Atrioventricular conduction and cardiovascular mortality: Assessment of recovery PR interval is superior to pre-exercise measurement

Nieminen, Tuomo; Verrier, Richard L.; Leino, Johanna; Nikus, Kjell; Lehtinen, Rami; Lehtimäki, Terho; Minkkinen, Mikko; Kööbi, Tiit; Turjanmaa, Väinö; Viik, Jari; Kähönen, Mika

doi:10.1016/j.hrthm.2010.02.029

Cited by 15 publications

(10 citation statements)

References 24 publications

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“…The pre-exercise PR interval was not prognostic after adjustment of cardiovascular risk factors; however, a prolonged AV interval at recovery was a significant predictor of mortality, both as a continuous variable and when categorized as ≥200 ms, over a four-year follow-up period. [7] Despite having a three vessel disease, our patient did not demonstrate classical markers associated with higher risk. The patient's recovery parameters were also normal.…”

Section: Abbreviationscontrasting

confidence: 55%

A rare sign of ischemia during exercise ECG: PR interval lengthening in the recovery period

Durakoğlugil¹

2012

Arch Turk Soc Cardiol

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Exercise electrocardiography (ECG) is one of the most commonly utilized tests in cardiology. Despite the drawbacks, exercise ECG is widely preferred due to low cost, standardization, and strong prognostic information. A prolonged PR interval during recovery has recently been proposed as an indicator of mortality. Herein, we report an interesting case of a patient who presented with the complaint of exertional dyspnea and exhibited PR lengthening during the recovery period on the exercise ECG. The patient had a PR interval of 240 ms before exercise, which decreased to 160 ms at peak stress. However, during recovery, the PR interval prolonged gradually, reaching 320 ms at the second minute and persisting at that length until the end of the recovery period. The patient achieved 87% of the age predicted maximum heart rate, and experienced non-disabling shortness of breath and a pressure sensation in the chest, with no apparent ST segment depression. Recovery parameters, including heart rate recovery and systolic blood pressure recovery, were also within normal limits. The patient underwent coronary angiography with the suspicion of CAD which revealed severe multi-vessel disease. This rare case emphasizes the importance of PR lengthening in the recovery period as a sign of severe ischemia, in addition to other signs, such as prominent ST-segment changes, chronotropic incompetence, impaired hemodynamic response, and poor exercise capacity during stress ECG evaluation.

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Section: Abbreviationscontrasting

confidence: 55%

A rare sign of ischemia during exercise ECG: PR interval lengthening in the recovery period

Durakoğlugil¹

2012

Arch Turk Soc Cardiol

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“…Lastly, we note that the 1% prevalence of first-degree heart block, usually not considered to bear any significant risk to adverse CVD outcome, except for its association with lamin A/C mutation in familial DCM, may in our PPCM cohort merely reflect the 1–2% prevalence in normal young adults 32. However, after recent reports implicating this so-called benign form of heart block in the general population with increased risk of atrial fibrillation and adverse CVD outcome 20 years down the line,32 and suggestions that post-exercise measurements of PR intervals may be more prognostic within five-year follow-up periods than resting ECG PR intervals,32 it would be useful to revise the prognostic implications of first-degree heart block post exercise in patients with underlying myocardial disease and congestive cardiac failure as in PPCM.…”

Section: Discussionmentioning

confidence: 87%

“…However, after recent reports implicating this so-called benign form of heart block in the general population with increased risk of atrial fibrillation and adverse CVD outcome 20 years down the line,32 and suggestions that post-exercise measurements of PR intervals may be more prognostic within five-year follow-up periods than resting ECG PR intervals,32 it would be useful to revise the prognostic implications of first-degree heart block post exercise in patients with underlying myocardial disease and congestive cardiac failure as in PPCM.…”

Section: Discussionmentioning

confidence: 99%

The 12-lead ECG in peripartum cardiomyopathy

Tibazarwa¹,

Lee²,

Mayosi³

et al. 2012

CVJA

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BackgroundThe value of the 12-lead electrocardiogram (ECG) to provide prognostic information in the deadly and disabling syndrome peripartum cardiomyopathy (PPCM) is unknown.AimsTo determine the prevalence of major and minor ECG abnormalities in PPCM patients at the time of diagnosis, and to establish whether there are ECG correlates of persistent left ventricular dysfunction and/or clinical stability at six months of follow up, where available.MethodsTwelve-lead ECGs were performed at the point of diagnosis on 78 consecutive women presenting with PPCM to two tertiary centres in South Africa and 44 cases (56%) at the six-month follow up. Blinded Minnesota coding identified major ECG abnormalities and minor ECG changes.ResultsThe cohort mainly comprised young women of black African ancestry (90%) [mean age 29 ± 7 years and median body mass index 24.3 (IQR: 22.7–27.5) kg/m2]. The majority of cases (n = 70; 90%) presented in sinus rhythm (mean heart rate 100 ± 21 beats/min). At baseline, at least one ECG abnormality/variant was detected in 96% of cases. Major ECG abnormalities and minor changes were detected in 49% (95% CI: 37–60%) and 62% (95% CI: 51–74%) of cases, respectively; the most common being T-wave changes (59%), p-wave abnormality (29%) and QRS-axis deviation (25%).Of the 44 cases (56%) reviewed at six months, normalisation of the 12-lead ECG occurred in 25%; the most labile ECG features being heart rate (mean reduction of 27 beats/min; p < 0.001) and abnormal QRS axis (36 vs 14%; p = 0.014). On an adjusted basis, major T-wave abnormalities on the baseline 12-lead ECG were associated with lower left ventricular ejection fraction (LVEF) at baseline (average of –9%, 95% CI: –1 to –16; p = 0.03) and at six months (–12%; 95% CI: –4 to –24; p = 0.006). Similarly, baseline ST-segment elevation was also associated with lower LVEF at six months (–25%; 95% CI: –0.7 to –50; p = 0.04).ConclusionsIn this unique study, we found that almost all women suffering from PPCM had an ‘abnormal’ 12-lead ECG. Pending more definitive studies, the ECG appears to be a useful adjunctive tool in both screening and prognostication in resource-poor settings.

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“…It has also been suggested, that using the postexercise assessment of AV conduction may improve cardiovascular risk prediction with better unmasking functional abnormalities of the heart. 37 Nevertheless, similarly to clinical practice, a protocol of taking single resting 12-lead ECG and using PR interval cut-off .200 ms to define prolongation was employed in this study.…”

Section: Discussionmentioning

confidence: 99%

Prognostic significance of prolonged PR interval in the general population

Aro

Anttonen

Kerola

et al. 2013

European Heart Journal

120

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AimsProlonged PR interval, or first degree AV block, has been traditionally regarded as a benign electrocardiographic finding in healthy individuals, until recent studies have suggested that it may be associated with increased mortality and morbidity. The aim of this study was to further elucidate clinical and prognostic importance of prolonged PR interval in a large middleaged population with a long follow-up. Methods and resultsWe evaluated 12-lead electrocardiograms of 10 785 individuals aged 30 -59 years (mean age 44 years, 52% males) recorded between 1966 and 1972, and followed the subjects for 30 + 11 years. Prolonged PR interval was defined as PR .200 ms, with further analysis performed using PR ≥220 ms. Main endpoints were all-cause mortality, cardiovascular mortality, and sudden cardiac death, and other endpoints included hospitalizations due to cardiovascular causes. During the baseline examination, prolonged PR interval .200 ms was present in 2.1% of the subjects, but PR interval normalized to ≤200 ms in 30% of these individuals during the follow-up. No increase in mortality or in hospitalizations due to coronary artery disease, heart failure, atrial fibrillation, or stroke was associated with prolonged PR interval (P ¼ non-significant for all endpoints). These results were not changed after multivariate adjustment or in several subanalyses. ConclusionIn the middle-aged general population, prolonged PR interval normalizes in a substantial proportion of subjects during the time course, and it is not associated with an increased risk of all-cause or cardiovascular mortality.--

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Atrioventricular conduction and cardiovascular mortality: Assessment of recovery PR interval is superior to pre-exercise measurement

Cited by 15 publications

References 24 publications

A rare sign of ischemia during exercise ECG: PR interval lengthening in the recovery period

A rare sign of ischemia during exercise ECG: PR interval lengthening in the recovery period

The 12-lead ECG in peripartum cardiomyopathy

Prognostic significance of prolonged PR interval in the general population

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