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Stabenau HF, Marcus M, Matos JD, McCormick I, Litmanovich D, Manning WJ, Carroll BJ, Waks JW. The spatial ventricular gradient is associated with adverse outcomes in acute pulmonary embolism. Ann Noninvasive Electrocardiol 2023; 28:e13041. [PMID: 36691977 DOI: 10.1111/anec.13041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/13/2022] [Accepted: 12/27/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The spatial ventricular gradient (SVG) is a vectorcardiographic measurement that reflects cardiac loading conditions via electromechanical coupling. OBJECTIVES We hypothesized that the SVG is correlated with right ventricular (RV) strain and is prognostic of adverse events in patients with acute pulmonary embolism (PE). METHODS Retrospective, single-center study of patients with acute PE. Electrocardiogram (ECG), imaging, and outcome data were obtained. SVG components were regressed on tricuspid annular plane systolic excursion (TAPSE), qualitative RV dysfunction, and RV/left ventricular (LV) ratio. Odds of adverse outcomes (30-day mortality, vasopressor requirement, or advanced therapy) after PE were regressed on demographics, RV/LV ratios, traditional ECG signs of RV dysfunction, and SVG components using a logit model. RESULTS ECGs from 317 patients (48% male, age 63.1 ± 16.6 years) with acute PE were analyzed; 36 patients (11.4%) experienced an adverse event. Worse RV hypokinesis, larger RV/LV ratio, and smaller TAPSE were associated with smaller SVG X and Y components, larger SVG Z components, and smaller SVG vector magnitude (p < .001 for all). In multivariable logistic regression, odds of adverse events after PE decreased with increasing SVG magnitude and TAPSE (OR 0.32 and 0.54 per standard deviation increase; p = .03 and p = .004, respectively). Receiver operating characteristic (ROC) analysis showed that, when combined with imaging, replacing traditional ECG criteria with the SVG significantly improved the area under the ROC from 0.70 to 0.77 (p = .01). CONCLUSION The SVG is correlated with RV dysfunction and adverse outcomes in acute PE and has a better prognostic value than traditional ECG markers.
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Affiliation(s)
- Hans Friedrich Stabenau
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mason Marcus
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason D Matos
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian McCormick
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Diana Litmanovich
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Warren J Manning
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Brett J Carroll
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan W Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Luijten D, Meijer FMM, Boon GJAM, Ende-Verhaar YM, Bavalia R, El Bouazzaoui LH, Delcroix M, Huisman MV, Mairuhu ATA, Middeldorp S, Pruszcyk P, Ruigrok D, Verhamme P, Vonk Noordegraaf A, Vriend JWJ, Vliegen HW, Klok FA. Diagnostic efficacy of ECG-derived ventricular gradient for the detection of chronic thromboembolic pulmonary hypertension in patients with acute pulmonary embolism. J Electrocardiol 2022; 74:94-100. [PMID: 36057190 DOI: 10.1016/j.jelectrocard.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/03/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Application of the chronic thromboembolic pulmonary hypertension (CTEPH) rule out criteria (manual electrocardiogram [ECG] reading and N-terminal pro-brain natriuretic peptide [NTproBNP] test) can rule out CTEPH in pulmonary embolism (PE) patients with persistent dyspnea (InShape II algorithm). Increased pulmonary pressure may also be identified using automated ECG-derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO). METHOD A predefined analysis of the InShape II study was performed. The diagnostic performance of the VG-RVPO for the detection of CTEPH and the incremental diagnostic value of the VG-RVPO as new rule-out criteria in the InShape II algorithm were evaluated. RESULTS 60 patients were included; 5 (8.3%) were ultimately diagnosed with CTEPH. The mean baseline VG-RVPO (at time of PE diagnosis) was -18.12 mV·ms for CTEPH patients and - 21.57 mV·ms for non-CTEPH patients (mean difference 3.46 mV·ms [95%CI -29.03 to 35.94]). The VG-RVPO (after 3-6 months follow-up) normalized in patients with and without CTEPH, without a clear between-group difference (mean Δ VG-RVPO of -8.68 and - 8.42 mV·ms respectively; mean difference of -0.25 mV·ms, [95%CI -12.94 to 12.44]). The overall predictive accuracy of baseline VG-RVPO, follow-up RVPO and Δ VG-RVPO for CTEPH was moderate to poor (ROC AUC 0.611, 0.514 and 0.539, respectively). Up to 76% of the required echocardiograms could have been avoided with VG-RVPO criteria replacing the InShape II rule-out criteria, however at cost of missing up to 80% of the CTEPH diagnoses. CONCLUSION We could not demonstrate (additional) diagnostic value of VG-RVPO as standalone test or as on top of the InShape II algorithm.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Fleur M M Meijer
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvonne M Ende-Verhaar
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Marion Delcroix
- Department of Pneumology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Piotr Pruszcyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Dieuwertje Ruigrok
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University Hospitals Leuven, Leuven, Belgium
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Joris W J Vriend
- Department of Cardiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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The value of ventricular gradient for predicting pulmonary hypertension and mortality in hemodialysis patients. Sci Rep 2022; 12:456. [PMID: 35013477 PMCID: PMC8748426 DOI: 10.1038/s41598-021-04186-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/09/2021] [Indexed: 01/29/2023] Open
Abstract
Pulmonary hypertension (PHT) is associated with increased mortality in hemodialysis (HD) patients. The ventricular gradient optimized for right ventricular pressure overload (VG-RVPO) is sensitive to early changes in right ventricular overload. The study aimed to assess the ability of the VG-RVPO to detect PHT and predict all-cause and cardiac mortality in HD patients. 265 selected HD patients were enrolled. Clinical, biochemical, electrocardiographic, and echocardiographic parameters were evaluated. Patients were divided into normal and abnormal VG-RVPO groups, and were followed-up for 3 years. Abnormal VG-RVPO patients were more likely to be at high or intermediate risk for PHT, were older, had longer HD vintage, higher prevalence of myocardial infarction, higher parathormone levels, shorter pulmonary flow acceleration time, lower left ventricular ejection fraction, higher values of left atrial volume index, left ventricular mass index, and peak tricuspid regurgitant velocity. Both all-cause and CV mortality were higher in abnormal VG-RVPO group. In multivariate Cox analysis, VG-RVPO remained an independent and strong predictor of all-cause and CV mortality. In HD patients, abnormal VG-RVPO not only predicts PHT, but also all-cause and CV mortality.
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Meijer F, Hendriks S, Huisman M, Swenne C, Kies P, Jongbloed M, Egorova A, Vliegen H, Klok F. The prognostic value of ECG-derived ventricular gradient in early adverse events in acute pulmonary embolism patients. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Meijer FMM, Hendriks SV, Huisman MV, van der Hulle T, Swenne CA, Kies P, Jongbloed MRM, Egorova AD, Vliegen HW, Klok FA. Lack of diagnostic utility of the ECG-derived ventricular gradient in patients with suspected acute pulmonary embolism. J Electrocardiol 2020; 61:141-146. [PMID: 32619875 DOI: 10.1016/j.jelectrocard.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/12/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The YEARS algorithm was successfully developed to reduce the number of computed tomography pulmonary angiography (CTPA) investigations in the diagnostic management of patients with suspected pulmonary embolism (PE), although half of patients still needed to be referred for CTPA. We hypothesized that ECG derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO), an easy to use tool for detecting PE-induced pulmonary hypertension (PH), may further improve the efficiency of the YEARS algorithm. METHODS In this post-hoc analysis of the Years study, ECGs of 479 patients with suspected PE managed according to the YEARS algorithm were available for analysis. The diagnostic performance of VG-RVPO was assessed and likelihood ratios were calculated. RESULTS PE was diagnosed in 88 patients (18%). In patients with confirmed PE, 34% had an abnormal VG-RVPO versus 24% of those without PE (odds ratio 1.6; 95%CI 0.94-2.6). The mean VG-RVPO was -22 ± 13 and did not differ between the two patient groups (-22 versus -20; mean difference - 2, 95% CI -4.8 to 1.3). The sensitivity of VG-RVPO for PE was 24% (95%CI 34-45), the specificity 76% (95%CI 71-80) and the c-statistic 0.45 (95% CI 0.38-0.51). When combined with the YEARS algorithm, the likelihood ratios of VG-RVPO remained close to 1.0. Ruling out PE in patients with an indication for CTPA based on a normal VG-RVPO would have resulted in 58 missed cases. CONCLUSIONS The VG-RVPO has no diagnostic value for suspected acute PE, either as stand-alone diagnostic test or combined with the YEARS algorithm. CONDENSED ABSTRACT This post-hoc analysis of the YEARS study failed to demonstrate incremental diagnostic value of VG-RVPO for acute PE, either as stand-alone diagnostic test or combined with the YEARS algorithm. Nevertheless, the role of VG-RVPO recorded on admission could potentially be valuable in the risk stratification of PE during hospitalization, although this remains to be studied.
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Affiliation(s)
- F M M Meijer
- Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands.
| | - S V Hendriks
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - T van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C A Swenne
- Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands
| | - P Kies
- Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands
| | - M R M Jongbloed
- Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands; Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - A D Egorova
- Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands
| | - H W Vliegen
- Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Sakhnova TA, Blinova EV, Belevskaya AA, Saidova MA, Arkhipova OA. Comparison of the integral indices of the vectorcardiogram with the data of echocardiography in patients with idiopathic and chronic thromboembolic pulmonary hypertension. TERAPEVT ARKH 2019; 91:11-16. [PMID: 31094452 DOI: 10.26442/00403660.2019.03.000043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM The aim of the work is to compare vectorcardiographic (VCG) variables - spatial QRS-T angle and electrocardiographic ventricular gradient (VG) with echocardiography (EchoCG) data in patients with idiopathic pulmonary hypertension (IPH) and chronic thromboembolic pulmonary hypertension (CTEPH). MATERIALS AND METHODS In 40 patients with IPH and 40 patients with CTEPH at the age of 45±12 years, systolic pulmonary artery pressure (SPAP); the sizes of heart chambers, parameters of RV systolic and diastolic function were evaluated with EchoCG. The QRS-T and VG angles were calculated on the VCG, derived from 12-lead digital ECG. RESULTS In all patients SPAP was greater than 40 mm Hg (mean 83±18 mm Hg), EchoCG data indicated hypertrophy and dilatation of RV, its systolic and diastolic function; dilatation of the right atrium (RA). Prognostically unfavorable changes in EchoCG were observed: the presence of pericardial effusion in 35 (44%) patients, RA area greater than 26 cm2 in 18 (23%) patients; TAPSE less than 1.5 cm in 37 (46%) patients. EchoCG and VCG variables had statistically significant differences in patients with III-IV functional class in comparison with I-II functional class. Statistically significant moderate correlations between VCG and EchoCG variables were revealed. VCG variables allowed to separate patient groups with the presence and absence of prognostically unfavorable changes in EchoCG with sensitivity from 54 to 78% and specificity from 66 to 87%. CONCLUSION In patients with IPH and CTEPH, changes of QRS-T angle and VG correlate with SPAP, the size of RV and RA, parameters of RV systolic and diastolic function. The possibility of the use of QRS-T angle and VG for the detection of patients with prognostically unfavorable echocardiographic changes in the general group of patients with IPH and CTEPH has been shown.
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Affiliation(s)
- T A Sakhnova
- A.L. Myasnikov Research Institute of Cardiology of National Medical Research Center of Сardiology of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - E V Blinova
- A.L. Myasnikov Research Institute of Cardiology of National Medical Research Center of Сardiology of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - A A Belevskaya
- A.L. Myasnikov Research Institute of Cardiology of National Medical Research Center of Сardiology of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - M A Saidova
- A.L. Myasnikov Research Institute of Cardiology of National Medical Research Center of Сardiology of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - O A Arkhipova
- A.L. Myasnikov Research Institute of Cardiology of National Medical Research Center of Сardiology of the Ministry of Health of the Russian Federation, Moscow, Russia
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ECG derived ventricular gradient exceeds echocardiography in the early detection of pulmonary hypertension in scleroderma patients. Int J Cardiol 2018; 273:203-206. [DOI: 10.1016/j.ijcard.2018.07.122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 01/13/2023]
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