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Waligóra M, Smorąg M, Bukała N, Zygmunt M, Kachnic N, Lis E, Zaczyńska K, Wilczek Ł, Wziątek B, Kopeć G. ECG patterns to predict pulmonary arterial hypertension in patients with severe tricuspid regurgitation. J Electrocardiol 2024; 82:52-58. [PMID: 38035654 DOI: 10.1016/j.jelectrocard.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/31/2023] [Accepted: 11/18/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Echocardiographic evaluation of tricuspid regurgitation (TR) velocity is a key measure in screening for pulmonary hypertension. Based on its value and additional features of right ventricle overload patients are classified into low, intermediate or high probability of pulmonary hypertension which transfers into decisions of further invasive evaluation. However, in the presence of severe TR echocardiography underestimates pulmonary artery pressure and therefore pulmonary hypertension may be overlooked in some patients. Accordingly, in the present study we aimed to assess the role of electrocardiography in predicting the presence of pulmonary arterial hypertension (PAH) in patients with severe TR. RESULTS We analysed 83 consecutive patients with severe TR who were diagnosed in our centre between February 2008 and 2021 and who underwent right heart catheterization. Of them 58 had PAH while 25 had isolated TR (iTR). We found that the following ECG criteria supported the diagnosis of PAH as opposed to the diagnosis of iTR: R:SV1 > 1.0, max RV1 or 2 + max S I or aVL -SV1 > 6 mm, SI/RI > 1 in I. For these parameters using ROC analysis we found that the optimal thresholds suggesting the presence of pulmonary hypertension were: R:SV1 > 1.5 (AUC = 0.74, p = 0.0004, sensitivity 57.1%,specificity of 85%), max RV1 or 2 + max S I or aVL - SV1 > 3 mm (AUC = 0.76, p < 0.0001, sensitivity 91.4%, specificity of 60%) and for SI:RI > 0.71 (AUC = 0.79, p < 0.0001, sensitivity 82.5%,specificity of 70.8%). Presence of atrial fibrillation predicted iTR with 76% sensitivity and 81% specificity. CONCLUSIONS ECG analysis can improve the diagnostic process for patients with severe TR. The presence of atrial fibrillation facilitates the diagnosis of isolated tricuspid regurgitation (iTR), while increased values of R:SV1, R:SI, and increased max RV1 or 2 + max SI or aVL - SV1 favor the diagnosis of TR secondary to PAH.
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Affiliation(s)
- Marcin Waligóra
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland; Center for Innovative Medical Education, Department of Medical Education, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Maria Smorąg
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland
| | - Natalia Bukała
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland
| | - Marianna Zygmunt
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland
| | - Natalia Kachnic
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland
| | - Emilia Lis
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland
| | - Klaudia Zaczyńska
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland
| | - Łukasz Wilczek
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland
| | - Barbara Wziątek
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland
| | - Grzegorz Kopeć
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Krakow, Poland.
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Piłka M, Darocha S, Florczyk M, Mańczak R, Banaszkiewicz M, Kędzierski P, Zieliński D, Wróbel K, Torbicki A, Kurzyna M. The Utility of a Resting Electrocardiogram (ECG-PH Index) in Evaluating the Efficacy of Pulmonary Endarterectomy in Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2023; 12:7621. [PMID: 38137690 PMCID: PMC10743524 DOI: 10.3390/jcm12247621] [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: 10/30/2023] [Revised: 11/27/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND The ECG-PH index (PH-ECG score) has been proposed as a valuable ECG-derived method of evaluating the effectiveness of balloon pulmonary angioplasty (BPA) in chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary endarterectomy (PEA) is the main form of therapy for CTEPH with a proximal clot location. The objective of this study was to assess the clinical utility of a resting electrocardiogram (ECG-PH index) in assessing the effectiveness of PEA in CTEPH patients. METHODS The retrospective analysis included 73 patients who underwent PEA. Their ECG-PH index values were calculated using four ECG parameters: R-wave amplitude V1 + S-wave amplitude V5/V6 > 10.5 mm, QRS-wave axis > 110 degrees, R-wave amplitude V1 > S-wave amplitude V1, and SIQIII pattern. PH-ECG scores were assessed after a median time of 13 months (IQR: 8-31 months) had passed since the PEA procedures. RESULTS The current analysis documented that ECG-PH index = 0 is a good reflection of mPAP < 25mmHg (sensitivity 76.1%; specificity 66.7%; positive predictive value 79.5%; negative predictive value 62.1%) or mPAP ≤ 20 mmHg (sensitivity 69.6%; specificity 70.6%; positive predictive value 88.6%; negative predictive value 41.4%) after PEA. The values of the area under the ROC curve for ECG-PH index were 0.772 (95% CI: 0.676-0.867) and 0.743 (95% CI: 0.637-0.849) for the mPAP < 25 mmHg and mPAP ≤ 20 mmHg patient groups, respectively. CONCLUSION The ECG-PH index may be useful for monitoring the haemodynamic effect of PEA in CTEPH patients.
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Affiliation(s)
- Michał Piłka
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland; (S.D.); (M.F.); (R.M.); (M.B.); (P.K.); (A.T.); (M.K.)
| | - Szymon Darocha
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland; (S.D.); (M.F.); (R.M.); (M.B.); (P.K.); (A.T.); (M.K.)
| | - Michał Florczyk
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland; (S.D.); (M.F.); (R.M.); (M.B.); (P.K.); (A.T.); (M.K.)
| | - Rafał Mańczak
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland; (S.D.); (M.F.); (R.M.); (M.B.); (P.K.); (A.T.); (M.K.)
| | - Marta Banaszkiewicz
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland; (S.D.); (M.F.); (R.M.); (M.B.); (P.K.); (A.T.); (M.K.)
| | - Piotr Kędzierski
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland; (S.D.); (M.F.); (R.M.); (M.B.); (P.K.); (A.T.); (M.K.)
| | - Dariusz Zieliński
- Cardiac Surgery Department, Medicover Hospital, 02-972 Warsaw, Poland; (D.Z.); (K.W.)
- Faculty of Medicine, Lazarski University, 02-662 Warsaw, Poland
| | - Krzysztof Wróbel
- Cardiac Surgery Department, Medicover Hospital, 02-972 Warsaw, Poland; (D.Z.); (K.W.)
- Faculty of Medicine, Lazarski University, 02-662 Warsaw, Poland
| | - Adam Torbicki
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland; (S.D.); (M.F.); (R.M.); (M.B.); (P.K.); (A.T.); (M.K.)
| | - Marcin Kurzyna
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland; (S.D.); (M.F.); (R.M.); (M.B.); (P.K.); (A.T.); (M.K.)
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Ley L, Grimminger F, Richter M, Tello K, Ghofrani A, Bandorski D. The Early Detection of Pulmonary Hypertension. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:823-830. [PMID: 37882345 PMCID: PMC10853922 DOI: 10.3238/arztebl.m2023.0222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Up to 1% of the world population and 10% of all persons over age 65 suffer from pulmonary hypertension (PH). The latency from the first symptom to the diagnosis is more than one year on average, and more than three years in 20% of patients. 40% seek help from more than four different physicians until their condition is finally diagnosed. METHODS This review is based on publications retrieved by a selective literature search on pulmonary hypertension. RESULTS The most common causes of pulmonary hypertension are left heart diseases and lung diseases. Its cardinal symptom is exertional dyspnea that worsens as the disease progresses. Additional symptoms of right heart failure are seen in advanced stages. Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are rare, difficult to diagnose, and of particular clinical relevance because specific treatments are available. For this reason, strategies for the early detection of PAH and CTEPH have been developed. The clinical suspicion of PH arises in a patient who has nonspecific symptoms, electrocardiographic changes, and an abnormal (NT-pro-)BNP concentration. Once the suspicion of PH has been confirmed by echocardiography and, if necessary, differential-diagnostic evaluation with a cardiopulmonary stress test, and after the exclusion of a primary left heart disease or lung disease, the patient should be referred to a PH center for further diagnostic assessment, classification, and treatment. CONCLUSION If both the (NT-pro-)BNP and the ECG are normal, PH is unlikely. Knowledge of the characteristic clinical manifestations and test results of PH is needed so that patients can be properly selected for referral to specialists and experts in PH.
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Affiliation(s)
- Lukas Ley
- Justus-Liebig-University Gießen, Campus Kerckhoff, Bad Nauheim
| | | | | | | | | | - Dirk Bandorski
- Semmelweis University, Department of Medicine, 20099 Hamburg
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Wade RC, Mkorombindo T, Ling SX, Helgeson ES, MacDonald DM, Pew K, Voelker H, Bittner V, Kunisaki KM, Lammi MR, Dransfield MT. Association between P-pulmonale and respiratory morbidity in COPD: a secondary analysis of the BLOCK-COPD trial. BMC Pulm Med 2023; 23:434. [PMID: 37946165 PMCID: PMC10634074 DOI: 10.1186/s12890-023-02748-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023] Open
Abstract
RATIONALE Pulmonary hypertension (PH) in COPD confers increased risk of exacerbations (ECOPD). Electrocardiogram (ECG) indicators of PH are prognostic both in PH and COPD. In the Beta-Blockers for the Prevention of Acute Exacerbations of COPD (BLOCK-COPD) trial, metoprolol increased risk of severe ECOPD through unclear mechanisms. OBJECTIVE We evaluated whether an ECG indicator of PH, P-pulmonale, would be associated with ECOPD and whether participants with P-pulmonale randomized to metoprolol were at higher risk of ECOPD and worsened respiratory symptoms given the potential detrimental effects of beta-blockers in PH. METHODS ECGs of 501 participants were analyzed for P-pulmonale (P wave enlargement in lead II). Cox proportional hazards models evaluated for associations between P-pulmonale and time to ECOPD (all and severe) for all participants and by treatment assignment (metoprolol vs. placebo). Linear mixed-effects models evaluated the association between treatment assignment and P-pulmonale on change in symptom scores (measured by CAT and SOBQ). RESULTS We identified no association between P-pulmonale and risk of any ECOPD or severe ECOPD. However, in individuals with P-pulmonale, metoprolol was associated with increased risk for ECOPD (aHR 2.92, 95% CI: 1.45-5.85). There was no association between metoprolol and ECOPD in individuals without P-pulmonale (aHR 1.01, 95% CI: 0.77-1.31). Individuals with P-pulmonale assigned to metoprolol experienced worsening symptoms (mean increase of 3.95, 95% CI: 1.32-6.58) whereas those assigned to placebo experienced a mean improvement in CAT score of -2.45 (95% CI: -0.30- -4.61). CONCLUSIONS In individuals with P-pulmonale, metoprolol was associated with increased exacerbation risk and worsened symptoms. These findings may explain the findings observed in BLOCK-COPD.
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Affiliation(s)
- R Chad Wade
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA.
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| | - Takudzwa Mkorombindo
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Sharon X Ling
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Erika S Helgeson
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - David M MacDonald
- Section of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Krystle Pew
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Helen Voelker
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Vera Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ken M Kunisaki
- Section of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Matthew R Lammi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, 1900 University BLVD, THT 422, Birmingham, AL, 35294, USA
- Section of Pulmonary, Acute Care Service, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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Ley L, Wiedenroth CB, Ghofrani HA, Hoeltgen R, Bandorski D. Analysis of Electrocardiographic Criteria of Right Ventricular Hypertrophy in Patients with Chronic Thromboembolic Pulmonary Hypertension before and after Balloon Pulmonary Angioplasty. J Clin Med 2023; 12:4196. [PMID: 37445229 DOI: 10.3390/jcm12134196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) may lead to typical electrocardiographic changes that can be reversed by balloon pulmonary angioplasty (BPA). The aim of this study was to investigate the significance of rarely used electrocardiogram (ECG) parameters, possible electrocardiographic differences between residual and significantly improved CTEPH and the role of electrocardiographic parameters in low mPAP (mean pulmonary arterial pressure) ranges since the mPAP threshold for the definition of pulmonary hypertension has recently been adjusted (≥25 mmHg to >20 mmHg). MATERIAL AND METHODS Between March 2014 and October 2020, 140 patients with CTEPH and 10 with CTEPD (chronic thromboembolic pulmonary disease) without pulmonary hypertension (PH) were retrospectively enrolled (12-lead ECG and right heart catheterization before and 6 months after BPA). The ECG parameters of right heart strain validated by studies and clinical experience were evaluated. Special attention was paid to six specific ECG parameters. After BPA, the cohort was divided into subgroups to investigate possible electrocardiographic differences with regard to the haemodynamic result. RESULTS The present study confirmed that the typical electrocardiographic signs of CTEPH can be found on an ECG, can regress after BPA and partially correlate well with haemodynamic parameters. "R V1, V2 + S I, aVL - S V1" was a parameter of particular note. BPA reduced its frequency (47% vs. 29%) statistically significantly after Bonferroni correction (p < 0.001). Moreover, it showed a good correlation with mPAP and PVR (r-values: 0.372-0.519, p-values: < 0.001). Exceeding its cut-off value before therapy was associated with more severe CTEPH before therapy (higher mPAP, PVR, NT-pro-BNP and troponin and lower TAPSE) and an increased risk of death. Exceeding its cut-off value before and after therapy was associated with more severe CTEPH after therapy (higher RAP, mPAP, PVR, NT-pro-BNP and NYHA class) and an increased risk of death. Men tend to be affected more frequently. After subgrouping, it was observed that a higher median mPAP was associated with a higher right atrial pressure (RAP), a higher pulmonary vascular resistance (PVR) and a lower cardiac output (CO) before and after BPA. In addition, under these conditions, more and more severe electrocardiographic pathologies were detected before and after BPA. Some patients with low mPAP also continued to show mild ECG changes after BPA. In some cases, very few to no pathological ECG changes were detected, and the ECG could present as mostly normal in some patients (5% before BPA and 13% after BPA). CONCLUSION "R V1, V2 + S I, aVL - S V1" seems to be able to support the diagnosis of CTEPH, indicate therapeutic improvement and estimate haemodynamics. It also seems capable of predicting a (persistent) severe disease with probably increased need for therapy and increased mortality. Mild PH has been observed to have either no or few mild ECG changes. This might complicate the (early) detection of PH.
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Affiliation(s)
- Lukas Ley
- Campus Kerckhoff, Justus-Liebig-University Giessen, 61231 Bad Nauheim, Germany
| | - Christoph B Wiedenroth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, 61231 Bad Nauheim, Germany
| | | | | | - Dirk Bandorski
- Faculty of Medicine, Semmelweis University Campus Hamburg, 20099 Hamburg, Germany
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Murni IK, Kato T, Wirawan MT, Arafuri N, Hermawan K, Hartopo AB, Anggrahini DW, Nugroho S, Noormanto N, Emoto N, Dinarti LK. An electrocardiographic score to predict pulmonary hypertension in children with atrial septal defect. BMC Pediatr 2023; 23:288. [PMID: 37301836 PMCID: PMC10257265 DOI: 10.1186/s12887-023-04102-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND In limited resource settings, identification of factors that predict the occurrence of pulmonary hypertension(PH) in children with atrial septal defect(ASD) is important to decide which patients should be prioritized for defect closure to prevent complication. Echocardiography and cardiac catheterization are not widely available in such settings. No scoring system has been proposed to predict PH among children with ASD. We aimed to develop a PH prediction score using electrocardiography parameters for children with ASD in Indonesia. METHODS A cross-sectional study reviewing medical record including ECG record was conducted among all children with newly diagnosed isolated ASD admitted to Dr Sardjito Hospital in Yogyakarta, Indonesia during 2016-2018. Diagnosis of ASD and PH was confirmed through echocardiography and/or cardiac catheterization. Spiegelhalter Knill-Jones approach was used to develop PH prediction score. Accuracy of prediction score was performed using a receiver operating characteristic (ROC) curve. RESULTS Of 144 children, 50(34.7%) had PH. Predictors of pulmonary hypertension were QRS axis ≥120°, P wave ≥ 3 mm at lead II, R without S at V1, Q wave at V1, right bundle branch block (RBBB), R wave at V1, V2 or aVR > normal limit and S wave at V6 or lead I > normal limit. ROC curve from prediction scores yielded an area under the curve (AUC) 0.908(95% CI 0.85-0.96). Using the cut-off value 3.5, this PH prediction score had sensitivity of 76%(61.8-86.9), specificity 96.8%(91.0-99.3), positive predictive value 92.7%(80.5-97.5), negative predictive value 88.4%(82.2-92.6), and positive likelihood ratio 23.8(7.7-73.3). CONCLUSIONS A presence of PH in children with ASD can be predicted by the simple electrocardiographic score including QRS axis ≥120°, P wave ≥3 mm at lead II, R without S at V1, Q wave at V1, RBBB, R wave at V1, V2 or aVR > normal limit and S wave at V6 or lead I > normal limit. A total score ≥ 3.5 shows a moderate sensitivity and high specificity to predict PH among children with ASD.
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Affiliation(s)
- Indah K Murni
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia.
- Centre for Child Health-Pediatric Research Office (CCH-PRO), Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | - Taichi Kato
- Department of Pediatrics/Developmental Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Muhammad Taufik Wirawan
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Nadya Arafuri
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Kristia Hermawan
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Anggoro Budi Hartopo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Dyah Wulan Anggrahini
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Sasmito Nugroho
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Noormanto Noormanto
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- Laboratory of Clinical Pharmaceutical Science, Kobe Pharmaceutical University, Kobe, Japan
| | - Lucia Kris Dinarti
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia
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Electrocardiogram in patients with pulmonary hypertension. J Electrocardiol 2023; 79:24-29. [PMID: 36913785 DOI: 10.1016/j.jelectrocard.2023.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a potentially life-threatening cardiovascular disease defined by a mean pulmonary arterial pressure (mPAP) > 20 mmHg. Due to non-specific symptoms, PH is often diagnosed late and at advanced stage. In addition to other diagnostic modalities, the electrocardiogram (ECG) can help in establishing the diagnosis. Knowledge of typical ECG signs could help to detect PH earlier. METHODS A non-systematic literature review on the typical electrocardiographic patterns of PH was performed. RESULTS Characteristic signs of PH include right axis deviation, SIQIIITIII and SISIISIII patterns, P pulmonale, right bundle branch block, deep R waves in V1 and V2, deep S waves in V5 and V6, and right ventricular hypertrophy (R in V1 + S in V5, V6 > 1,05 mV). Repolarisation abnormalities such as ST segment depressions or T wave inversions in leads II, III, aVF, and V1 to V3 are common as well. Furthermore, a prolonged QT/QTc interval, an increased heart rate, or supraventricular tachyarrhythmias can be observed. Some parameters may even provide information about the patient's prognosis. CONCLUSION Not every PH patient shows electrocardiographic PH signs, especially in mild PH. Thus, the ECG is not useful to completely rule out PH, but provides important clues to PH when symptoms are present. The combination of typical ECG signs and the co-occurrence of electrocardiographic signs with clinical symptoms and elevated BNP levels are particularly suspicious. Diagnosing PH earlier could prevent further right heart strain and improve patient prognosis.
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Zhao YT, Wang L. Missed Signs of Acute Pulmonary Embolism in Electrocardiogram Findings. JAMA Intern Med 2022; 182:572-573. [PMID: 35344010 DOI: 10.1001/jamainternmed.2022.0384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Yun-Tao Zhao
- Department of Cardiology, Aerospace Center Hospital, Beijing, China
| | - Lei Wang
- Department of Cardiology, Aerospace Center Hospital, Beijing, China
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Su XF, Fan N, Yang XM, Song JM, Peng QH, Liu X. A Novel Electrocardiography Model for the Diagnosis of Acute Pulmonary Embolism. Front Cardiovasc Med 2022; 9:825561. [PMID: 35479265 PMCID: PMC9035687 DOI: 10.3389/fcvm.2022.825561] [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: 01/18/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
Acute pulmonary embolism (acPE) is a severe disease that is often misdiagnosed as it is difficult to detect quickly and accurately. In this study, a novel electrocardiogram (ECG) model was used to estimate the probability of acPE rapidly via analysis of ECG characteristics. A total of 327 patients with acPE who were diagnosed at the Sichuan Provincial People's Hospital (SPPH) between 2018 and 2021 were retrospectively studied. A total of 331 patients were randomly selected as the control group, which included patients hospitalized during the same time period. The control group included patients who presented with characteristic symptoms of acPE, but this diagnosis was ruled out following further diagnostic testing. This study compared the diagnostic value of the ECG model with those of another ECG scoring model (Daniel-ECG score) and the most common prediction models (Wells score and Geneva score). This study established an ECG-predictive model using analysis of the ECG abnormalities in patients with acPE. The final ECG model included certain novel ECG signs that had not been incorporated in the previous ECG score of the patients, and thus, compared to the previous ECG score, exhibited a more favorable area under the receiver operating characteristic curve (AUC) value (0.8741). The model developed in this study was named the SPPH-ECG model. Furthermore, this study compared the SPPH-ECG model with Daniel-ECG score, Wells score, and Geneva score, and the SPPH-ECG model was demonstrated to exhibit a superior AUC value (0.8741), sensitivity (79.08%), negative predictive value (79.52%), and test accuracy (79.42%), while the Geneva score presented superior specificity (100%) and positive predictive value (100%) compared with the SPPH-ECG model. In conclusion, the SPPH-ECG model may play a role in ruling out acPE in patients during diagnostic testing and diagnose acPE rapidly and accurately in combination with the Geneva scoring system.
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Affiliation(s)
- Xiao-Feng Su
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Na Fan
- Department of Echocardiography and Non-Invasive Cardiology Laboratory, Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Xue-Mei Yang
- Sichuan Provincial People's Hospital, Chengdu, China
| | - Jun-Mei Song
- Sichuan Provincial People's Hospital, Chengdu, China
| | | | - Xin Liu
- Sichuan Provincial People's Hospital, Chengdu, China
- *Correspondence: Xin Liu
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10
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Nakayama K, Nakajima Y, Tanaka R, Hirata KI, Emoto N. Predictors of Long-term Outcomes in Patients With Connective Tissue Disease Associated With Pulmonary Arterial Hypertension. J Clin Rheumatol 2021; 27:e371-e377. [PMID: 32511146 PMCID: PMC8612911 DOI: 10.1097/rhu.0000000000001447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Pulmonary arterial hypertension (PAH) is a progressive disease characterized by increased pulmonary arterial pressure and pulmonary vascular resistance that can lead to right-sided heart failure. Connective tissue disease-associated PAH (CTD-PAH) often has poorer outcomes than idiopathic or hereditary PAH, suggesting the presence of non-PAH factors that could affect the prognoses. This cohort study aimed to identify prognostic factors for CTD-PAH management. METHODS Medical records from April 1999 to November 2014 were reviewed to determine the time from treatment initiation to the occurrence of a clinically worsening event and the time elapsed until death. Data at baseline and the final assessment were used to identify prognostic factors associated with events using univariate and multivariate analyses by the stepwise Cox regression method. RESULTS In 36 patients with CTD-PAH analyzed, the proportions with no clinically worsening events at 1, 2, and 3 years after treatment initiation were 62%, 52%, and 45%, respectively, with survival rates of 88%, 77%, and 77%, respectively. The regression model showed that reduced hemoglobin at baseline, reduced qR pattern in electrocardiogram lead V1, increased 60-minute erythrocyte sedimentation rate, and increased mean pulmonary arterial pressure at the final assessment were risk factors that were significantly associated with clinical worsening. For survival, no prognostic factor was identifiable. CONCLUSIONS Hemodynamic and non-PAH factors, such as anemia, nutritional status, and inflammatory activity of the underlying CTD, which are not listed in the risk assessment table of PAH guidelines, should be strictly controlled to improve the prognosis of patients with CTD-PAH. A more multifactorial treatment strategy should be developed.
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Affiliation(s)
- Kazuhiko Nakayama
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo
| | | | - Rika Tanaka
- Medical Division, GlaxoSmithKline K.K. Minato-ku, Tokyo
| | - Ken-ichi Hirata
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo
| | - Noriaki Emoto
- From the Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo
- Clinical Pharmaceutical Science Kobe Pharmaceutical University, Kobe, Hyogo, Japan
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11
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Assessment of Clinical Usefulness of Resting Electrocardiogram (PH-ECG Score) in Monitoring the Efficacy of Balloon Pulmonary Angioplasty (BPA) in Patients with Chronic Thromboembolic Pulmonary Hypertension (CTEPH). J Clin Med 2021; 10:jcm10194548. [PMID: 34640565 PMCID: PMC8509271 DOI: 10.3390/jcm10194548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) is a form of therapy for chronic thromboembolic pulmonary hypertension (CTEPH). The study objective is to assess the clinical usefulness of resting ECG (PH-ECG score) in monitoring the efficacy of BPA in CTEPH patients. METHODS AND RESULTS Ninety-four (n = 94) CTEPH patients were included in the analysis. A standard 12-lead-ECG was performed before the first BPA session and after completion of treatment. The whole analysed population (n = 94) was divided into the following two groups: derivation cohort (n = 41) and validation cohort (n = 53). The derivation cohort was divided into the following two subgroups: patients with mean pulmonary artery pressure (mPAP) after the completion of therapy < 25 mmHg (n = 21) and patients with mPAP after the completion of therapy ≥ 25 mmHg (n = 20). In the first subgroup, four (R-wave V1 + S-wave V5/V6 > 10.5 mm, QRS-wave axis > 110 degrees, R-wave V1 > S-wave V1, SIQIII pattern) of the six ECG parameters of overload of the right cardiac chambers showed statistically significant differences (p < 0.005). That was followed by a determination of the sensitivity and specificity, positive (PPV) and negative predictive value (NPV), and ROC curve (AUC 0.9; 95% CI: 0.792-1.000) for the variable that was a sum of the above four ECG parameters (PH-ECG score). The absence of all of the four ECG parameters at rest (PH-ECG score = 0) well reflected patients with mPAP < 25 mmHg (sensitivity, 100%; specificity, 80%; PPV, 84%; NPV, 100%). In the validation cohort with mPAP < 25 mmHg and PH-ECG score = 0, sensitivity, specificity, PPV, and NPV were 86%, 77%, 73%, and 89%, respectively. CONCLUSIONS Resting ECG trace is clinically useful in the monitoring of therapeutical effects of BPA in CTEPH patients.
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12
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Extended Precordial T Wave Inversions Are Associated with Right Ventricular Enlargement and Poor Prognosis in Pulmonary Hypertension. J Clin Med 2021; 10:jcm10102147. [PMID: 34065768 PMCID: PMC8156460 DOI: 10.3390/jcm10102147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 11/23/2022] Open
Abstract
In pulmonary hypertension (PH), T wave inversions (TWI) are typically observed in precordial leads V1–V3 but can also extend further to the left-sided leads. To date, the cause and prognostic significance of this extension have not yet been assessed. Therefore, we aimed to assess the relationship between heart morphology and precordial TWI range, and the role of TWI in monitoring treatment efficacy and predicting survival. We retrospectively analyzed patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) treated in a reference pulmonary hypertension center. Patients were enrolled if they had a cardiac magnetic resonance (cMR) and 12-lead surface ECG performed at the time of assessment. They were followed from October 2008 until March 2021. We enrolled 77 patients with PAH and 56 patients with inoperable CTEPH. They were followed for a mean of 51 ± 33.5 months, and during this time 47 patients died (35.3%). Precordial TWI in V1–V6 were present in 42 (31.6%) patients, while no precordial TWI were observed only in 9 (6.8%) patients. The precordial TWI range correlated with markers of PH severity, including right ventricle to left ventricle volume RVEDVLVEDV (R = 0.76, p < 0.0001). The presence of TWI in consecutive leads from V1 to at least V5 predicted severe RV dilatation (RVEDVLVEDV ≥ 2.3) with a sensitivity of 88.9% and specificity of 84.1% (AUC of 0.90, 95% CI = 0.83–0.94, p < 0.0001). Presence of TWI from V1 to at least V5 was also a predictor of mortality in Kaplan–Meier estimation (p = 0.02). Presence of TWI from V1 to at least V5 had a specificity of 64.3%, sensitivity of 58.1%, negative predictive value of 75%, and positive predictive value of 45.5% as a mortality predictor. In patients showing a reduction in TWI range of at least one lead after treatment compared with patients without this reduction, we observed a significant improvement in RV-EDV and RV−EDVLV−EDV. We concluded that the extension of TWI to left-sided precordial leads reflects significant pathological alterations in heart geometry represented by an increase in RV/LV volume and predicts poor survival in patients with PAH and CTEPH. Additionally, we found that analysis of precordial TWI range can be used to monitor the effectiveness of hemodynamic response to treatment of pulmonary hypertension.
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13
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Littmann L. A new electrocardiographic concept: V1-V2-V3 are not only horizontal, but also frontal plane leads. J Electrocardiol 2021; 66:62-68. [PMID: 33774422 DOI: 10.1016/j.jelectrocard.2021.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 01/15/2023]
Abstract
According to conventional teaching, the limb leads in the electrocardiogram (ECG) represent the frontal plane electrical vectors of the heart, whereas the chest leads signify the horizontal plane. The anterior chest leads V1-V2-V3, however, also have strong frontal plane representation which can result in morphological similarities in these leads to the augmented unipolar leads of the Einthoven triangle. This review highlights the significance of recognizing V1-V2-V3 as not only horizontal, but also as frontal plane leads. Appreciation of this phenomenon helps elucidate a colorful variety of clinically important but seemingly bizarre ECG manifestations that could not be explained otherwise.
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Affiliation(s)
- Laszlo Littmann
- Department of Internal Medicine, Atrium Health - Carolinas Medical Center, P. O. Box 32861, Charlotte, NC 28232, United States of America.
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14
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Ray N, Gibbs MA, Littmann L. Left or Right? When Diffuse T-Wave Inversion Is Worse Than Coronary Ischemia. Am J Med 2020; 133:1418-1420. [PMID: 32277890 DOI: 10.1016/j.amjmed.2020.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/12/2020] [Accepted: 02/25/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Neha Ray
- Department of Emergency Medicine, Atrium Health - Carolinas Medical Center, Charlotte, NC
| | - Michael A Gibbs
- Department of Emergency Medicine, Atrium Health - Carolinas Medical Center, Charlotte, NC
| | - Laszlo Littmann
- Department of Internal Medicine, Atrium Health - Carolinas Medical Center, Charlotte, NC.
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15
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Vereckei A, Simon A, Szénási G, Katona G, Hankó L, Krix M, Szőke VB, Baracsi Botos V, Járai Z, Masszi T. Usefulness of a Novel Electrocardiographic Score to Estimate the Pre-Test Probability of Acute Pulmonary Embolism. Am J Cardiol 2020; 130:143-151. [PMID: 32653085 DOI: 10.1016/j.amjcard.2020.05.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 01/29/2023]
Abstract
According to our experience the 12-lead electrocardiogram (ECG) may be used to estimate the pretest probability of acute pulmonary embolism (acPE). To this end, we devised a novel ECG score (nECGs) composed of 5 known ECG criteria, best characterizing the key pathogenetic steps of acPE. A retrospective derivation cohort including 136 patients with acPE and a prospective validation cohort including 149 consecutive patients were used to devise and validate the nECGs. The latter cohort consisted of 76 patients with acPE and 73 controls presenting with characteristic symptoms of acPE, in whom the work-up ruled out acPE. We compared the diagnostic value of our nECGs with those of another ECG score (Daniel-ECG-score) and of the best prediction rules (3 Wells score and 2 Geneva score variants). The sensitivity (98.7%), negative predictive value (98%), test accuracy (84.4%) and the negative likelihood ratio (LR) (0.019) of the nECGs were superior to those of all other investigated methods. There was no between-groups difference in the positive LR. The specificity (69%) of the nECGs was inferior to those of the Daniel-ECG-score and Wells scores and did not differ or was superior to those of the Geneva score variants. The positive predictive value (77.3%) of the nECGs was superior to those of the 2 Geneva scores and did not differ from those of the other methods. In conclusion, the nECGs due to its superior sensitivity, negative predictive value, test accuracy, and negative LR estimated the pretest probability of acPE better than the Daniel-ECG-score and the prediction rules.
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16
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García Lledó A. The electrocardiogram in Pulmonary Hypertension: Scanning for an Iceberg. Arch Bronconeumol 2020; 57:319-320. [PMID: 32839056 DOI: 10.1016/j.arbres.2020.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Alberto García Lledó
- Servicio de Cardiología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España; Departamento de Medicina, Universidad de Alcalá, Alcalá de Henares, Madrid, España.
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17
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Piłka M, Darocha S, Banaszkiewicz M, Wieteska-Miłek M, Mańczak M, Mańczak R, Kędzierski P, Florczyk M, Dobosiewicz A, Torbicki A, Kurzyna M. Assessment of electrocardiographic markers of acute and long-term hemodynamic improvement in patients with pulmonary hypertension. Ann Noninvasive Electrocardiol 2020; 25:e12758. [PMID: 32335975 PMCID: PMC7507443 DOI: 10.1111/anec.12758] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/22/2020] [Accepted: 03/08/2020] [Indexed: 01/23/2023] Open
Abstract
Background The remodeling of the right heart in patients with chronic pulmonary hypertension (cPH) is associated with the appearance of electrocardiographic (ECG) abnormalities. We investigated the resolution of ECG markers of right ventricular hypertrophy (RVH) caused by acute and long‐term hemodynamic improvement. Methods Twenty‐nine (29) patients with chronic thromboembolic pulmonary hypertension (CTEPH) and seven patients with pulmonary arterial hypertension (PAH) were included in the analysis. Patients with CTEPH achieved a significant long‐term hemodynamic improvement following the treatment with balloon pulmonary angioplasty (BPA); all the patients with PAH reported significant acute hemodynamic relief after a single inhalation of iloprost, fulfilling the criteria of responder. Standard 12‐lead ECG was performed before and after intervention. Results The interval between baseline and control ECG in CTEPH and PAH groups was 28 (IQR: 17–36) months and 15 min (IQR: 11–17), respectively. Despite similar hemodynamic improvement in both groups, only the CTEPH group presented significant changes in most analyzed ECG parameters: T‐wave axis (p = .002), QRS‐wave axis (p = .012), P‐wave amplitude (p < .001) and duration in II (p = .049), R‐wave amplitude in V1 (p = .017), R:S ratio in V1 (p = .046), S‐wave amplitude in V5 (p = .004), R‐wave amplitude in V5 (p = .044), R:S ratio in V5 (p = .004), S‐wave amplitude in V6 (p = .026), R‐wave amplitude in V6 (p = .01), and R‐wave amplitude in aVR (p = .031). In patients with PAH, significant differences were found only for P wave in II (duration: p = .035; amplitude: p = .043) and QRS axis (p = .018). Conclusions The effective treatment of cPH ensures improvement in ECG parameters of RVH, but it requires extended time.
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Affiliation(s)
- Michał Piłka
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Marta Banaszkiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Maria Wieteska-Miłek
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Małgorzata Mańczak
- Department of Gerontology, Public Health and Didactics, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Rafał Mańczak
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Piotr Kędzierski
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Michał Florczyk
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Anna Dobosiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
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18
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Zhan ZQ, Li Y, Li YH, Nikus K, Pérez-Riera AR, Li JP. Predicting the outcome of acute pulmonary embolism by dynamic changes of the QRS complex in lead V1. J Electrocardiol 2019; 55:144-151. [PMID: 31203174 DOI: 10.1016/j.jelectrocard.2019.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/29/2019] [Accepted: 06/06/2019] [Indexed: 11/17/2022]
Abstract
Electrocardiography can provide useful prognostic information in acute pulmonary embolism (APE). Several abnormal QRS changes in lead V1, including notched or fragmented QRS, incomplete or complete right bundle branch block (IRBBB or CRBBB) and the QR sign, which are associated with APE, are of prognostic significance. To illustrate this, we describe lead V1 QRS changes in combination with the clinical state of six APE patients. The dynamic ECG changes suggest that a change from a diminution of the S wave amplitude to notched S wave, next to RBBB and then to the QR sign indicate worsening of the patients' condition, and vice versa. Also, a diminution of the S wave amplitude in lead V1 associated with a final R' wave in the right precordial accessory leads indicates the possibility of hidden RBBB. Understanding dynamic QRS changes in APE may aid in risk stratification.
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Affiliation(s)
- Zhong-Qun Zhan
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Guangming district, Shenzhen City, PR China.
| | - Yang Li
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Guangming district, Shenzhen City, PR China
| | - Yang-Hua Li
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Guangming district, Shenzhen City, PR China
| | - Kjell Nikus
- Heart Center, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Finland.
| | | | - Jian-Ping Li
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Guangming district, Shenzhen City, PR China
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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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20
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Nishiyama T, Takatsuki S, Kawakami T, Katsumata Y, Kimura T, Kataoka M, Tsuruta H, Itabashi Y, Murata M, Yuasa S, Aizawa Y, Fukuda K. Improvement in the electrocardiograms associated with right ventricular hypertrophy after balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension. IJC HEART & VASCULATURE 2018; 19:75-82. [PMID: 29892707 PMCID: PMC5993172 DOI: 10.1016/j.ijcha.2018.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 05/07/2018] [Accepted: 05/13/2018] [Indexed: 11/30/2022]
Abstract
Background Balloon pulmonary angioplasty (BPA) is a treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Methods and results In 60 patients with CTEPH, we examined the hemodynamic data before and after BPA. In addition, the sequential ECG findings for right ventricular hypertrophy (RVH) were assessed. The mean pulmonary arterial pressure (mPAP) decreased from 38 ± 11 to 20 ± 4 mm Hg (p < 0.05). The ROC analysis showed that the S waves in V5, R waves in V1 + S waves in V5, S waves in I, and QRS axis were significant predictors of an mPAP ≧ 30 mm Hg (AUC > 0.75, p < 0.01). The predictive values for the mPAP before the BPA were the S and R waves in lead V6, and P waves in lead II (33.417 + 0.078 × P in II − 0.10 × R in V6 + 0.012 × S in V6). The change in the mPAP (ΔmPAP) correlated with the change in the amplitudes of the ECGs: ΔS wave in lead I (R = 0.544, p < 0.001), ΔR in V1 + S in V5 (R = 0.476, p < 0.001), and ΔP wave in II (R = 0.511, p < 0.001). At 6 months of follow-up, the improvement in an R in V1 + S in V5 of ≧10 mm implied a better functional status. Conclusion BPA therapy reduced the pulmonary arterial pressure in patients with CTEPH and was associated with an improvement in the ECG findings related to RVH.
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Affiliation(s)
| | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, Japan
| | - Takashi Kawakami
- Department of Cardiology, Keio University School of Medicine, Japan
| | | | - Takehiro Kimura
- Department of Cardiology, Keio University School of Medicine, Japan
| | - Masaharu Kataoka
- Department of Cardiology, Keio University School of Medicine, Japan
| | - Hikaru Tsuruta
- Department of Cardiology, Keio University School of Medicine, Japan
| | - Yuji Itabashi
- Department of Cardiology, Keio University School of Medicine, Japan
| | | | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Japan
| | - Yoshiyasu Aizawa
- Department of Cardiology, Keio University School of Medicine, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Japan
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21
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ECG Markers of Hemodynamic Improvement in Patients with Pulmonary Hypertension. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4606053. [PMID: 29850519 PMCID: PMC5914124 DOI: 10.1155/2018/4606053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/02/2018] [Accepted: 02/27/2018] [Indexed: 11/17/2022]
Abstract
Introduction Several diagnostic tests have been recommended for risk assessment in pulmonary hypertension (PH), but the role of electrocardiography (ECG) in monitoring of PH patients has not been yet established. Therefore the aim of the study was to evaluate which ECG patterns characteristic for pulmonary hypertension can predict hemodynamic improvement in patients treated with targeted therapies. Methods Consecutive patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) were eligible to be included if they had had performed two consecutive right heart catheterization (RHC) procedures before and after starting of targeted therapies. Patients were followed up from June 2009 to July 2017. ECG patterns of right ventricular hypertrophy according to American College of Cardiology Foundation were assessed. Results We enrolled 80 patients with PAH and 11 patients with inoperable CTEPH. The follow-up RHC was performed within 12.6 ± 10.0 months after starting therapy. Based on median change of pulmonary vascular resistance, we divided our patients into two subgroups: with and without significant hemodynamic improvement. RV1, maxRV1,2 + maxSI,aVL − SV1, and PII improved along with the improvement of hemodynamic parameters including PVR. They predicted hemodynamic improvement with similarly good accuracy as shown in ROC analysis: RV1 (AUC: 0.75; 95% CI: 0.63–0.84), PII (AUC: 0.67, 95% CI: 0.56–0.77), and maxRV1,2 + maxSI,aVL − SV1 (0.73; 95% CI: 0.63–0.82). In Cox regression only change in RV1 remained significant mortality predictor (HR: 1.12, 95% CI: 1.01–1.24). Conclusion Electrocardiogram may be useful in predicting hemodynamic effects of targeted therapy in precapillary pulmonary hypertension. Decrease of RV1, maxRV1,2 + maxSI,aVL − SV1, and PII corresponds with hemodynamic improvement after treatment. Of these changes a decrease of R wave amplitude in V1 is associated with better survival.
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