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Ren Y. The clinical value of P-wave terminal force in lead V1 in evaluating pericardial thickness in tuberculous constrictive pericarditis. J Cardiothorac Surg 2024; 19:89. [PMID: 38347560 PMCID: PMC10863288 DOI: 10.1186/s13019-024-02526-z] [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: 07/03/2023] [Accepted: 01/28/2024] [Indexed: 02/15/2024] Open
Abstract
AIM To investigate the relationship between p wave terminal force (Ptfv1) and pericardial thickness in patients with tuberculous constrictive pericarditis. METHODS From January 2018 to October 2022, 95 patients with tuberculous constrictive pericarditis who needed pericarditis dissection in a hospital were collected, and 3 patients who did not meet the criteria were excluded, a total of 92 cases. The absolute value of Ptfv1 in conventional electrocardiogram was tested before surgery, and pericardial thickness was measured by echocardiography and chest CT. Pericardial thickness was measured after pericardial dissection. Pearson correlation analysis was used, R software was used to make scatter plot, and non-parametric square test was used. The correlation of postoperative measurements with echocardiography, chest CT and absolute value of Ptfv1 was analyzed. RESULTS Pearson correlation analysis was conducted with postoperative measurements and echocardiography measurements, postoperative measurements and chest CT measurements, and postoperative measurements and absolute value of Ptfv1. Pearson correlation analysis showed that the correlation coefficients between postoperative measurements and echocardiography, chest CT and Ptfv1 values were statistically significant. Scatter plot and nonparametric Chi-square test showed that postoperative measurements were consistent with absolute values of echocardiography, chest CT and Ptfv1 (p < 0.05). And this study found that the distribution of the value of Ptfv1 ≥ 5 was higher than the value of Ptfv1 < 5 after pericardiectomy (0.95:0.05) in the absolute value of Ptfv1 ≥ 0.04 which measured before pericardiectomy. The hypothesis was statistically significant (p < 0.05). CONCLUSION The absolute value of Ptfv1 in electrocardiogram can be used as an auxiliary diagnostic index to evaluate pericardial thickness in tuberculous constrictive pericarditis.
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Affiliation(s)
- Yanhong Ren
- Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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2
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Fukuda Y, Nitta K, Morita Y, Higashihara T, Takeda A, Nakano T, Sada Y, Watanabe N, Ikenaga H, Nakano Y. P-Wave Terminal Force V1 Is Associated with Left Ventricular Diastolic Function in Patients with No Significant Perfusion Abnormality. Int Heart J 2022; 63:299-305. [PMID: 35354750 DOI: 10.1536/ihj.21-712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
P-wave terminal force in lead V1 (PTFV1) is a marker of increased left atrial (LA) overload. Whether PTFV1 is associated with left ventricular (LV) diastolic function remains undetermined. We tested the hypothesis that PTFV1 is associated with LV diastolic parameters derived from gated myocardial perfusion single-photon emission computed tomography (SPECT) in patients with no significant perfusion abnormalities.The study population included 158 patients with preserved ejection fraction and no significant perfusion abnormalities. The amplitude and duration of the P-wave negative phase in lead V1 were measured using an electrocardiogram, and PTFV1 was calculated. The peak filling rate (PFR) and one-third mean filling rate (1/3 MFR) were obtained as LV diastolic parameters using gated SPECT.PTFV1 showed a weak correlation with the LA volume index (r = 0.31; P < 0.001). Significant associations were observed between PTFV1 and PFR (r = -0.27; P < 0.001) and 1/3 MFR (r = -0.26; P = 0.001). A multivariate linear regression analysis showed that age (β = -0.26; P < 0.001), LV end-diastolic volume index (β = -0.27; P = 0.001), and PTFV1 (β = -0.15; P = 0.036) were significant factors associated with PFR. Moreover, male gender (β = -0.16; P = 0.041), LV mass index (β = -0.17; P = 0.046), and PTFV1 (β = -0.17; P = 0.022) were significant factors associated with the 1/3 MFR.PTFV1 is associated with LV diastolic function, as derived from gated SPECT in patients with no significant perfusion abnormalities.
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Affiliation(s)
- Yukihiro Fukuda
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuhiro Nitta
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yuichi Morita
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Tasuku Higashihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Atsushi Takeda
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Takayuki Nakano
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yoshiharu Sada
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Noriaki Watanabe
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
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Gupta P, Jain H, Gill M, Bharaj G, Khalid N, Chaudhry W, Chhabra L. Electrocardiographic changes in Emphysema. World J Cardiol 2021; 13:533-545. [PMID: 34754398 PMCID: PMC8554360 DOI: 10.4330/wjc.v13.i10.533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/25/2021] [Accepted: 09/26/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic obstructive lung disease (COPD), predominantly emphysema, causes several thoracic anatomical and hemodynamic changes which may cause changes in various electrocardiographic parameters. A 12-lead electrocardiogram (ECG), which is often a part of routine evaluation in most clinical settings, may serve as a useful screening modality for diagnosis of COPD or emphysema. Our current article aims to provide a comprehensive review of the electrocardiographic changes encountered in COPD/emphysema utilizing published PubMed and Medline literature database. Several important ECG changes are present in COPD/emphysema and may serve as a good diagnostic tool. Verticalization of P-vector, changes in QRS duration, pattern recognition of precordial R-wave progression and axial shifts can be considered some of the most valuable markers among other changes. In conclusion, 12-lead surface electrocardiogram can serve as a valuable tool for the diagnosis of COPD and/or emphysema. An appropriate knowledge of these ECG changes can not only help in the diagnosis but can also immensely help in an appropriate clinical management of these patients.
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Affiliation(s)
- Puneet Gupta
- Department of Interventional Cardiology, Northeast Ohio Medical University, Canton, OH 44272, United States
| | - Hitangee Jain
- BA-MD, Brooklyn College, Brooklyn, NY 11210, United States
| | - Misbah Gill
- Department of Family Medicine, Memorial Hospital of Carbondale, Carbondale, IL 62901, United States
| | - Gurpreet Bharaj
- Psychiatry, Loretto Hospital, Chicago, IL 60644, United States
| | - Nauman Khalid
- Department of Interventional Cardiology, St. Francis Medical Center, Monroe, LA 71201, United States
| | - Waseem Chaudhry
- Department of Cardiology, Westchester Medical Center Network Advanced Physician Services, Poughkeepsie, NY 12601, United States
| | - Lovely Chhabra
- Department of Cardiology, Westchester Medical Center Network Advanced Physician Services, Poughkeepsie, NY 12601, United States.
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4
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Lin H, Lin T, Lin L, Ye M. Roles of Morris Index on Poor Outcomes in Patients with Non-ST Segment Elevation Acute Coronary Syndrome. Med Sci Monit 2020; 26:e924418. [PMID: 33075040 PMCID: PMC7583546 DOI: 10.12659/msm.924418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background This study aimed to assess the roles of the Morris index in predicting poor outcomes in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). Material/Methods This study included 905 patients with newly diagnosed NSTE-ACS. The Morris index, also known as P wave terminal force in lead V1 (PTFV1), was recorded at admission and discharge. PTVF1 (+) was defined as an absolute value >0.04 mm·s, while PTFV1 (−) was defined as an absolute value <0.04 mm·s. Based on their PTFV1 values at admission/discharge, patients were divided into 4 groups: PTFV1 (−)/(−), PTFV1 (+)/(−), PTFV1 (−)/(+), and PTFV1 (+)/(+). Univariate and multivariate regression analyses were utilized to identify the variables that could contribute to NSTE-ACS risk. Results Compared with the PTFV1 (−)/(−) group, the incidence of poor outcomes was significantly higher in the PTFV1 (−)/(+) (hazard ratio [HR], 3.548; 95% confidence interval [95% CI], 2.024–6.219) and PTFV1 (+)/(+) (HR, 2.133; 95% CI, 1.141–3.986) groups, but not statistically different in the PTFV1 (+)/(−) group (risk ratio, 0.983; 95% CI, 0.424–2.277). Conclusions Primary PTFV1 (+) at discharge and PTFV1 (+) during hospitalization were independent risk factors for poor outcomes, which may provide useful prognostic information for patients with NSTE-ACS.
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Affiliation(s)
- Huizhong Lin
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China (mainland)
| | - Tao Lin
- Fujian Medical University, Fuzhou, Fujian, China (mainland)
| | - Lan Lin
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China (mainland)
| | - Mingfang Ye
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China (mainland)
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5
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Chhabra L. Abnormal P-terminal force and deep terminal negativity in V1 in conditions other than lead misplacement. J Electrocardiol 2019; 63:181-182. [PMID: 30786959 DOI: 10.1016/j.jelectrocard.2019.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/07/2019] [Accepted: 02/12/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Lovely Chhabra
- Heartland Regional Medical Center, Marion, IL 62959, USA; Southern Illinois University, Carbondale, IL, USA.
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6
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Chhabra L. Abnormal P-Wave Axis and Risk of Atrial Fibrillation: Not Just the Left Atrial Enlargement but Other Factors Also Play a Significant Role. Am J Cardiol 2018; 121:1445. [PMID: 29656780 DOI: 10.1016/j.amjcard.2018.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/12/2018] [Indexed: 11/19/2022]
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Ha LD, Grober AF, Hock J, Wheeler M, Elbadawi A, Biniwale N, Baig B, Froelicher V. Electrocardiographic left atrial abnormalities predict cardiovascular mortality. J Electrocardiol 2018; 51:652-657. [PMID: 29997006 DOI: 10.1016/j.jelectrocard.2018.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/24/2018] [Accepted: 04/27/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Clinical utilization of electrocardiography for diagnosis of left atrial abnormalities is hampered by variable P-wave morphologies, multiple empiric criteria, and lack of an imaging "gold standard". Our aim was to determine the prevalence of P-wave patterns and demonstrate which components have associations with cardiovascular death (CVD). METHODS This is a retrospective analysis of 20,827 veterans <56 years of age who underwent electrocardiograms at a Veteran's Affairs Medical Center from 1987 to 1999, followed for a median duration of 17.8 years for CVD. Receiver Operating Characteristic, Kaplan-Meier and Cox Hazard analyses were applied, the latter with adjustment for age, gender and electrocardiography abnormalities. RESULTS The mean age was 43.3 ± 8 years, and 888 CVD (4.3%) occurred. A single positive deflection of the P-wave (Pattern 1) was present in 29% for V1 and 81% for V2. A singular negative P-wave (Pattern 2) was present in 4.6% for V1 and 1.6% in V2. A P-wave with an upward component followed by downward component (Pattern 3) was present in 64.5% for V1 and 17.5% for V2. When the downward component in Patterns 2 and/or 3 is at least -100 μV, a significant association is observed with CVD (adjusted hazard ratios [HRs] 2.9-4.1, P < 0.001). Total P-wave duration ≥140 ms was also associated with CVD (adjusted HR 2.2, P < 0.001). CONCLUSIONS A negative P-wave in V1 or V2 ≤-100 μV, and P-wave with a duration of ≥140 ms, all have independent and significant associations with CVD, with HRs comparable to other electrocardiography abnormalities.
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Affiliation(s)
- Le Dung Ha
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, United States.
| | - Aaron F Grober
- Stanford University School of Medicine, Department of Medicine/Internal Medicine Residency Program, Stanford, CA, United States
| | - Julia Hock
- German Heart Center Munich, Technical University Munich, Department of Pediatric Cardiology and Congenital Heart Disease, Germany
| | - Matthew Wheeler
- The Division of Cardiovascular Medicine, Department of Medicine, Stanford School of Medicine, Stanford, CA, United States
| | - Ayman Elbadawi
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, United States
| | - Nishit Biniwale
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, United States
| | - Basarat Baig
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, United States
| | - Victor Froelicher
- The Division of Cardiovascular Medicine, Department of Medicine, Stanford School of Medicine, Stanford, CA, United States
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8
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Gurukripa Kowlgi N, Chhabra L. The role of P-wave indices in the diagnosis of emphysema. Int J Cardiol 2015; 201:148-9. [DOI: 10.1016/j.ijcard.2015.07.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
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9
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Affiliation(s)
- Lovely Chhabra
- Dept. of Cardiovascular Medicine, Hartford Hospital, University of Connecticut School of Medicine, Hartford, CT 06102, USA.
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10
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Christos GA. P-wave indices in emphysema. What do we actually know? Int J Cardiol 2015; 202:80. [PMID: 26397397 DOI: 10.1016/j.ijcard.2015.08.150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Goudis A Christos
- Department of Cardiology, Grevena General Hospital, Grevena, Greece.
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11
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Chhabra L, Chaubey VK, Spodick DH. Letter by Chhabra et al regarding article, "Prevalence and prognostic significance of abnormal P terminal force in lead V1 of the electrocardiogram in the general population". Circ Arrhythm Electrophysiol 2015; 8:243. [PMID: 25691561 DOI: 10.1161/circep.114.002646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lovely Chhabra
- Department of Cardiovascular Medicine, Hartford Hospital, University of Connecticut School of Medicine, Hartford
| | - Vinod K Chaubey
- Department of Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester
| | - David H Spodick
- Department of Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester
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12
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Eranti A, Aro AL, Kerola T, Anttonen O, Rissanen HA, Tikkanen JT, Junttila MJ, Kenttä TV, Knekt P, Huikuri HV. Response to letter regarding article, "Prevalence and prognostic significance of abnormal P terminal force in lead V1 of the electrocardiogram in the general population". Circ Arrhythm Electrophysiol 2015; 8:244. [PMID: 25691562 DOI: 10.1161/circep.115.002696] [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: 11/16/2022]
Affiliation(s)
- Antti Eranti
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Aapo L Aro
- Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Tuomas Kerola
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Olli Anttonen
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Harri A Rissanen
- Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare, Helsinki, Finland
| | - Jani T Tikkanen
- Department of Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital and University of Oulu, Oulu, Finland
| | - M Juhani Junttila
- Department of Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital and University of Oulu, Oulu, Finland
| | - Tuomas V Kenttä
- Department of Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital and University of Oulu, Oulu, Finland
| | - Paul Knekt
- Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare, Helsinki, Finland
| | - Heikki V Huikuri
- Department of Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital and University of Oulu, Oulu, Finland
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Snyder ML, Soliman EZ, Whitsel EA, Gellert KS, Heiss G. Short-term repeatability of electrocardiographic P wave indices and PR interval. J Electrocardiol 2013; 47:257-63. [PMID: 24360345 DOI: 10.1016/j.jelectrocard.2013.11.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND P wave indices and PR interval from 12-lead electrocardiograms (ECGs) are predictors of cardiovascular morbidity and mortality, but their repeatability has not been examined. OBJECTIVES Determine the short-term repeatability of P wave indices (P axis, maximum P area and duration, P dispersion and P terminal force in V1) and PR interval. METHODS Participants (n=63) underwent two standard ECGs at each of two visits, two weeks apart. We calculated the intra-class correlation coefficient (ICC), weighted kappa, and minimal detectable change and difference. RESULTS ICCs were 0.93 for PR interval, 0.78 for P axis, 0.77 for maximum P area, and 0.58 for maximum P duration. Within- and between-visit Kappa were 0.30 and 0.11 for P dispersion, and 0.68 and 0.46 for P terminal force. CONCLUSION Repeatability of PR duration was excellent, that of P wave axis and maximum area was fair, and maximum P wave duration and terminal force was poor. Repeatability of P wave dispersion was fair within visit, yet poor between visits. These results illustrate potential biases when measurement error of some P wave indices is ignored in clinical and epidemiologic studies.
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Affiliation(s)
- Michelle L Snyder
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center (EPICARE), Division of Public Health Sciences Wake Forest School of Medicine, Division of Public Health Sciences, Winston Salem, NC, USA
| | - Eric A Whitsel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kapuaola S Gellert
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gerardo Heiss
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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14
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Lanjewar SS, Chhabra L, Chaubey VK, Joshi S, Kulkarni G, Kothagundla C, Kaul S, Spodick DH. Diagnostic electrocardiographic dyad criteria of emphysema in left ventricular hypertrophy. Int J Chron Obstruct Pulmon Dis 2013; 8:591-4. [PMID: 24293995 PMCID: PMC3842216 DOI: 10.2147/copd.s50680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The electrocardiographic diagnostic dyad of emphysema, namely a combination of the frontal vertical P-vector and a narrow QRS duration, can serve as a quasidiagnostic marker for emphysema, with specificity close to 100%. We postulated that the presence of left ventricular hypertrophy in emphysema may affect the sensitivity of this electrocardiographic criterion given that left ventricular hypertrophy generates prominent left ventricular forces and may increase the QRS duration. METHODS We reviewed the electrocardiograms and echocardiograms for 73 patients with emphysema. The patients were divided into two groups based on the presence or absence of echocardiographic evidence of left ventricular hypertrophy. The P-vector, QRS duration, and forced expiratory volume in one second (FEV1) were computed and compared between the two subgroups. RESULTS There was no statistically significant difference in qualitative lung function (FEV1) between the subgroups. There was no statistically significant difference in mean P-vector between the subgroups. The mean QRS duration was significantly longer in patients with left ventricular hypertrophy as compared with those without left ventricular hypertrophy. CONCLUSION The presence of left ventricular hypertrophy may not affect the sensitivity of the P-vector verticalization when used as a lone criterion for diagnosing emphysema. However, the presence of left ventricular hypertrophy may significantly reduce the sensitivity of the electrocardiographic diagnostic dyad in emphysema, as it causes a widening of the QRS duration.
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Affiliation(s)
- Swapnil S Lanjewar
- Department of Internal Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA
| | - Lovely Chhabra
- Department of Internal Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA
| | - Vinod K Chaubey
- Department of Internal Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA
| | - Saurabh Joshi
- Department of Internal Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ganesh Kulkarni
- Department of Internal Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA
| | - Chandrasekhar Kothagundla
- Department of Internal Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sudesh Kaul
- Department of Internal Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA
| | - David H Spodick
- Department of Cardiovascular Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA
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