu ed o a iabili y in he esul s and should be
add essed in u u e s udies wi h mo e p ecise ea men in o ma ion.
5. Conclusions
In conclusion, ou s udy demons a es ha ABSI and BRI—no el adiposi y indices
ha mo e accu a ely e lec body shape and isce al a dis ibu ion—a e independen ly
and in e sely associa ed wi h ECG-de i ed Sokolow–Lyon Index alues in hype ensi e
indi iduals. These indings sugges ha cen al adiposi y may obscu e he de ec ion o LVH
using s anda d ECG c i e ia, unde sco ing he need o adjus ed in e p e a ion s a egies in
obese pa ien s. Fu u e esea ch, ideally longi udinal and mul icen ic, should in es iga e
J. Pe s. Med. 2025,15, 229 9 o 11
whe he inco po a ing hese indices in o clinical algo i hms can imp o e he diagnos ic
and p ognos ic accu acy o ECG-based LVH de ec ion.
Supplemen a y Ma e ials: The ollowing suppo ing in o ma ion can be downloaded a :
h ps://www.mdpi.com/a icle/10.3390/jpm15060229/s1, Figu e S1: Compa a i e Table o An-
h opome ic Indices (wi h Ad an ages).
Au ho Con ibu ions: Concep ualiza ion, G.G. and P.F.; o mal analysis,; in es iga ion, G.G., R.L.M.,
V.P., V.C., A.G. and A.B.; da a cu a ion, F.P., L.Z. and G.G.; w i ing—o iginal d a p epa a ion, G.G.
and P.F.; w i ing— e iew and edi ing, F.P., A.G., A.B., L.N., A.S., L.L.V., J.G., R.P., G.M. and C.C.;
isualiza ion, G.G. and F.P.; supe ision, J.G., R.P., G.M. and C.C. All au ho s ha e ead and ag eed o
he published e sion o he manusc ip .
Funding: This esea ch ecei ed no ex e nal unding.
Ins i u ional Re iew Boa d S a emen : The s udy was conduc ed in acco dance wi h he Decla a ion
o Helsinki, and app o ed by E hical Commi ee o Pale mo (No. 28, 10/12/2024, app o al da e:
10 Decembe 2024.
In o med Consen S a emen : In o med consen was ob ained om all subjec s in ol ed in
he s udy.
Da a A ailabili y S a emen : Da a abou his s udy will be made a ailable on easonable eques .
Con lic s o In e es : The au ho s decla e no con lic s o in e es .
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