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Valente D, Segreti A, Celeski M, Polito D, Vicchio L, Di Gioia G, Ussia GP, Antonelli-Incalzi R, Grigioni F. Electrocardiographic alterations in chronic obstructive pulmonary disease. J Electrocardiol 2024; 85:58-65. [PMID: 38865856 DOI: 10.1016/j.jelectrocard.2024.05.083] [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: 02/11/2024] [Revised: 04/26/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024]
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality, and its incidence has grown within several years, quickly becoming the third leading cause of mortality. The disease is characterized by alveolar destruction, air-trapping, and chronic inflammation due to persistent exposure to a large spectrum of harmful particles. The diagnosis of COPD is made by demonstration of persistent and not fully reversible airflow limitation, and different phenotypes may be recognized based on pathophysiological, clinical, and radiological features. However, COPD is a systemic disease with effects involving several organs. For example, mechanical and functional alterations secondary to COPD involve heart function. Indeed, cardiovascular diseases are highly prevalent in patients affected by COPD and represent the primary cause of mortality in such patients. An electrocardiogram is a simple and cheap test that gives much information about the heart status of COPD patients. Consequently, variations from "normality" can be appreciated in these patients, with the most frequent abnormalities being P-wave, QRS axis, and ventricular repolarization abnormalities, in addition to conduction alterations and a vast number of arrhythmias. As a result, ECG should be routinely performed as a valuable tool to recognize alterations due to COPD (i.e., mechanical and functional) and possible associated heart diseases. This review aims to describe the typical ECG features in most COPD patients and to provide a systematic summary that can be used in clinical practice.
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Affiliation(s)
- Daniele Valente
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Andrea Segreti
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy.
| | - Mihail Celeski
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Dajana Polito
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Luisa Vicchio
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Giuseppe Di Gioia
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy; Institute of Sports Medicine and Science, National Italian Olympic Committee, Rome, Italy
| | - Gian Paolo Ussia
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Raffaele Antonelli-Incalzi
- Research Unit of Geriatrics, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Internal Medicine, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Francesco Grigioni
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Kazibwe R, Ahmad MI, Luqman-Arafat T, Chen H, Yeboah J, Soliman EZ. Relationship between abnormal P-wave axis, chronic obstructive pulmonary disease and mortality in the general population. J Electrocardiol 2023; 79:100-107. [PMID: 37030109 DOI: 10.1016/j.jelectrocard.2023.03.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/21/2023] [Accepted: 03/26/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND It is unclear whether the presence of a vertical P-wave axis on electrocardiogram modifies the association of COPD with mortality. OBJECTIVE To examine the association and interaction of abnormal P-wave axis and COPD with mortality. STUDY DESIGN AND METHODS The analysis included 7359 with ECG data from the Third National Health and Nutrition Examination Survey (NHANES-III) who were free of cardiovascular disease (CVD) at enrollment. Abnormal P-wave axis (aPWA) was defined as values above 75°. COPD was self-reported as either a diagnosis of emphysema or chronic bronchitis. National Death Index was used to identify the date of death and cause of death. Using multivariable Cox proportional hazard analysis, we examined the association of COPD with all-cause mortality by aPWA status. RESULTS Over a median follow-up of 14 years, 2435 deaths occurred. Participants with concomitant presence of aPWA and COPD experienced higher death rates (73.9 per 1000 person-years (PY)) compared to either COPD or aPWA alone (36.4 per 1000 PY and 31.1 per 1000 PY), respectively. In multivariable-adjusted models, a stronger association between COPD and mortality was noted in the presence compared to the absence of aPWA (HR 95% CI): 1.71 (1.37-2.13) vs. 1.22(1.00-1.49), respectively (interaction P-value = 0.02). Similarly, a stronger association between aPWA and mortality was observed in the presence compared to the absence of COPD (HR 95% CI): 1.66(1.26-2.19) vs. 1.18(1.06-1.31), respectively (interaction P-value = 0.02). Similar higher death rates and mortality risk was observed when spirometry-confirmed COPD and aPWA were present together than in isolation. CONCLUSION The concomitant presence of aPWA and COPD leads to a significantly higher mortality rate compared to the presence either COPD or aPWA alone as a clinical variable. P-wave axis, reported routinely on ECG printout, can potentially identify patients with COPD who need intensive control of risk factors and disease management.
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Evaluation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbation in the Emergency Department. Emerg Med Clin North Am 2022; 40:539-563. [DOI: 10.1016/j.emc.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Otake S, Chubachi S, Nakayama S, Sakurai K, Irie H, Hashiguchi M, Itabashi Y, Yamada Y, Jinzaki M, Murata M, Nakamura H, Asano K, Fukunaga K. Clinical Utility of the Electrocardiographic P-Wave Axis in Patients with Chronic Obstructive Pulmonary Disease. Respiration 2021; 101:345-352. [PMID: 34784604 DOI: 10.1159/000519668] [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: 03/21/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The vertical P-wave axis on electrocardiography (ECG) is a useful criterion for screening patients with chronic obstructive pulmonary disease (COPD). This study aimed to investigate the clinical characteristics of patients with COPD with a vertical P-wave axis as they have not yet been elucidated. METHODS Keio University and its affiliated hospitals conducted an observational COPD cohort study over 3 years. We analyzed 201 patients using ECG and chest computed tomography. RESULTS The severity of airflow limitation was higher in patients with a P-wave axis >75° than in those with a P-wave axis ≤75°. Patients with a P-wave axis >75° exhibited significantly higher total COPD assessment test scores and increased St. George's Respiratory Questionnaire total, activity, and impact scores than those with a P-wave axis ≤75°. The incidence of exacerbations over 1 and 3 years was significantly higher in patients with a P-wave axis >75° than in those with a P-wave axis ≤75°. The optimal cutoff for the P-wave axis for a percentage of the predicted forced expiratory volume in 1 s <50% and future exacerbations over 3 years was 70° (the areas under the curve [AUC]: 0.788; sensitivity: 65.3%; specificity: 78.3%) and 79° (AUC: 0.642; sensitivity: 36.7%; specificity: 92.6%). The ratio of the low attenuation area was also significantly higher in patients with a P-wave axis >75° than in those with a P-wave axis ≤75°. However, the ratio of the airway wall area did not differ between the 2 groups. CONCLUSIONS Patients with COPD with a vertical P-wave axis exhibited severe airflow limitation and emphysema, a worse health status, and more frequent exacerbation than patients without a vertical P-wave. Detection of the vertical P-wave axis by ECG is beneficial for the management of patients with COPD.
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Affiliation(s)
- Shiro Otake
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shotaro Chubachi
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shingo Nakayama
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kaori Sakurai
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidehiro Irie
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mizuha Hashiguchi
- Division of Pulmonary Medicine, Department of Medicine, Keiyu Hospital, Yokohama, Japan
| | - Yuji Itabashi
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshitake Yamada
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Jinzaki
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuru Murata
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidetoshi Nakamura
- Division of Pulmonary Medicine, Saitama Medical University Hospital, Saitama, Japan
| | - Koichiro Asano
- Division of Pulmonary Medicine, Department of Medicine, Tokai University, School of Medicine, Kanagawa, Japan
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
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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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Alter P, Watz H, Kahnert K, Rabe KF, Biertz F, Fischer R, Jung P, Graf J, Bals R, Vogelmeier CF, Jörres RA. Effects of airway obstruction and hyperinflation on electrocardiographic axes in COPD. Respir Res 2019; 20:61. [PMID: 30917825 PMCID: PMC6437876 DOI: 10.1186/s12931-019-1025-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/12/2019] [Indexed: 12/14/2022] Open
Abstract
Background COPD influences cardiac function and morphology. Changes of the electrical heart axes have been largely attributed to a supposed increased right heart load in the past, whereas a potential involvement of the left heart has not been sufficiently addressed. It is not known to which extent these alterations are due to changes in lung function parameters. We therefore quantified the relationship between airway obstruction, lung hyperinflation, several echo- and electrocardiographic parameters on the orientation of the electrocardiographic (ECG) P, QRS and T wave axis in COPD. Methods Data from the COPD cohort COSYCONET were analyzed, using forced expiratory volume in 1 s (FEV1), functional residual capacity (FRC), left ventricular (LV) mass, and ECG data. Results One thousand, one hundred and ninety-five patients fulfilled the inclusion criteria (mean ± SD age: 63.9 ± 8.4 years; GOLD 0–4: 175/107/468/363/82). Left ventricular (LV) mass decreased from GOLD grades 1–4 (p = 0.002), whereas no differences in right ventricular wall thickness were observed. All three ECG axes were significantly associated with FEV1 and FRC. The QRS axes according to GOLD grades 0–4 were (mean ± SD): 26.2° ± 37.5°, 27.0° ± 37.7°, 31.7° ± 42.5°, 46.6° ± 42.2°, 47.4° ± 49.4°. Effects of lung function resulted in a clockwise rotation of the axes by 25°-30° in COPD with severe airway disease. There were additional associations with BMI, diastolic blood pressure, RR interval, QT duration and LV mass. Conclusion Significant clockwise rotations of the electrical axes as a function of airway obstruction and lung hyperinflation were shown. The changes are likely to result from both a change of the anatomical orientation of the heart within the thoracic cavity and a reduced LV mass in COPD. The influences on the electrical axes reach an extent that could bias the ECG interpretation. The magnitude of lung function impairment should be taken into account to uncover other cardiac disease and to prevent misdiagnosis. Electronic supplementary material The online version of this article (10.1186/s12931-019-1025-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Peter Alter
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Baldingerstrasse 1, 35033, Marburg, Germany.
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Kathrin Kahnert
- Department of Internal Medicine V, Ludwig Maximilians University (LMU), Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Klaus F Rabe
- Department of Internal Medicine, LungenClinic Grosshansdorf and Christian-Albrechts University, Kiel, Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Frank Biertz
- Institute for Biostatistics, Center for Biometry, Medical Informatics and Medical Technology, Hannover Medical School, Hannover, Germany
| | - Ronald Fischer
- Institute for Biostatistics, Center for Biometry, Medical Informatics and Medical Technology, Hannover Medical School, Hannover, Germany
| | | | - Jana Graf
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig Maximilians University (LMU), Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Ziemssenstrasse 1, 80336, Munich, Germany
| | - Robert Bals
- Department of Internal Medicine V - Pulmonology, Allergology, Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Baldingerstrasse 1, 35033, Marburg, Germany
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig Maximilians University (LMU), Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Ziemssenstrasse 1, 80336, Munich, Germany.
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Sandau KE, Funk M, Auerbach A, Barsness GW, Blum K, Cvach M, Lampert R, May JL, McDaniel GM, Perez MV, Sendelbach S, Sommargren CE, Wang PJ. Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e273-e344. [DOI: 10.1161/cir.0000000000000527] [Citation(s) in RCA: 166] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kleiven Ø, Ørn S. P-wave axis as a predictor of mortality. Eur J Prev Cardiol 2017; 24:1991-1993. [PMID: 29083242 DOI: 10.1177/2047487317739044] [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: 11/17/2022]
Affiliation(s)
- Øyunn Kleiven
- 1 Cardiology Department, Stavanger University Hospital, Stavanger, Norway
| | - Stein Ørn
- 1 Cardiology Department, Stavanger University Hospital, Stavanger, Norway.,2 Department of Electrical Engineering and Computer Science, University of Stavanger, Stavanger, Norway
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Lazzeroni D, Bini M, Camaiora U, Castiglioni P, Moderato L, Ugolotti PT, Brambilla L, Brambilla V, Coruzzi P. Predictive role of P-wave axis abnormalities in secondary cardiovascular prevention. Eur J Prev Cardiol 2017; 24:1994-1999. [PMID: 28969493 DOI: 10.1177/2047487317734892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Abnormal P-wave axis has been correlated with an increased risk of all-cause and cardiovascular mortality in a general population. We aimed to evaluate the prognostic role of abnormal P-wave axis in patients undergoing myocardial revascularisation or cardiac valve surgery. Methods We considered data of 810 patients with available P-wave axis measure from a prospective monocentric registry of patients undergoing cardiovascular rehabilitation. A total of 436 patients (54%) underwent myocardial revascularisation, 253 (31%) valve surgery, 71 (9%) combined valve and coronary artery bypass graft surgery and 50 (6%) cardiac surgery for other cardiovascular disease. Mean follow-up was 47 ± 27 months. Results Over the whole group, P-wave axis was 43.8° ± 27.5° and an abnormal P-wave axis was found in 94 patients (12%). The risk of overall (hazard ratio (HR) 2.5, 95% confidence interval (CI) 1.6-4.0, P < 0.001) and cardiovascular mortality (HR 2.9, 95% CI 1.5-5.8, P = 0.002) was significantly higher in patients with abnormal P-wave axis even after adjustment for age, other electrocardiographic variables (PR, QRS, QTc intervals), left ventricular ejection fraction and left atrial volume index. After dividing the population according to the type of disease, patients with abnormal P-wave axis and ischaemic heart disease had 3.9-fold higher risk of cardiovascular mortality (HR 3.9, 95% CI 1.3-12.1, P = 0.017), while a 2.2-fold higher risk of cardiovascular mortality (HR 3.6, 95% CI 1.3-10.1, P = 0.015) was found in those with cardiac valve disease. Conclusion An abnormal P-wave axis represents an independent predictor of both overall and cardiovascular mortality in patients undergoing myocardial revascularisation or cardiac valve surgery.
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Affiliation(s)
| | - Matteo Bini
- 2 Department of Medicine and Surgery, University of Parma, Italy
| | | | | | - Luca Moderato
- 2 Department of Medicine and Surgery, University of Parma, Italy
| | | | | | | | - Paolo Coruzzi
- 2 Department of Medicine and Surgery, University of Parma, Italy
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Larssen MS, Steine K, Hilde JM, Skjørten I, Hodnesdal C, Liestøl K, Gjesdal K. Mechanisms of ECG signs in chronic obstructive pulmonary disease. Open Heart 2017; 4:e000552. [PMID: 28533915 PMCID: PMC5437720 DOI: 10.1136/openhrt-2016-000552] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/29/2016] [Accepted: 01/03/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Patients with chronic obstructive pulmonary disease (COPD) often have abnormal ECGs. Our aim was to separate the effects on ECG by airway obstruction, emphysema and right ventricular (RV) afterload in patients with COPD. METHODS A cross-sectional study was performed on 101 patients with COPD without left heart disease and 32 healthy age-matched controls. Body mass index (BMI) was measured, and pulmonary function tests, ECG, echocardiography and right heart catheterisation (only patients) were performed. Variables were grouped into (1) airway obstruction by FEV% (percentage of forced expiratory volume)_predicted, (2) emphysema by residual volume/total lung capacity and residual volume (percent of predicted) and (3) RV afterload by mean pulmonary pressure, artery compliance, vascular resistance and RV wall thickness. RESULTS In multivariate regression analysis, emphysema correlated negatively to R+S amplitudes in horizontal and frontal leads, RV/left ventricle (LV) end-diastolic volume ratio to horizontal amplitudes and BMI negatively to frontal amplitudes. Increased airway obstruction, RV afterload and BMI correlated with horizontal QRS-axis clockwise rotation. Airway obstruction, RV afterload, RV/LV end-diastolic volume ratio and BMI correlated to the Sokolow-Lyon Index for RV, and RV afterload negatively to Sokolow-LyonIndex for LV. Several classical ECG changes could, however, not be ascribed to specific mechanisms. CONCLUSIONS In COPD, the various pathophysiological mechanisms modify the ECG differently. Increased airway obstruction and RV afterload mainly increase the Sokolow-Lyon Index for RV mass and associate with clockwise rotation of the horizontal QRS-axis, whereas emphysema reduces the QRS amplitudes. BMI is an equally important determinant for the majority of the ECG changes.
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Affiliation(s)
- Marte Strømsnes Larssen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology Ullevål, Oslo University Hospital, Oslo, Norway
| | - Kjetil Steine
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Akershus University Hospital, Oslo, Norway
| | | | | | - Christian Hodnesdal
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology Ullevål, Oslo University Hospital, Oslo, Norway
| | - Knut Liestøl
- Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Knut Gjesdal
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology Ullevål, Oslo University Hospital, Oslo, Norway
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11
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Identification of electrocardiographic values that indicate chronic obstructive pulmonary disease. Heart Lung 2016; 45:359-62. [PMID: 27178740 DOI: 10.1016/j.hrtlng.2016.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 04/20/2016] [Accepted: 04/21/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this study was to investigate the association between respiratory function and electrocardiogram (ECG) characteristics in patients with chronic obstructive pulmonary disease (COPD), and to identify the ECG results that indicate possible COPD. METHODS The association between respiratory function and ECG results was retrospectively analyzed in 45 patients with COPD and 100 patients without COPD (controls). RESULTS Multiple logistic regression analysis revealed that QRS amplitude in lead І was a significant predictor of COPD (partial regression coefficient = -4.208, p = 0.002). Receiver operating characteristic curve analysis showed that a QRS amplitude less than 0.54 mV in lead І indicated possible COPD (sensitivity: 71%, specificity: 76%, area under the curve: 0.78 [95% confidence interval: 0.69-0.86], p < 0.001). CONCLUSION Low voltage in lead І (QRS less than 0.54 mV) is an important criterion in detecting COPD.
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12
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Suau SJ, DeBlieux PMC. Management of Acute Exacerbation of Asthma and Chronic Obstructive Pulmonary Disease in the Emergency Department. Emerg Med Clin North Am 2016; 34:15-37. [PMID: 26614239 DOI: 10.1016/j.emc.2015.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute asthma and chronic obstructive pulmonary disease (COPD) exacerbations are the most common respiratory diseases requiring emergent medical evaluation and treatment. Asthma and COPD are chronic, debilitating disease processes that have been differentiated traditionally by the presence or absence of reversible airflow obstruction. Asthma and COPD exacerbations impose an enormous economic burden on the US health care budget. In daily clinical practice, it is difficult to differentiate these 2 obstructive processes based on their symptoms, and on their nearly identical acute treatment strategies; major differences are important when discussing anatomic sites involved, long-term prognosis, and the nature of inflammatory markers.
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Affiliation(s)
- Salvador J Suau
- Louisiana State University, University Medical Center of New Orleans, 2000 Canal Street, D&T 2nd Floor - Suite 2720, New Orleans, LA 70112, USA.
| | - Peter M C DeBlieux
- Louisiana State University, University Medical Center of New Orleans, 2000 Canal Street, D&T 2nd Floor - Suite 2720, New Orleans, LA 70112, USA
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13
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Electrocardiographic characteristics in the underweight and obese in accordance with the World Health Organization classification. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.ijcme.2015.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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14
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Goudis CA, Konstantinidis AK, Ntalas IV, Korantzopoulos P. Electrocardiographic abnormalities and cardiac arrhythmias in chronic obstructive pulmonary disease. Int J Cardiol 2015. [DOI: 10.1016/j.ijcard.2015.06.096] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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15
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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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Effect of electrocardiographic P-wave axis on mortality. Am J Cardiol 2014; 113:372-6. [PMID: 24176072 DOI: 10.1016/j.amjcard.2013.08.050] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 11/20/2022]
Abstract
Although P-wave axis is routinely reported on the printouts of most contemporary electrocardiograms, the prognostic significance of its abnormality has not been systematically evaluated. We examined the association between abnormal P-wave axis and cardiovascular and all-cause mortality in 7,501 participants (53% women, mean age 59 years) from the United States Third National Health and Nutrition Examination Survey. P-wave axis of 0° to 75° was considered normal. Participants were linked to the National Death Index to identify the underlying cause of death listed on the death certificates using the International Classification of Disease. During a median follow-up of 13.8 years, a total of 2,541 deaths occurred; of which 1,077 were due to a cardiovascular cause. Abnormal P-wave axis was associated with 55% increased risk of all-cause mortality (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.43 to 1.69, p <0.01) and 41% increased risk of cardiovascular mortality (HR 1.41, 95% CI 1.24 to 1.62, p <0.01). After adjustment for age, gender, race/ethnicity, diabetes, systolic blood pressure, body mass index, smoking status, total/high-density lipoprotein cholesterol ratio, previous cardiovascular disease, chronic obstructive pulmonary disease, bronchial asthma, heart rate, and use of antiarrhythmic or atrioventricular nodal blocking drugs, the risk of mortality remained significantly high (HR 1.24 95% CI 1.13 to 1.36, p <0.01 for all-cause mortality and HR 1.19 95% CI 1.03 to 1.38, p = 0.02 for cardiovascular mortality) and was consistent across several subgroups of the participants. In conclusion, abnormal P-wave axis is associated with an increased risk of death, findings that call for attention to this routinely reported finding on contemporary electrocardiographic machines.
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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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Chhabra L, Chaubey VK, Kothagundla C, Bajaj R, Kaul S, Spodick DH. P-wave indices in patients with pulmonary emphysema: do P-terminal force and interatrial block have confounding effects? Int J Chron Obstruct Pulmon Dis 2013; 8:245-50. [PMID: 23690680 PMCID: PMC3656814 DOI: 10.2147/copd.s45127] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Pulmonary emphysema causes several electrocardiogram changes, and one of the most common and well known is on the frontal P-wave axis. P-axis verticalization (P-axis > 60°) serves as a quasidiagnostic indicator of emphysema. The correlation of P-axis verticalization with the radiological severity of emphysema and severity of chronic obstructive lung function have been previously investigated and well described in the literature. However, the correlation of P-axis verticalization in emphysema with other P-indices like P-terminal force in V1 (Ptf), amplitude of initial positive component of P-waves in V1 (i-PV1), and interatrial block (IAB) have not been well studied. Our current study was undertaken to investigate the effects of emphysema on these P-wave indices in correlation with the verticalization of the P-vector. MATERIALS AND METHODS Unselected, routinely recorded electrocardiograms of 170 hospitalized emphysema patients were studied. Significant Ptf (s-Ptf) was considered ≥40 mm.ms and was divided into two types based on the morphology of P-waves in V1: either a totally negative (-) P wave in V1 or a biphasic (+/-) P wave in V1. RESULTS s-Ptf correlated better with vertical P-vectors than nonvertical P-vectors (P = 0.03). s-Ptf also significantly correlated with IAB (P = 0.001); however, IAB and P-vector verticalization did not appear to have any significant correlation (P = 0.23). There was a very weak correlation between i-PV1 and frontal P-vector (r = 0.15; P = 0.047); however, no significant correlation was found between i-PV1 and P-amplitude in lead III (r = 0.07; P = 0.36). CONCLUSION We conclude that increased P-tf in emphysema may be due to downward right atrial position caused by right atrial displacement, and thus the common assumption that increased P-tf implies left atrial enlargement should be made with caution in patients with emphysema. Also, the lack of strong correlation between i-PV1 and P-amplitude in lead III or vertical P-vector may suggest the predominant role of downward right atrial distortion rather than right atrial enlargement in causing vertical P-vector in emphysema.
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Affiliation(s)
- Lovely Chhabra
- Department of Internal Medicine, University of Massachusetts Medical School, Plantation Street #813,Worcester, MA 01604, USA.
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MALIK MAREK, STOCKBRIDGE NORMAN. Thorough QT Studies and Indirect Causes of QTc Changes. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1411-2. [DOI: 10.1111/pace.12008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
This case report reviews the ECG manifestations of chronic obstructive pulmonary disease (COPD). Distinct changes of the P-wave axis, QRS axis and morphology are a direct result of the pathophysiological and anatomical changes associated with COPD. These changes are illustrated in a patient with a history of COPD presenting with hypoxaemia and symptoms of shortness of breath.
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Affiliation(s)
- Dante A Suffredini
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Brulotte CA, Lang ES. Acute exacerbations of chronic obstructive pulmonary disease in the emergency department. Emerg Med Clin North Am 2012; 30:223-47, vii. [PMID: 22487106 DOI: 10.1016/j.emc.2011.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality worldwide. Acute exacerbations of COPD (AECOPDs) are a common presentation to emergency departments and are an important cause of respiratory failure. This article discusses the disease process and diagnosis of COPD and AECOPD. A further in-depth discussion is undertaken of evidence-based treatments, palliation, and disposition of patients who present to emergency departments with AECOPD.
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Affiliation(s)
- Cory A Brulotte
- Department of Emergency Medicine, Alberta Health Services: Calgary Zone, Foothills Medical Center, 1403 29th Street Northwest, Room C231, Calgary, Alberta, Canada T2N 2T9.
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Chhabra L, Sareen P, Gandagule A, Spodick D. Computerized tomographic quantification of chronic obstructive pulmonary disease as the principal determinant of frontal P vector. Am J Cardiol 2012; 109:1046-9. [PMID: 22221942 DOI: 10.1016/j.amjcard.2011.11.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 11/07/2011] [Accepted: 11/07/2011] [Indexed: 11/29/2022]
Abstract
Verticalization of the P-wave axis is characteristic of chronic obstructive pulmonary disease (COPD). We studied the correlation of P-wave axis and computerized tomographically quantified emphysema in patients with COPD/emphysema. Individual correlation of P-wave axis with different structural types of emphysema was also studied. High-resolution computerized tomographic scans of 23 patients >45 years old with known COPD were reviewed to assess the type and extent of emphysema using computerized tomographic densitometric parameters. Electrocardiograms were then independently reviewed and the P-wave axis was calculated in customary fashion. Degree of the P vector (DOPV) and radiographic percent emphysematous area (RPEA) were compared for statistical correlation. The P vector and RPEA were also directly compared to the forced expiratory volume at 1 second. RPEA and the P vector had a significant positive correlation in all patients (r = +0.77, p <0.0001) but correlation was very strong in patients with predominant lower lobe emphysema (r = +0.89, p <0.001). Forced expiratory volume at 1 second and the P vector had almost a linear inverse correlation in predominantly lower lobe emphysema (r = -0.92, p <0.001). DOPV positively correlated with radiographically quantified emphysema. DOPV and RPEA were strong predictors of qualitative lung function in patients with predominantly lower lobe emphysema. In conclusion, a combination of high DOPV and predominantly lower lobe emphysema indicates severe obstructive lung dysfunction in patients with COPD.
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Affiliation(s)
- Lovely Chhabra
- Department of Internal Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, USA.
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Chhabra L, Sareen P, Gandagule A, Spodick DH. Visual computed tomographic scoring of emphysema and its correlation with its diagnostic electrocardiographic sign: the frontal P vector. J Electrocardiol 2012; 45:136-40. [PMID: 22244933 DOI: 10.1016/j.jelectrocard.2011.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Verticalization of the frontal P vector in patients older than 45 years is virtually diagnostic of pulmonary emphysema (sensitivity, 96%; specificity, 87%). We investigated the correlation of P vector and the computed tomographic visual score of emphysema (VSE) in patients with established diagnosis of chronic obstructive pulmonary disease/emphysema. METHODS High-resolution computed tomographic scans of 26 patients with emphysema (age, >45 years) were reviewed to assess the type and extent of emphysema using the subjective visual scoring. Electrocardiograms were independently reviewed to determine the frontal P vector. The P vector and VSE were compared for statistical correlation. Both P vector and VSE were also directly compared with the forced expiratory volume at 1 second. RESULTS The VSE and the orientation of the P vector (ÂP) had an overall significant positive correlation (r = +0.68; P = .0001) in all patients, but the correlation was very strong in patients with predominant lower-lobe emphysema (r = +0.88; P = .0004). Forced expiratory volume at 1 second and ÂP had almost a linear inverse correlation in predominant lower-lobe emphysema (r = -0.92; P < .0001). CONCLUSION Orientation of the P vector positively correlates with visually scored emphysema. Both ÂP and VSE are strong reflectors of qualitative lung function in patients with predominant lower-lobe emphysema. A combination of more vertical ÂP and predominant lower-lobe emphysema reflects severe obstructive lung dysfunction.
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Affiliation(s)
- Lovely Chhabra
- Department of Internal Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA.
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Chhabra L, Sareen P, Perli D, Srinivasan I, Spodick DH. Vertical P-wave axis: the electrocardiographic synonym for pulmonary emphysema and its severity. Indian Heart J 2012; 64:40-2. [PMID: 22572424 PMCID: PMC3861074 DOI: 10.1016/s0019-4832(12)60009-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The correlation between vertical P-wave axis (P-axis > 60°) and pulmonary emphysema was investigated on a very large controlled series to see if P-axis verticalisation as lone criterion can be effectively used to screen emphysema in general population. Correlation between degrees of P-axis verticalisation and the severity of the obstructive lung disease (as per global initiative for chronic obstructive lung disease [GOLD] criteria) was also studied to see if this criterion can be used for gross quantification of the chronic obstructive pulmonary disease (COPD) in routine clinical practice. MATERIALS AND METHODS Around 6500 unselected, routine electrocardiograms (ECGs) were reviewed which yielded 600 ECGs with vertical P-axis in sinus rhythm. 635 ECGs from the same continuum were selected with P-axis ≤60° matched for patient's age and sex serving as controls. Charts were reviewed for the diagnosis of COPD and emphysema based on medical history, pulmonary function tests, and imaging studies. RESULTS Prevalence of emphysema in patients with vertical P-axis was strikingly higher than in the control group: 85% vs 4.4%. The sensitivity and specificity of vertical P-axis for diagnosing emphysema was 94.76% and 86.47%, respectively. Vertical P-axis and forced expiratory volume (FEV1) were inversely correlated (Pearson correlation coefficient=-0.683). Prevalence of severe COPD was strikingly higher in patients with P-axis > 75° as compared to the group with P-axis 60°-75°: 96.3% vs 4.6%. Close to 80% of the emphysema patients with P-axis > 85° had very severe disease (FEV1 < 30%). CONCLUSION P-axis verticalisation is highly effective for screening emphysema and degree of verticalisation provides a gross quantification of the disease.
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Affiliation(s)
- Lovely Chhabra
- University of Massachusetts Medical School, Worcester, MA 01608, USA.
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Madias JE. Vertical P-wave axis and narrow QRS complexes: a diagnostic dyad for emphysema. Am J Cardiol 2011; 108:475-6. [PMID: 21757047 DOI: 10.1016/j.amjcard.2011.05.005] [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: 04/11/2011] [Accepted: 05/09/2011] [Indexed: 11/17/2022]
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