Electrocardiography to Define Clinical Status in Primary Pulmonary Hypertension and Pulmonary Arterial Hypertension Secondary to Collagen Vascular Disease

doi:10.1378/chest.122.2.524

Chest

Volume 122, Issue 2, August 2002, Pages 524-527

https://doi.org/10.1378/chest.122.2.524 Get rights and content

Study objectives

To determine the utility of the ECG for predicting clinical status in adults with primary pulmonary hypertension (PPH) or pulmonary arterial hypertension (PAH) secondary to collagen vascular disease.

Design

Retrospective study.

Setting

Outpatient clinic in a tertiary referral center.

Patients

Adult outpatients with PPH or PAH secondary to collagen vascular disease who underwent electrocardiography within 30 days of undergoing right-heart catheterization, echocardiography, and 6-min walk testing.

Interventions

None.

Measurements and results

The following measurements were recorded from each ECG: P-wave amplitude in lead II; mean frontal QRS axis; QRS duration; R-wave and S-wave deflections in leads I and V6; and the T-wave configurations in the precordial leads. These ECG variables were correlated with hemodynamic variables, RV size, and exercise capacity. Of the 61 patients included in this study, 56 (92%) were women. Eight of 61 patients (13%) had normal findings on ECGs. There was no significant difference in the demographics or hemodynamics when comparing groups with normal vs abnormal ECGs. All ECG parameters had no more than moderate correlation with hemodynamic variables, ventricular size measured by echocardiogram, and exercise capacity as measured by a 6-min walk. The best correlation was between mean the frontal QRS axis and cardiac index (r = −0.46).

Conclusions

The ECG is an inadequate screening tool to rule out the presence of clinically relevant pulmonary hypertension, either primary or secondary to collagen vascular disease. The mean frontal QRS axis correlated best with the severity of hemodynamic impairment.

Section snippets

Materials and Methods

Sixty-one patients with PPH or pulmonary hypertension secondary to collagen vascular disease were identified retrospectively. The diagnosis of PPH or pulmonary hypertension was established according to standard criteria.⁹ Only patients who had undergone echocardiograms and cardiac catheterizations within 30 days of undergoing a 12-lead ECG were included in this study. Right-heart catheterizations were performed according to standard procedures. Cardiac outputs were calculated using the

Results

Of the 61 patients studied, 56 (92%) were women. Baseline patient information is presented in Table 1. Eight of 61 ECGs (13%) were read as being completely normal. There was a trend toward lower PVR and pulmonary artery pressure as well as toward a higher cardiac index in patients who had normal ECG findings; however, there were no significant differences in this limited patient sample.

Correlations of selected ECG parameters with hemodynamic, echocardiographic, and exercise capacity are shown

Discussion

An elevated right atrial (RA) pressure is an ominous finding in patients with PAH and is predictive of mortality.¹⁰¹¹¹² A markedly elevated RA pressure, however, occurs late in the course of the disease when there is marked functional impairment. Ideally, ECG parameters would be both sensitive and specific in identifying patients early in the course of the disease when symptoms are mild. It is possible that therapy would be more efficacious if instituted early in the course of the disease

References (14)

RichS
Medical treatment of primary pulmonary hypertension: a bridge to transplantation?
Am J Cardiol
(1995)
FerrariE et al.
The ECG in pulmonary embolism: predictive value of negative T waves in precordial leads; 80 case reports
Chest
(1997)
KramerMR et al.
Recovery of the right ventricle after single-lung transplantation in pulmonary hypertension
Am J Cardiol
(1994)
ChapmanPJ et al.
Prognostic and therapeutic considerations in clinical primary pulmonary hypertension
Respir Med
(1990)
RichS et al.
Characteristics of surviving and nonsurviving patients with primary pulmonary hypertension
Am J Med
(1984)
BarstRJ et al.
A comparison of continuous intravenous epoprostenol (prostacyclin) with conventional therapy for primary pulmonary hypertension: the Primary Pulmonary Hypertension Study Group
N Engl J Med
(1996)
BadeschDB et al.
Continuous intravenous epoprostenol for pulmonary hypertension due to the scleroderma spectrum of disease: a randomized, controlled trial
Ann Intern Med
(2000)

There are more references available in the full text version of this article.

Cited by (124)

Electrocardiogram Parameters Associated With the Diagnosis of Pulmonary Hypertension in High-Altitude Tibetan Populations: A Retrospective Single-Centre Study
2024, Heart Lung and Circulation
Electrocardiogram (ECG) is a commonly used diagnostic method for pulmonary hypertension (PH) in Tibetan areas, but its sensitivity and specificity are not good enough. This study aimed to investigate the ECG parameters associated with the diagnosis of PH in Tibetan areas.
Ninety-four PH patients of Tibetan ethnicity who were treated at the hospital between March 2019 and October 2020, and 52 Tibetan individuals as controls, were included. The ECG parameters were compared between groups. Multivariate logistic analysis was performed to identify the ECG parameters that can be used for the diagnosis of PH. The univariate significances of ECG parameters were included in the multivariate analyses, whereas those exhibiting opposite trends between different PH subtypes were excluded.
Two ECG parameters were significant in multivariate analysis. The final model included S wave amplitude in lead V3 (OR 5.81; 95% CI 2.79–12.11; p<0.001) and a negative T wave in leads V1–V3 (OR 0.05; 95% CI 0.01–0.41; p=0.005). The ROC curve analysis on the final model yielded an AUC of 0.830 (95% CI 0.766–0.894; p<0.001), indicating good diagnostic performance. A nomogram for diagnosis of PH was also established using S wave amplitude in lead V3 and a negative T wave in leads V1–V3.
The ECG parameters S wave amplitude in lead V3 and a negative T wave in leads V1–V3 were independent factors associated with the diagnosis of PH in high-altitude Tibetan populations.
Electrocardiographic manifestations of pulmonary stenosis versus pulmonary hypertension
2023, Journal of Electrocardiology
Right ventricular hypertrophy can be caused by conditions such as pulmonary stenosis and pulmonary hypertension. ECG is a readily available and affordable test, the aim of this study was the evaluation of the electrocardiographic aspects of pulmonary stenosis, and pulmonary hypertension.
A list of patients diagnosed with isolated pulmonary stenosis and pulmonary hypertension patients hospitalized and treated between 2019 and 2021 were extracted from the hospital archives. Furthermore, the ECG of the patients was analyzed in terms of the prevalence of the variables in the study using FECG Caliper software. Finally, the data of 93 patients (in both groups) were analyzed.
In this study, 46 patients were in the severe pulmonary stenosis group, and 49 were in the severe or moderate-to-severe pulmonary hypertension group. The heart rate in the pulmonary hypertension group was significantly higher. R/S > 1 in precordial leads differs between the two groups and higher amplitude R wave in V1(p-value = 0.05). in the pulmonary stenosis group. While in the pulmonary hypertension group, R wave growth occurs later, and this ratio is greater than one after V4. Bundle block in the form of RBBB(p-value <0.001) and maximum QRS duration is more in the pulmonary stenosis group(p-value = 0.001).
Our findings show the different strains of the right ventricle in two groups. It can be concluded that the effects of severe pulmonary stenosis on the ECG are more on the QRS wave and in the form of a block, while severe pulmonary hypertension affects the ST segment and T wave.
Electrocardiogram in patients with pulmonary hypertension
2023, Journal of Electrocardiology
Pulmonary hypertension (PH) is a potentially life-threatening cardiovascular disease defined by a mean pulmonary arterial pressure (mPAP) > 20 mmHg. Due to non-specific symptoms, PH is often diagnosed late and at advanced stage. In addition to other diagnostic modalities, the electrocardiogram (ECG) can help in establishing the diagnosis. Knowledge of typical ECG signs could help to detect PH earlier.
A non-systematic literature review on the typical electrocardiographic patterns of PH was performed.
Characteristic signs of PH include right axis deviation, SIQIIITIII and SISIISIII patterns, P pulmonale, right bundle branch block, deep R waves in V1 and V2, deep S waves in V5 and V6, and right ventricular hypertrophy (R in V1 + S in V5, V6 > 1,05 mV). Repolarisation abnormalities such as ST segment depressions or T wave inversions in leads II, III, aVF, and V1 to V3 are common as well. Furthermore, a prolonged QT/QTc interval, an increased heart rate, or supraventricular tachyarrhythmias can be observed. Some parameters may even provide information about the patient's prognosis.
Not every PH patient shows electrocardiographic PH signs, especially in mild PH. Thus, the ECG is not useful to completely rule out PH, but provides important clues to PH when symptoms are present. The combination of typical ECG signs and the co-occurrence of electrocardiographic signs with clinical symptoms and elevated BNP levels are particularly suspicious. Diagnosing PH earlier could prevent further right heart strain and improve patient prognosis.
Global weighted LBP based entropy features for the assessment of pulmonary hypertension
2019, Pattern Recognition Letters
Pulmonary hypertension (PH) is characterized by elevated pulmonary arterial pressure. Echocardiography, or cardiac ultrasound, is a helpful imaging tool to screen for PH. However, expert interpretation is required for successful screening. Development of a more automated method for diagnosis of PH would be useful to minimize error, thereby improving patient health. This task is challenging and the literature pertaining to the problem is still nascent. In this paper, we propose a computer aided diagnosis (CAD) tool, using ultrasound images, to expedite the screening of PH. Textural components play a significant role in ultrasound imaging for the efficient identification of PH. The extraction of such features is accomplished by computing several entropy measurements over a globally weighted local binary pattern (LBP). Thereafter, the blend of ranked maximum and fuzzy entropy features are input to a support vector machine, resulting in a maximum accuracy of approximately 92%. A comparison with variants indicates improved performance of the proposed globally weighted LBP.
Electrocardiogram signs of right ventricular hypertrophy may help identify pulmonary hypertension in patients with dilated cardiomyopathy
2019, IJC Heart and Vasculature
Citation Excerpt :
We failed to detect the predicting value of ECG parameters of lead V1, including RV1 > 6 mm, R:SV1 > 1, SV1 < 2 mm, R peak V1 (QRS duration<0.12 s), RSRV1 and QRV1 in diagnosing PH in patients with DCM. The mean frontal QRS axis of >100° had a highly predictive value of RVH and moderate correlation with mPAP [18]. Lau et al. also concluded the QRS axis were significantly correlated with mPAP [19].
To the authors' knowledge, limited data are available regarding the association between Electrocardiogram (ECG) signs of right ventricular hypertrophy (RVH) and pulmonary hypertension (PH) in patients with dilated cardiomyopathy (DCM). We aimed to assess the accuracy of the recommended ECG criteria of RVH for predicting PH in patients with DCM.
According to the definition of PH (mPAP ≥ 25 mm Hg), 35 patients with DCM were divided into 2 groups: DCM with PH (n = 22) and DCM without PH (n = 13). Right heart catheterization was performed in all patients. Seventeen parameters of RVH recommended by the AHA/ACCF/HRS for diagnosis of RVH on ECG were determinded.
The following parameters were correlated with mPAP: R_V1 > 6 mm, S_V5 > 10 mm, R:S_V6 < 0.4, R_V1 + S_{V5 or V6} > 10.5 mm and P_II amplitude. The following parameters were significantly different between DCM patients with and without PH: S in V₅ (S_V5) > 10 mm, S in V₆ (S_V6) > 3 mm, R:S ratio in V₅ (R:S_V5) < 0.75, R_V1 + S_{V5 or V6} > 10.5 mm, S > R inI, S > R inII and R:S _V1 > R:S _V3, although results were no longer significant after correcting for multiple comparisons. High specificity (92.3–100%), lowsensitivity (31.8–50%), high positive predictive value, and low negative predictive value of established parameters of RVH were noted for predicting PH in patients with DCM.
Several ECG signs of RVH may be useful for in the diagnosis PH in patients with DCM.
ECG derived ventricular gradient exceeds echocardiography in the early detection of pulmonary hypertension in scleroderma patients
2018, International Journal of Cardiology
Patients with systemic sclerosis (SSc) are at risk for developing pulmonary hypertension (PH) which is a major cause of death in this population. Echocardiographic (TTE) derived pulmonary arterial pressure (PAP) can be unreliable for the early detection of PH. Previous studies demonstrate that the ECG derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO) can detect PH in a heterogeneous population suspected of PH.
The aim of this study is to assess the use of the VG-RVPO as a screening and monitoring instrument of early PH in SSc patients.
Serial ECGs and TTEs from twenty-seven SSc patients who underwent right heart catheterization (RHC) were retrospectively analyzed. The changes in PAP and VG-RVPO over time were studied in patients with and without diagnosed PH.
Twenty-four patients (52.5% female, mean age 58.4 years SD 14.3) were studied. In eleven patients PH was confirmed with RHC. In these patients VG-RVPO was significantly higher −8 ± 19 than in patients without PH −23 ± 10 mV·ms, (P < 0.05). In addition, in PH patients the VG-RVPO increased over time in contrast to patients without PH (P < 0.01). The VG was more sensitive to detect disease progression in earlier stages of disease as compared to echocardiographic derived PAP.
The VG-RVPO is a sensitive, non-invasive and cost effective tool for early detection of PH in SSc patients. Serial measurements indicate that the VG-RVPO can be used as a follow-up instrument and outperforms TTE to detect early changes in right ventricular pressure over time.

View all citing articles on Scopus

View full text

Chest

Clinical InvestigationsCARDIOLOGYElectrocardiography to Define Clinical Status in Primary Pulmonary Hypertension and Pulmonary Arterial Hypertension Secondary to Collagen Vascular Disease

Study objectives

Design

Setting

Patients

Interventions

Measurements and results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Am J Cardiol

Chest

Am J Cardiol

Respir Med

Am J Med

A comparison of continuous intravenous epoprostenol (prostacyclin) with conventional therapy for primary pulmonary hypertension: the Primary Pulmonary Hypertension Study Group

N Engl J Med

Continuous intravenous epoprostenol for pulmonary hypertension due to the scleroderma spectrum of disease: a randomized, controlled trial

Ann Intern Med

Clinical Investigations
CARDIOLOGY
Electrocardiography to Define Clinical Status in Primary Pulmonary Hypertension and Pulmonary Arterial Hypertension Secondary to Collagen Vascular Disease