New electrocardiographic criteria for diagnosing right ventricular hypertrophy in mitral stenosis--comparison with the Bonner's and Mortara's criteria

ECG Markers of Hemodynamic Improvement in Patients with Pulmonary Hypertension

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. R_V1, max⁡R_V1,2 + max⁡S_I,aVL − S_V1, and P_II improved along with the improvement of hemodynamic parameters including PVR. They predicted hemodynamic improvement with similarly good accuracy as shown in ROC analysis: R_V1 (AUC: 0.75; 95% CI: 0.63–0.84), P_II (AUC: 0.67, 95% CI: 0.56–0.77), and max⁡R_V1,2 + max⁡S_I,aVL − S_V1 (0.73; 95% CI: 0.63–0.82). In Cox regression only change in R_V1 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 R_V1, max⁡R_V1,2 + max⁡S_I,aVL − S_V1, and P_II corresponds with hemodynamic improvement after treatment. Of these changes a decrease of R wave amplitude in V₁ is associated with better survival.

An interoperable system for automated diagnosis of cardiac abnormalities from electrocardiogram data

Electrocardiogram (ECG) data are stored and analyzed in different formats, devices, and computer platforms. As a result, ECG data from different monitoring devices cannot be displayed unless the user has access to the proprietary software of each particular device. This research describes an ontology and encoding for representation of ECG data that allows open exchange and display of ECG data in a web browser. The ontology is based on the Health Level Seven (HL7) medical device communication standard. It integrates ECG waveform data, HL7 standard ECG data descriptions, and cardiac diagnosis rules, providing a capability to both represent ECG waveforms as well as perform automated diagnosis of 37 different cardiac abnormalities. The ECG ontology is encoded in XML, thus allowing ECG data from any digital ECG device that maps to it to be displayed in a general-purpose Internet browser. An experiment was conducted to test the interoperability of the system (ability to openly share ECG data without error in a web browser) and also to assess the accuracy of the diagnosis model. Results showed 100% interoperability using 276 ECG data files and 93% accuracy in diagnosis of abnormal cardiac conditions.

Predictive values of the electrocardiogram in diagnosing pulmonary hypertension

OBJECTIVE

Determination of the prevalences and predictive values of specific electrocardiograms (ECG) criteria of right ventricular hypertrophy (RVH) or right atrial enlargement for pulmonary hypertension.

METHODS

We examined the ECG and trans-thoracic echocardiograms (TTE) of 372 patients who had TTE and 12-lead ECG, performed within 24 h interval, during a 12-month period. There were 282 consecutive adults with pulmonary hypertension (pulmonary artery systolic pressure (PASP) >30 mm Hg) and 90 subjects with normal cardiac anatomy and normal PASP. The mean age of patients with pulmonary hypertension was 74.0+/-11.0 years and 66% of them were females. The control subjects had a mean age of 56.3+/-17.5 years and 58.8% were females.

RESULTS

ECG patterns focusing on the R and S amplitudes and R/S ratio in V1 were more predictive of pulmonary hypertension than ECG patterns involving leads V5 and V6. In particular, each of the following ECG patterns had good positive predictive values for pulmonary hypertension (greater than 80%): R in I less than 2 mm+S in V1</=2 mm, R/S in V1 more than 1, R/S V6 less than 1, QRS axis more than 110 degrees , qR in V1. Right axis deviation with QRS axis more than 110 degrees had the best positive predictive value of severe pulmonary hypertension (PASP>/=60 mm Hg). Electrocardiographic criterion for right atrial enlargement was not found in any of the patients with pulmonary hypertension.

CONCLUSIONS

ECG criteria of RVH were rare in patients with pulmonary hypertension. ECG patterns focusing on the R and S amplitude in V1 and right axis deviation with QRS axis deviation>/=110 degrees had excellent positive predictive values of pulmonary hypertension. However, the absence of ECG criteria of RVH could not exclude with certainty the presence of pulmonary hypertension.

Precordial leads QRST time integrals for evaluation of right ventricular overload in children with congenital heart diseases

It was previously shown that body surface QRST isointegral maps of the anterior chest were abnormal in patients with right ventricular overload and that the abnormalities varied with hemodynamic status. The QRST isointegral maps were first characterized by using a departure index map for normal controls. The study group consisted of 14 patients with pulmonary stenosis (PS), 20 with tetralogy of Fallot, (TOF) and 43 with atrial septal defect (ASD). The QRST isointegral maps of these three groups were compared with the data on 23 to 65 age-matched normal children. In mean departure index maps, the patients with right ventricular pressure overload (PS or TOF) showed an increase in departure index on the anterior midchest, while those of right ventricular volume overload (ASD) showed two maxima on the anterior and left lateral chest, with a trough-like negative area between them. Since the abnormal findings were seen on the anterior chest, we evaluated the diagnostic usefulness of QRST time integral values for precordial leads of the routine electrocardiogram (ECG) in a second part of this study. The precordial QRST time integral values from 9 patients with PS and 11 with TOF (0-2 years of age, mean 1.1 years) and 22 ASD patients (6-15 years, mean 10.1 years) were compared with those of the age-matched control children. The QRST time integral values of the precordial leads in right ventricular pressure overload were significantly increased in the right precordial leads (V1, V2). In right ventricular volume overload, the QRST time integral values of the V1, V2, V4, and V6 leads demonstrated a significant deviation from those of the control group. Therefore, a discrimination formula was constructed by using the values of these leads, and the criteria derived from this formula revealed good (98%) diagnostic accuracy. In detection of right ventricular overload, the QRST time integral values of the precordial lead ECG, if confirmed in a larger data set, may be useful as a simple screening method.

QRST isointegral map reflects the sudden reduction of right ventricular pressure after balloon pulmonary valvuloplasty

To elucidate the mechanism of electrocardiographic changes due to right ventricular pressure overload, serial changes on body surface maps recorded in two children with valvular pulmonary stenosis before and after successful reduction of right ventricular pressure by balloon valvuloplasty (BVP) were studied. Body surface maps and 12-lead electrocardiograms were simultaneously recorded before and 1-1.5 hours, 8 hours, and 5 days after BVP. Before BVP, QRST isointegral maps showed either two maxima or an expanded single maximum on the right anterior chest. These abnormal characteristics become normal or near normal 1-1.5 hours after BVP. Electrocardiographic waveforms and QRS and ST-T isointegral maps showed minimal changes. Changes in QRST isointegral maps were observed near the center of the midanterior chest. These results suggest that increased right ventricular pressure caused a primary repolarization abnormality in the mid-anterior chest that was easily detected by body surface QRST isointegral maps.