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Coleman JA, Doste R, Beltrami M, Coppini R, Olivotto I, Raman B, Bueno-Orovio A. Electrophysiological mechanisms underlying T wave pseudonormalisation on stress ECGs in hypertrophic cardiomyopathy. Comput Biol Med 2024; 169:107829. [PMID: 38096763 DOI: 10.1016/j.compbiomed.2023.107829] [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: 08/23/2023] [Revised: 11/09/2023] [Accepted: 12/04/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Pseudonormal T waves may be detected on stress electrocardiograms (ECGs) in hypertrophic cardiomyopathy (HCM). Either myocardial ischaemia or purely exercise-induced changes have been hypothesised to contribute to this phenomenon, but the precise electrophysiological mechanisms remain unknown. METHODS Computational models of human HCM ventricles (n = 20) with apical and asymmetric septal hypertrophy phenotypes with variable severities of repolarisation impairment were used to investigate the effects of acute myocardial ischaemia on ECGs with T wave inversions at baseline. Virtual 12-lead ECGs were derived from a total of 520 biventricular simulations, for cases with regionally ischaemic K+ accumulation in hypertrophied segments, global exercise-induced serum K+ increases, and/or increased pacing frequency, to analyse effects on ECG biomarkers including ST segments, T wave amplitudes, and QT intervals. RESULTS Regional ischaemic K+ accumulation had a greater impact on T wave pseudonormalisation than exercise-induced serum K+ increases, due to larger reductions in repolarisation gradients. Increases in serum K+ and pacing rate partially corrected T waves in some anatomical and electrophysiological phenotypes. T wave morphology was more sensitive than ST segment elevation to regional K+ increases, suggesting that T wave pseudonormalisation may sometimes be an early, or the only, ECG feature of myocardial ischaemia in HCM. CONCLUSIONS Ischaemia-induced T wave pseudonormalisation can occur on stress ECG testing in HCM before significant ST segment changes. Some anatomical and electrophysiological phenotypes may enable T wave pseudonormalisation due to exercise-induced increased serum K+ and pacing rate. Consideration of dynamic T wave abnormalities could improve the detection of myocardial ischaemia in HCM.
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Affiliation(s)
- James A Coleman
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Ruben Doste
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Raffaele Coppini
- Department of NeuroFarBa, University of Florence, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Meyer Children's Hospital IRCCS, Florence, Italy
| | - Betty Raman
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
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Li S, He J, Xu J, Zhuang B, Wu B, Wei B, Huang J, Yin G, Chen X, Zhu Z, Wang H, Zhao S, Lu M. Patients who do not fulfill criteria for hypertrophic cardiomyopathy but have unexplained giant T-wave inversion: a cardiovascular magnetic resonance mid-term follow-up study. J Cardiovasc Magn Reson 2021; 23:67. [PMID: 34078401 PMCID: PMC8173876 DOI: 10.1186/s12968-020-00700-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients who have unexplained giant T-wave inversions but do not meet criteria for hypertrophic cardiomyopathy (HCM) (left ventricular (LV) wall thickness < 1.5 cm) demonstrate LV apical morphological features that differ from healthy subjects. Currently, it remains unknown how the abnormal LV apical morphology in this patient population changes over time. The purpose of this study was to investigate LV morphological and functional changes in these patients using a mid-term cardiovascular magnetic resonance (CMR) exam. METHODS Seventy-one patients with unexplained giant T-wave inversion who did not fulfill HCM criteria were studied. The mean interval time of the follow-up CMR was 24.4 ± 8.3 months. The LV wall thickness was measured in each LV segment according to the American Heart Association 17-segmented model. The apical angle (ApA) was also measured. A receiver operating curve (ROC) was used to identify the predictive values of the CMR variables. RESULTS Of 71 patients, 16 (22.5%) progressed to typical apical HCM, while 55 (77.5%) did not progress to HCM criteria. The mean apical wall thickness was significantly different between the two groups at both baseline and follow-up, with the apical HCM group having greater wall thickness at both time points (all p < 0.001). There was a significant difference between the two groups in the change of ApA (- 1.5 ± 2.7°/yr vs. - 0.7 ± 2.0°/yr, p < 0.001) over time. The combination of mean apical wall thickness and ApA proved to be the best predictor for fulfilling criteria for apical HCM with a threshold value of 8.1 mm and 90° (sensitivity 93.8%, specificity 85.5%). CONCLUSIONS CMR metrics identify predictors for progression to HCM in patients with unexplained giant T-wave inversion.
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Affiliation(s)
- Shuang Li
- Department of Magnetic Resonance Imaging, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Jian He
- Department of Magnetic Resonance Imaging, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Jing Xu
- Department of Magnetic Resonance Imaging, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Baiyan Zhuang
- Department of Magnetic Resonance Imaging, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Bailing Wu
- Department of Radiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Bingqi Wei
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinghan Huang
- The Heart-Lung Testing Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gang Yin
- Department of Magnetic Resonance Imaging, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
- Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Xiuyu Chen
- Department of Magnetic Resonance Imaging, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China
- Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Zhenhui Zhu
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Wang
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Minjie Lu
- Department of Magnetic Resonance Imaging, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
- Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, 100037, China.
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Wu B, Lu M, Zhang Y, Song B, Ling J, Huang J, Yin G, Lan T, Dai L, Song L, Jiang Y, Wang H, He Z, Lee J, Yong HS, Patel MB, Zhao S. CMR assessment of the left ventricle apical morphology in subjects with unexplainable giant T-wave inversion and without apical wall thickness ≥15 mm. Eur Heart J Cardiovasc Imaging 2016; 18:186-194. [DOI: 10.1093/ehjci/jew045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/18/2016] [Indexed: 01/09/2023] Open
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Kim SS, Choi WH, Kim HY, Kim SH, Bang DH, Kang KW, An CH, Lim JG, Kwak JJ, Kwon SU, Doh JH, Namgung J, Lee SY, Lee WR. Clinical implications of T-wave inversion in an asymptomatic population undergoing annual medical screening (from the Korean Air Forces Electrocardiogram Screening). Am J Cardiol 2014; 113:1561-6. [PMID: 24731653 DOI: 10.1016/j.amjcard.2014.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 02/04/2014] [Accepted: 02/04/2014] [Indexed: 10/25/2022]
Abstract
This study aimed to determine prevalence, differentiate underlying causes, and identify the benign group in subjects with asymptomatic T-wave inversion (TWI). We retrospectively read 12-lead electrocardiograms from 3,929 consecutive asymptomatic men in the air force (3,929 participants, mean age 39.3 ± 8.7 years) who underwent medical screening at the Aerospace Medical Center, Korea, from September 2010 to August 2012. TWIs other than in right precordial leads (V1 and V2) were present in 23 men (0.6%). All subjects with persistent TWI for 1 year (n = 18) underwent additional study, with the exception of 1 patient who refused further evaluation. Of 17 subjects with investigated persistent TWI, 8 (47.1%) had an apically displaced papillary muscle, 5 (29.4%) exhibited idiopathic TWI, 3 (17.6%) had apical hypertrophic cardiomyopathy, and 1 (5.9%) had Maron type 2 hypertrophic cardiomyopathy with dynamic left ventricular outflow obstruction. The depth of TWI was significantly shallow in the benign group (idiopathic TWI, 1.6 ± 0.5 mm) compared with potentially nonbenign group (the others; 5.5 ± 3.3 mm, p = 0.021). Lateral lead TWI was significantly correlated with potentially nonbenign group (46% vs 0%, p = 0.049). In conclusion, asymptomatic TWI is not rare (0.6%), even in a healthy population such as Korean Air Force society, and at least 29.4% of subjects with TWI are considered to belong to the benign group that does not require aggressive evaluation and criteria of TWI ≤2 mm other than lateral leads without co-morbidity could help to distinguish the benign group from the potentially nonbenign group.
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Affiliation(s)
- Sung Su Kim
- Department of Cardiology, Chonnam National University Medical School, Gwangju, Korea
| | - Won Ho Choi
- Department of Internal Medicine, Vision 21 Cardiac and Vascular Center, Inje University College of Medicine, Ilsan Paik Hospital, Korea.
| | - Hyung Yoon Kim
- Department of Internal Medicine, Vision 21 Cardiac and Vascular Center, Inje University College of Medicine, Ilsan Paik Hospital, Korea
| | - Se Hun Kim
- Aerospace Medical Center, Republic of Korea Air Force, Cheongwon-gun, Korea
| | - Dong-Ho Bang
- Aerospace Medical Center, Republic of Korea Air Force, Cheongwon-gun, Korea
| | - Kyung Wook Kang
- Aerospace Medical Center, Republic of Korea Air Force, Cheongwon-gun, Korea
| | - Chang Ho An
- Aerospace Medical Center, Republic of Korea Air Force, Cheongwon-gun, Korea
| | - Jung Gu Lim
- Aerospace Medical Center, Republic of Korea Air Force, Cheongwon-gun, Korea
| | - Jae-Jin Kwak
- Department of Internal Medicine, Vision 21 Cardiac and Vascular Center, Inje University College of Medicine, Ilsan Paik Hospital, Korea
| | - Sung Uk Kwon
- Department of Internal Medicine, Vision 21 Cardiac and Vascular Center, Inje University College of Medicine, Ilsan Paik Hospital, Korea
| | - Joon Hyung Doh
- Department of Internal Medicine, Vision 21 Cardiac and Vascular Center, Inje University College of Medicine, Ilsan Paik Hospital, Korea
| | - June Namgung
- Department of Internal Medicine, Vision 21 Cardiac and Vascular Center, Inje University College of Medicine, Ilsan Paik Hospital, Korea
| | - Sung Yun Lee
- Department of Internal Medicine, Vision 21 Cardiac and Vascular Center, Inje University College of Medicine, Ilsan Paik Hospital, Korea
| | - Won Ro Lee
- Department of Internal Medicine, Vision 21 Cardiac and Vascular Center, Inje University College of Medicine, Ilsan Paik Hospital, Korea
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Pérez-Riera AR, de Lucca AA, Barbosa-Barros R, Yanowitz FG, de Cano SF, Cano MN, Palandri-Chagas AC. Value of electro-vectorcardiogram in hypertrophic cardiomyopathy. Ann Noninvasive Electrocardiol 2014; 18:311-26. [PMID: 23879271 DOI: 10.1111/anec.12067] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The electrocardiogram is an important tool for the initial diagnostic suspicion of hypertrophic cardiomyopathy in any of its forms, both in symptomatic and in asymptomatic patients because it is altered in more than 90 percent of the cases. Electrocardiographic anomalies are more common in patients carriers of manifest hypertrophic cardiomyopathy and the electrocardiogram alterations are earlier and more sensitive than the increase in left ventricular wall thickness detected by the echocardiogram. Nevertheless, despite being the leading cause of sudden death among young competitive athletes there is no consensus over the need to include the method in the pre-participation screening. In apical hypertrophic cardiomyopathy the electrocardiographic hallmarks are the giant negative T waves in anterior precordial leads. In the vectorcardiogram, the QRS loop is located predominantly in the left anterior quadrant and T loop in the opposite right posterior quadrant, which justifies the deeply negative T waves recorded. The method allows estimating the left ventricular mass because it relates to the maximal spatial vector voltage of the left ventricle in the QRS loop. The recording on electrocardiogram or Holter monitoring of nonsustained monomorphic ventricular tachycardia in patients with syncope, recurrent syncope in young patient, hypotension induced by strain, bradyarrhythmia, or concealed conduction are markers of poor prognosis. The presence of rare sustained ventricular tachycardia is observed in mid-septal obstructive HCM with apical aneurysm. The presence of complete right bundle branch block pattern is frequent after the percutaneous treatment and complete left bundle branch block is the rule after myectomy.
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