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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: 2] [Impact Index Per Article: 0.5] [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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Yamamoto H, Satomi K, Aizawa Y. Electrocardiographic manifestations in a large right-sided pneumothorax. BMC Pulm Med 2021; 21:101. [PMID: 33757495 PMCID: PMC7989373 DOI: 10.1186/s12890-021-01470-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/17/2021] [Indexed: 12/27/2022] Open
Abstract
Background Pneumothorax is an extrapulmonary air accumulation within the pleural space between the lung and chest wall. Once pneumothorax acquires tension physiology, it turns into a potentially lethal condition requiring prompt surgical intervention. Common symptoms are chest pain and dyspnea; hence an electrocardiogram (ECG) is often performed in emergent settings. However, early diagnosis of pneumothorax remains challenging since chest pain and dyspnea are common symptomatology in various life-threatening emergencies, often leading to overlooked or delayed diagnosis. While the majority of left-sided pneumothorax-related ECG abnormalities have been reported, right-sided pneumothorax-related ECG abnormalities remain elucidated. Case presentation A 51-year-old man presented to the emergency department with acute-onset chest pain and dyspnea. Upon initial examination, the patient had a blood pressure of 98/68 mmHg, tachycardia of 100 beats/min, tachypnea of 28 breaths/min, and oxygen saturation of 94% on ambient air. Chest auscultation revealed decreased breath sounds on the right side. ECG revealed sinus tachycardia, phasic voltage variation of QRS complexes in V4–6, P-pulmonale, and vertical P-wave axis. Chest radiographs and computed tomography (CT) scans confirmed a large right-sided pneumothorax. The patient’s symptoms, all the ECG abnormalities, and increased heart rate on the initial presentation resolved following an emergent tube thoracostomy. Moreover, we found that these ECG abnormalities consisted of two independent factors: respiratory components and the diaphragm level. Besides, CT scans demonstrated the large bullae with a maximum diameter of 46 × 49 mm in the right lung apex. Finally, the patient showed complete recovery with a thoracoscopic bullectomy. Conclusions Herein, we describe a case of a large right-sided primary spontaneous pneumothorax with characteristic ECG findings that resolved following re-expansion of the lung. Our case may shed new light on the mechanisms underlying ECG abnormalities associated with a large right-sided pneumothorax. Moreover, ECG manifestations may provide useful information to suspect a large pneumothorax or tension pneumothorax in emergent settings where ECGs are performed on patients with acute chest pain and dyspnea. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01470-1.
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Affiliation(s)
- Hiroyuki Yamamoto
- Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, 1-1-1 Hiyoshidai, Tomisato, Chiba, 286-0201, Japan.
| | - Kazuhiro Satomi
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Yoshiyasu Aizawa
- Department of Cardiovascular Medicine, International University of Health and Welfare, Chiba, Japan
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Fisher HK. Hypoxemia in COVID-19 patients: An hypothesis. Med Hypotheses 2020; 143:110022. [PMID: 32634734 PMCID: PMC7308039 DOI: 10.1016/j.mehy.2020.110022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/09/2020] [Accepted: 06/19/2020] [Indexed: 02/06/2023]
Abstract
The current SARS-Cov-2 virus pandemic challenges critical care physicians and other caregivers to find effective treatment for desperately ill patients - especially those with sudden and extreme hypoxemia. Unlike patients with other forms of Acute Respiratory Distress Syndrome, these patients do not exhibit increased lung stiffness or dramatic dyspnea., even in the presence of arterial blood oxygen levels lower than that seen normally in mixed venous blood. Urgent intubation and mechanical ventilation with high inflation pressures and raised inhaled oxygen concentration have proved unhelpful or worse, but why? Our Hypothesis is that sudden opening of a previously undetected probe-patent foramen ovale (PPFO) may explain this mystery. As hypoxemia without acidosis is a rather weak stimulus of dyspnea or increased ventilation, and opening of such an intracardiac shunt would not worsen lung mechanical properties, the absence of dramatic symptom changes would not be surprising. We point out the high frequency of PFO both in life and at autopsy, and the physiological evidence of large shunt fractions found in Covid-19 patients. Published evidence of hypercoagulability and abundant evidence of pulmonary emboli found at autopsy are in accord with our hypothesis, as they would contribute to raised pressure in the pulmonary arteries and right heart chambers, potentially causing a shunt to open. We review the interaction between viral corona spike protein and ACE-2 receptors present on the surface of alveolar lining cells, and contribution to hypercoagulabilty caused by the spike protein. Search for an open PFO after a large drop in arterial oxygen saturation can be performed at the bedside with a variety of well-established techniques including bedside echocardiography, nitrogen washout test, and imaging studies. Potential treatments might include balloon or patch closure of the shunt, and various drug treatments to lower pulmonary vascular resistance.
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Affiliation(s)
- H K Fisher
- 910 S Gretna Green Way, Los Angeles, CA 90049, United States.
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Rio PP, Hariawan H, Anggrahini DW, Hartopo AB, Dinarti LK. The Accuracy of Combined Electrocardiogram Criteria to Diagnose Right Atrial Enlargement in Adults With Uncorrected Secundum Atrial Septal Defect. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2019; 13:1179546819869948. [PMID: 31447597 PMCID: PMC6693022 DOI: 10.1177/1179546819869948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/23/2019] [Indexed: 11/26/2022]
Abstract
Background: Right atrium (RA) enlargement in uncorrected atrial septal defect (ASD) is
due to chronic volume overload. Several electrocardiogram (ECG) criteria had
been proposed for screening RA enlargement. This study aimed to compare the
accuracy of ECG criteria in detecting RA enlargement in adults with
uncorrected ASD. Methods: This was a cross-sectional study involving 120 adults with uncorrected
secundum ASD. The subjects underwent ECG examination, transthoracic
echocardiography, and right heart catheterization. An RA enlargement was
determined with RA volume index by transthoracic echocardiography. Various
ECG and combined ECG criteria were evaluated. Statistical analysis was
performed to analyze the sensitivity, specificity, accuracy, positive
predictive value (PPV), and negative predictive value (NPV). Results: An RA enlargement was detected in 64.2% subjects. The P wave height > 2.5
mm in lead II criterion had the best specificity (100%) and PPV (100%), but
low sensitivity (19%) and accuracy (48%). The combined 2 ECG criteria (QRS
axis > 90°, R/S ratio > 1 in V1) had 82% sensitivity, 56% specificity,
73% accuracy, 77% PPV, and 63% NPV. The combined 3 ECG criteria (QRS axis
> 90°, R/S ratio > 1 in V1, and P wave height > 1.5 mm in V2) had
35% sensitivity, 86% specificity, 53% accuracy, 82% PPV, and 43% NPV. Conclusions: The combined 2 ECG criteria (QRS axis > 90° and R/S ratio > 1 in V1)
had increased sensitivity, better accuracy, and more balance of PPV and NPV
as compared with P wave > 2.5 mm in II criterion and combined 3 ECG
criteria to diagnose RA enlargement in adults with uncorrected ASD.
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Affiliation(s)
- Purwati Pole Rio
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada and Dr Sardjito Hospital, Yogyakarta, Indonesia
| | - Hariadi Hariawan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada and Dr Sardjito Hospital, Yogyakarta, Indonesia
| | - Dyah Wulan Anggrahini
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada and Dr Sardjito Hospital, Yogyakarta, Indonesia
| | - Anggoro Budi Hartopo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada and Dr Sardjito Hospital, Yogyakarta, Indonesia
| | - Lucia Kris Dinarti
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada and Dr Sardjito Hospital, Yogyakarta, Indonesia
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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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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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8
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Hayashi H, Miyamoto A, Kawaguchi T, Naiki N, Xue JQ, Matsumoto T, Murakami Y, Horie M. P-pulmonale and the development of atrial fibrillation. Circ J 2013; 78:329-37. [PMID: 24284921 DOI: 10.1253/circj.cj-13-0654] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND P wave ≥0.25mV in inferior leads (P pulmonale) occurs in chronic lung diseases that underlie atrial fibrillation (AF). The purpose of this study was to elucidate the prognostic value of P pulmonale for development of AF. METHODS AND RESULTS Digital analysis of 12-lead electrocardiogram (ECG) was conducted to enroll patients with P pulmonale from among a database containing 308,391 ECGs. In a total of 591 patients (382 men; 56.4±14.8 years) with P pulmonale (follow-up, 46.7±65.6 months), AF occurred in 61 patients (AF group), but did not occur in 530 patients (non-AF group). Male gender was significantly more prevalent in the AF group than in the non-AF group (80.3% vs. 62.8%, P=0.0047). P-wave duration and PQ interval were significantly longer in the AF group than in the non-AF group (115.4±17.2ms vs. 107.0±17.2ms, P=0.0003 and 166.3±23.9ms vs. 153.2±25.4ms, P=0.0001, respectively). In the total patient group, multivariate Cox proportional-hazards analysis confirmed that male gender (hazard ratio [HR], 2.24; 95% confidence interval [CI]: 1.02-5.49; P=0.045), PQ interval >150ms (HR, 6.89; 95% CI: 2.39-29.15; P<0.0001), and P-wave axis <74° (HR, 2.55; 95% CI: 1.20-5.41; P=0.016) were associated with AF development. In medication-free patients (n=400), only PQ interval >150ms (HR, 9.26; 95% CI: 1.75-170.65; P=0.0055) was independently and significantly associated with AF development. CONCLUSIONS PQ interval is the strongest stratifier for AF development in P pulmonale.
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Affiliation(s)
- Hideki Hayashi
- Departments of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science
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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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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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Krupienicz A, Czarnecki R, Adamus J. QT dispersion magnitude is related to the respiratory phase in healthy subjects. Am J Cardiol 1997; 80:1232-4. [PMID: 9359561 DOI: 10.1016/s0002-9149(97)00649-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Twelve-lead electrocardiograms in 20 healthy volunteers during quiet respiration, maximum inspiration, and maximum expiration were recorded. QT dispersion was statistically significantly shorter both at maximum inspiration and maximum expiration than during quiet breathing.
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Affiliation(s)
- A Krupienicz
- Department of Cardiology, Military Medical Academy, Warsaw, Poland
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Kaplan JD, Evans GT, Foster E, Lim D, Schiller NB. Evaluation of electrocardiographic criteria for right atrial enlargement by quantitative two-dimensional echocardiography. J Am Coll Cardiol 1994; 23:747-52. [PMID: 8113560 DOI: 10.1016/0735-1097(94)90763-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES This study was conducted to evaluate the sensitivity and specificity of traditional electrocardiographic (ECG) criteria for right atrial enlargement and identify improve criteria, using quantitative two-dimensional echocardiography. BACKGROUND Traditional ECG criteria for right atrial enlargement, such as P pulmonale, have been increasingly criticized as insensitive and nonspecific. Quantitative two-dimensional echo-cardiography has been shown to be a useful method for evaluating atrial size. METHODS Hospitalized patients with mild, moderate and severe right atrial enlargement were selected from our laboratory's data base and compared with age- and gender-correlated hospitalized control subjects. After exclusions, 100 patients with right atrial enlargement and 25 control patients remained. Planimetric measurement of right atrial volumes was accomplished by two independent observers using the single-plane method of discs algorithm. Electrocardiograms were independently evaluated for current and newly proposed right atrial enlargement criteria. RESULTS Fifty-two patients (52%) were in sinus rhythm, 41 were in atrial fibrillation, 5 were in atrial flutter, and 2 were in ectopic atrial rhythm. All control subjects were in sinus rhythm. The right atrial volume for the control group was 35.0 +/- 7.4 ml (mean +/- SD), with a narrow, roughly normal distribution. The right atrial volume for the patient group was 147.6 +/- 69.1 ml (median 127.2) in a wide, skewed distribution. The difference of mean values was highly significant (p = 0.0001). Right ventricular enlargement was found to some degree in all patients with right atrial enlargement. The most powerful predictors of right atrial enlargement were a QRS axis > 90 degrees, a P wave height in lead V2 > 1.5 mm and an R/S ratio > 1 in lead V1 in the absence of complete right bundle branch block. The combined sensitivity of these three criteria was 49%, with preservation of 100% specificity. P pulmonale detected only 6% of patients with right atrial enlargement. CONCLUSIONS Using quantitative two-dimensional echocardiography, we found that most previously reported ECG criteria for right atrial enlargement have low predictive power. The best predictors of right atrial enlargement were a P wave height > 1.5 mm in lead V2 and, as new criteria, a QRS axis > 90 degrees and an R/S ratio > 1 in lead V1 in the absence of complete right bundle branch block. The combined sensitivity of these three criteria was 49%, with preservation of 100% specificity. Further studies are needed to prospectively validate these findings.
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Affiliation(s)
- J D Kaplan
- John Henry Mills Memorial Adult Echocardiography Laboratory, H.C. Moffitt Hospital, San Francisco, California
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Hida W, Taguchi O, Kikuchi Y, Ohe M, Shirato K, Takishima T. P wave height during incremental exercise in patients with chronic airway obstruction. Chest 1992; 102:23-30. [PMID: 1623759 DOI: 10.1378/chest.102.1.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We examined changes in P wave height in lead 2 of an ECG obtained during progressive exercise in 23 patients with COPD, and measured both P wave changes and pulmonary hemodynamics during exercise at a constant workload corresponding to approximately 50 to 60 percent of VO2 max in nine patients. The P wave response to exercise (delta P/delta VO2, %/ml/min), estimated by the relationship between percentage of change in P wave height and VO2, was significantly greater (p less than 0.01) in 15 patients who had a decrease in PaO2 with exercise (group A) than eight patients who did not have a fall in PaO2 with exercise (group B). There was a significant negative correlation between change in PaO2 and change in P wave height from rest to maximal exercise (r = -0.68, p less than 0.001). Oxygen therapy in nine patients in group A reduced the increase in P wave height during exercise. Furthermore, change in P wave height from rest to exercise correlated significantly with that of mean pulmonary artery pressure (r = 0.75, p less than 0.01). These results suggest that increase in P wave height during exercise in COPD patients is related partly to oxygen desaturation during exercise, and continuous measurement of P wave change may be useful for noninvasively predicting the pulmonary vascular pressure response to exercise.
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Affiliation(s)
- W Hida
- First Department of Internal Medicine, Tohoku University School of Medicine, Sendai, Japan
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