Electrocardiogram in patients with pulmonary hypertension

Alterations in ECG and Right Heart Catheterization Data in PAH Patients Who Died From Sudden Death Compared With Right Heart Failure

A meaningful number of patients with PAH die suddenly, and there is little data to understand the events surrounding sudden death in PAH. We tested the hypothesis that sudden death is associated with pre-mortem ECG or hemodynamics changes compared to those who died of RHF. We extracted data from the Vanderbilt University Medical Center Synthetic Derivative. Patients 18 years of age and older with Group 1 PAH secondary to any etiology who died between 2009 and 2017 with both ECG and RHC data from the inpatient and outpatient setting were included in the study. Continuous variables were compared using the Wilcoxon rank-sum test while categorical variables were compared using the χ 2 test. Logistic regression models, adjusted for age and sex, were then used to evaluate the association between death and specific ECG or RHC measurements. Comparing the final ECG before death, those who died of SD had significantly shorter terminal 40 ms interval of the QRS than those who died of RHF, which became nonsignificant when adjusted for age and sex. We observed differences in baseline RHC data between SD and RHF including higher RV systolic pressure which remained significant when adjusted for age and sex. Using this data, we hope to find clinical data that can be used to predict increased risk of sudden death and aid in stratifying Group I PAH patients to earlier and more aggressive interventions.

An ensemble learning model for detection of pulmonary hypertension using electrocardiogram, chest X-ray, and brain natriuretic peptide

Aims

Delayed diagnosis of pulmonary hypertension (PH) is a known cause of poor patient prognosis. We aimed to develop an artificial intelligence (AI) model, using ensemble learning method to detect PH using electrocardiography (ECG), chest X-ray (CXR), and brain natriuretic peptide (BNP), facilitating accurate detection and prompting further examinations.

Methods and results

We developed a convolutional neural network model using ECG data to predict PH, labelled by ECG from seven institutions. Logistic regression was used for the BNP prediction model. We referenced a CXR deep learning model using ResNet18. Outputs from each of the three models were integrated into a three-layer fully connected multimodal model. Ten cardiologists participated in an interpretation test, detecting PH from patients' ECG, CXR, and BNP data both with and without the ensemble learning model. The area under the receiver operating characteristic curves of the ECG, CXR, BNP, and ensemble learning model were 0.818 [95% confidence interval (CI), 0.808-0.828], 0.823 (95% CI, 0.780-0.866), 0.724 (95% CI, 0.668-0.780), and 0.872 (95% CI, 0.829-0.915). Cardiologists' average accuracy rates were 65.0 ± 4.7% for test without AI model and 74.0 ± 2.7% for test with AI model, a statistically significant improvement (P < 0.01).

Conclusion

Our ensemble learning model improved doctors' accuracy in detecting PH from ECG, CXR, and BNP examinations. This suggests that earlier and more accurate PH diagnosis is possible, potentially improving patient prognosis.

Fragmented QRS complex could predict all-cause mortality in patients with connective tissue disease-associated pulmonary arterial hypertension

OBJECTIVES

To investigate the prognostic impact and pathophysiological characteristics of fragmented QRS complex (fQRS) on patients with CTD-associated pulmonary arterial hypertension (CTD-PAH).

METHODS

This was a multicentre retrospective study recruiting 141 patients with CTD-PAH diagnosed by right heart catheterization (114 cases in the discovery cohort and 27 cases in the validation cohort). fQRS and ST-T change were detected on conventional 12-lead ECG. Patients were followed up every 3 months to update their status and the primary endpoint was all-cause death. Clinical information and ECG characteristics were compared between survival and death groups and Kaplan-Meier curve was used for survival analysis.

RESULTS

There were significant differences in age, gender, 6-min walk distance, N-terminal pro-brain natriuretic peptide, World Health Organization class, presence of fQRS, and presence of ST-T change in inferior leads between survival group and death group. Inferior fQRS and ST-T change were significantly associated with right ventricular dilatation and reduced right ventricular ejection fraction. Kaplan-Meier curve showed that all-cause mortality was higher in CTD-PAH with fQRS (P = 0.003) and inferior ST-T change (P = 0.012). Low- and intermediate-risk CTD-PAH with inferior ST-T change had higher all-cause mortality (P = 0.005). The prognostic value of fQRS and inferior ST-T change was validated in external validation cohort.

CONCLUSION

The presence of inferior fQRS and ST-T change could predict poor prognosis in CTD-PAH.

CLINICAL TRIAL REGISTRATION

NCT05980728, https://clinicaltrials.gov.

Electrocardiographic markers predict hemodynamic parameters in adults with uncorrected secundum atrial septal defect

BACKGROUND

Precapillary pulmonary hypertension (PH) as complication in atrial septal defect (ASD) is closely related to right heart hemodynamics, such as right atrial pressure (RAP) and pulmonary vascular resistance (PVR). Right heart catheterization (RHC) as the gold standard for their measurement is invasive and not widely available in Indonesia. Electrocardiography (ECG) was proposed to be alternative in this matter.

METHOD

This is a retrospective observational study with cross-sectional design. We collected data and measured ECG parameters of secundum ASD patients who underwent elective RHC from May 2019 until November 2023. We compared several ECG parameters based on RAP (< 8 and ≥ 8 mmHg) and PVR (< 5 and ≥ 5 WU).

RESULT

Eighty-three patients were included. The RV1 was the only ECG marker that showed significant difference based on RAP (AUC 0.639, sensitivity 61.7%, specificity 61.1%, p = 0.030) and PVR (AUC 0.801, sensitivity 73.2%, specificity 81%, p < 0.001). Several ECG parameters were found significantly different based on PVR value only, namely SV5 (AUC 0.773, sensitivity 80.5%, specificity 71.4%, p < 0.001), SV6 (AUC 0.823, sensitivity 80.5%, specificity 81%, p < 0.001), right ventricular Sokolow-Lyon index (RVSLI) (AUC 0.841, sensitivity 82.9%, specificity 83.3%, p < 0.001), R/SV1 (sensitivity 97.6%, specificity 16.7%, p = 0.031) as well as right ventricular strain (sensitivity 87.8%, specificity 69%, p < 0.001). Multivariate regression analysis showed RVSLI (OR 15.66 (4.46-55.02), CI 95%) and right ventricular strain pattern (OR 9.23 (2.43-35.14), CI 95%) had the best predictive value for PVR ≥ 5 WU.

CONCLUSION

In adults with secundum ASD, several ECG markers have potential role in predicting PVR ≥ 5 WU with satisfying sensitivity and specificity, but not in predicting RAP.

Pulmonary veno-occlusive disease: a clinical review

Pulmonary vasculopathy presents as a spectrum of diseases affecting the precapillary pulmonary arterioles, the capillaries and the venules. Pulmonary veno-occlusive disease (PVOD) is classified under group 1 pulmonary arterial hypertension (PAH) as subgroup 1.5 (PAH with features of capillary/venous involvement), and represents a progressive and fatal spectrum of pulmonary vascular disorders. PVOD and pulmonary capillary haemangiomatosis (PCH) can be clinically indistinguishable and often coexist, along with the same risk factors and genetic alterations; they are referred to together as PVOD/PCH in the literature. For brevity, we use the clinical term PVOD in this article. PVOD cannot be distinguished from other forms of PAH based on symptoms and haemodynamics. Risk factors include exposure to toxins/chemotherapeutic drugs and genetic mutation in the EIF2AK4 gene. Radiographic features such as mediastinal adenopathy, centrilobular ground-glass opacities, and interlobular septal thickening, along with the presence of hypoxia and reduced diffusion capacity of the lung may be required for a clinical diagnosis of PVOD, as lung biopsy carries a high risk for bleeding. Characteristic histological findings include narrowing/occlusion of small pulmonary veins. The development of pulmonary oedema with pulmonary vasodilator therapy limits therapeutic options for PVOD. With limited treatment options, lung transplantation remains the only curative treatment.

The Diagnostic Accuracy of an Electrocardiogram in Pulmonary Hypertension and the Role of "R V1, V2 + S I, aVL - S V1"

Background: Pulmonary hypertension (PH) can cause characteristic electrocardiographic (ECG) changes due to right ventricular hypertrophy and/or strain. The aims of the present study were to explore the diagnostic accuracy of ECG parameters for the diagnosis of PH, applying the recently adjusted mean pulmonary artery pressure (mPAP) threshold of >20 mmHg, and to determine the role of "R V1, V2 + S I, aVL - S V1". Methods: Between July 2012 and November 2023, 100 patients without PH, with pulmonary arterial hypertension, or with chronic thromboembolic pulmonary hypertension were retrospectively enrolled. Results: The sensitivity and specificity of the ECG parameters for the diagnosis of PH varied from 3 to 98% and from 3 to 100% (means: 39% and 87%). After optimising the parameters' cut-offs, the mean sensitivity (39% to 66%) increased significantly but the mean specificity (87% to 74%) slightly decreased. "R V1, V2 + S I, aVL - S V1" was able to predict an mPAP >20 mmHg (OR: 34.33; p < 0.001) and a pulmonary vascular resistance >5 WU (OR: 17.14, p < 0.001) but could not predict all-cause mortality. Conclusions: Even with improved cut-offs, ECG parameters alone are not able to reliably diagnose or exclude PH because of their low sensitivity. However, they still might be helpful to reveal a suspicion of PH, especially in early diagnostic stages, e.g., in primary care with general practitioners or non-specialised cardiologists and pulmonologists. "R V1, V2 + S I, aVL - S V1" was able to predict the diagnosis of (severe) PH but could not predict all-cause mortality. Nevertheless, it can still be useful in risk stratification.

Clinical significance and prognostic value of right bundle branch block in permanent pacemaker patients

AIMS

In patients undergoing pacemaker implantation with no prior history of heart failure (HF), the presence of left bundle branch block (LBBB) has been identified as an independent predictor of HF-related death or hospitalization, while the prognostic significance of right bundle branch block (RBBB) remains uncertain. We aimed to assess the long-term risk of all-cause mortality in patients with a standard indication for permanent pacing and normal or moderately depressed left ventricular function when RBBB is detected at the time of implantation.

METHODS

We retrospectively enrolled 1348 consecutive patients who had undergone single- or dual-chamber pacemaker implantation at the study center, from January 1990 to December 2022. Patients with a left ventricular ejection fraction ≤35% or a prior diagnosis of HF were excluded.

RESULTS

The baseline 12-lead electrocardiogram revealed an RBBB in 241 (18%) and an LBBB in 98 (7%) patients. During a median follow-up of 65 [25th-75th percentile: 32-117] months, 704 (52%) patients died. The combined endpoint of cardiovascular death or HF hospitalization was reached by 173 (13%) patients. On multivariate analysis, RBBB was confirmed as an independent predictor of death [hazard ratio, 1.33; 95% confidence interval (CI), 1.09-1.63; P  = 0.005]. However, when considering the combined endpoint of cardiovascular death and HF hospitalization, this endpoint was independently associated with LBBB (hazard ratio, 2.13; 95% CI, 1.38-3.29; P  < 0.001), but not with RBBB.

CONCLUSION

In patients with standard pacemaker indications and normal or moderately depressed left ventricular function, the presence of basal RBBB was an independent predictor of mortality. However, it was not associated with the combined endpoint of cardiovascular death and HF hospitalization.

An electrocardiogram-based AI algorithm for early detection of pulmonary hypertension

BACKGROUND

Early diagnosis of pulmonary hypertension (PH) is critical for effective treatment and management. We aimed to develop and externally validate an artificial intelligence algorithm that could serve as a PH screening tool, based on analysis of a standard 12-lead ECG.

METHODS

The PH Early Detection Algorithm (PH-EDA) is a convolutional neural network developed using retrospective ECG voltage-time data, with patients classified as "PH-likely" or "PH-unlikely" (controls) based on right heart catheterisation or echocardiography. In total, 39 823 PH-likely patients and 219 404 control patients from Mayo Clinic were randomly split into training (48%), validation (12%) and test (40%) sets. ECGs taken within 1 month of PH diagnosis (diagnostic dataset) were used to train the PH-EDA at Mayo Clinic. Performance was tested on diagnostic ECGs within the test sets from Mayo Clinic (n=16 175/87 998 PH-likely/controls) and Vanderbilt University Medical Center (VUMC; n=6045/24 256 PH-likely/controls). In addition, performance was tested on ECGs taken 6-18 months (pre-emptive dataset), and up to 5 years prior to a PH diagnosis at both sites.

RESULTS

Performance testing yielded an area under the receiver operating characteristic curve (AUC) of 0.92 and 0.88 in the diagnostic test sets at Mayo Clinic and VUMC, respectively, and 0.86 and 0.81, respectively, in the pre-emptive test sets. The AUC remained a minimum of 0.79 at Mayo Clinic and 0.73 at VUMC up to 5 years before diagnosis.

CONCLUSION

The PH-EDA can detect PH at diagnosis and 6-18 months prior, demonstrating the potential to accelerate diagnosis and management of this debilitating disease.

Electrocardiographic abnormalities in patients with sickle cell disease: A systematic review and meta-analysis

BACKGROUND

Previous studies have documented that electrocardiography (ECG) can reveal a range of abnormalities, offering valuable insights into the cardiac evaluation of patients with sickle cell disease (SCD). The objective of this study is to assess the patterns of ECG abnormalities observed in these patients with SCD, and to determine their prevalence.

METHOD

We systematically reviewed the literature using online databases of PubMed, Scopus, Web of Science, Embase, and Google Scholar to identify original studies that reported findings of standard ECG assessments in patients with SCD. Statistical analyses were performed using the random effects model. Additional analyses including sensitivity analysis and subgroup analysis were also conducted.

RESULTS

Analysis of data from 59 studies involving 897,920 individuals with SCD revealed that 75% of these patients had abnormal ECG findings (67%-81%), which were predominantly nonspecific ST-T changes, left ventricular hypertrophy, T-wave changes, prolonged corrected QT (QTc) interval, and ischemic changes. Besides, it was shown that these patients had significantly higher odds of having any ECG abnormalities (OR of 17.50, 4.68-65.49), right atrial enlargement (6.09, 1.48-25.09), left ventricular hypertrophy (3.45, 1.73-6.89), right ventricular hypertrophy (7.18, 2.28-22.57), biventricular hypertrophy (10.11, 1.99-51.38), prolonged QTc interval (5.54, 2.44-12.59), ST depression (3.34, 1.87-5.97), and T-wave changes (5.41, 1.43-20.56). Moreover, the mean of QTc interval was significantly higher among those with SCD (23.51 milliseconds, 16.08-30.94).

CONCLUSION

Our meta-analysis showed a higher prevalence of abnormal ECG findings among individuals with SCD. A significant proportion of these patients had various ECG abnormalities, suggesting a potential need for regular ECG assessments for patients with SCD.

Electrocardiographic Changes after Endovascular Mechanical Thrombectomy in a Patient with Pulmonary Embolism-A Case Report and Literature Review

Background: Pulmonary embolism (PE) is a common disease with an annual incidence of about 1/1000 persons. About every sixth patient dies within the first 30 days after diagnosis. The electrocardiogram (ECG) is one of the first diagnostic tests performed, and is able to confirm the suspicion of PE with typical electrocardiographic signs. Some ECG signs and their regression are also prognostically relevant. Endovascular mechanical thrombectomy is one option for PE treatment, and aims to relieve right heart strain immediately. The first studies on endovascular mechanical thrombectomy using a dedicated device (FlowTriever System, Inari Medical, Irvine, CA, USA) yielded promising results. Methods: In the following, we report the case of a 66-year-old male patient who presented with New York Heart Association III dyspnea in our emergency department. Among typical clinical and laboratory results, he displayed very impressive electrocardiographic and radiological findings at the time of PE diagnosis. Results: After endovascular mechanical thrombectomy, the patient's complaints and pulmonary hemodynamics improved remarkably. In contrast, the ECG worsened paradoxically 18 h after intervention. Nevertheless, control echocardiography 4 days after the intervention no longer showed any signs of right heart strain, and dyspnea had disappeared completely. At a 4-month follow-up visit, the patient presented as completely symptom-free with a high quality of life. His ECG and echocardiography were normal and excluded recurrent right heart strain. Conclusions: Overall, the patient benefitted remarkably from endovascular mechanical thrombectomy, resulting in an almost complete resolution of electrocardiographic PE signs at the 4-month follow-up after exhibiting multiple typical electrocardiographic PE signs at time of diagnosis and initial electrocardiographic worsening 18 h post successful intervention.

The Early Detection of Pulmonary Hypertension

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.

What changed after the 2022 guidelines for pulmonary hypertension?

With an estimated prevalence of around 1%, pulmonary hypertension (PH) presents a relevant burden worldwide. In this review, we aim to give an overview of the novelties from the revised European Society of Cardiology (ESC) /European Respiratory Society (ERS) guidelines for the diagnosis and treatment of PH and their implication for the everyday clinical practice.

Electrocardiographic manifestations of pulmonary stenosis versus pulmonary hypertension

BACKGROUND

Right ventricular hypertrophy can be caused by conditions such as pulmonary stenosis and pulmonary hypertension. ECG is a readily available and affordable test, the aim of this study was the evaluation of the electrocardiographic aspects of pulmonary stenosis, and pulmonary hypertension.

METHODS

A list of patients diagnosed with isolated pulmonary stenosis and pulmonary hypertension patients hospitalized and treated between 2019 and 2021 were extracted from the hospital archives. Furthermore, the ECG of the patients was analyzed in terms of the prevalence of the variables in the study using FECG Caliper software. Finally, the data of 93 patients (in both groups) were analyzed.

RESULTS

In this study, 46 patients were in the severe pulmonary stenosis group, and 49 were in the severe or moderate-to-severe pulmonary hypertension group. The heart rate in the pulmonary hypertension group was significantly higher. R/S > 1 in precordial leads differs between the two groups and higher amplitude R wave in V1(p-value = 0.05). in the pulmonary stenosis group. While in the pulmonary hypertension group, R wave growth occurs later, and this ratio is greater than one after V4. Bundle block in the form of RBBB(p-value <0.001) and maximum QRS duration is more in the pulmonary stenosis group(p-value = 0.001).

CONCLUSION

Our findings show the different strains of the right ventricle in two groups. It can be concluded that the effects of severe pulmonary stenosis on the ECG are more on the QRS wave and in the form of a block, while severe pulmonary hypertension affects the ST segment and T wave.