The Prognostic Role of the ECG in Primary Pulmonary Hypertension

Bossone, Eduardo; Paciocco, Giuseppe; Iarussi, D; Agretto, A; Iacono, A; Gillespie, Brenda W.; Rubenfire, Melvyn

doi:10.1378/chest.121.2.513

Cited by 136 publications

(95 citation statements)

References 24 publications

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“…Right ventricular hypertrophy (RVH) might also be portentous in IPAH, as suggested by three electrocardiographic (ECG) studies (24,25,27). In the largest (86 patients, 42 deaths), an inverse correlation was found between survival and the number of points scored on the Sokolow-Lyon criteria for RVH (24).…”

Section: Discussionmentioning

confidence: 99%

“…In the largest (86 patients, 42 deaths), an inverse correlation was found between survival and the number of points scored on the Sokolow-Lyon criteria for RVH (24). Bossone et al (25) found that patients with WHO criteria for RVH were 4.3 times more likely to die than those without (51 patients, 16 deaths). However, in the only imaging study (CMR) to measure RV mass or wall thickness, neither were significant (11).…”

Section: Discussionmentioning

confidence: 99%

“…2. The SD of the variable; taken from repeatability SD for indices of prognostic importance (RVEDV, LVEDV, RV EF, and RV mass) (11,12,24,25). 3.…”

Section: Statisticsmentioning

confidence: 99%

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Measuring the heart in pulmonary arterial hypertension (PAH): Implications for trial study size

Bradlow

Hughes

Keenan

et al. 2009

Magnetic Resonance Imaging

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Purpose: To calculate the sample size for a theoretical pulmonary arterial hypertension (PAH) randomized controlled trial (RCT) by using cardiovascular magnetic resonance (CMR) imaging to determine the repeatability of measures between two scans. Materials and Methods:Two same-day examinations from 10 PAH patients were analyzed manually and semiautomatically. Study size was calculated from the standard deviation (SD) of repeatability. Different approaches to right-ventricle (RV) mass were investigated, agreement between methods tested and interobserver reproducibility measured by Bland-Altman analysis to explore how the PAH heart might be best measured.Results: Repeatability was good for almost all manuallymeasured indices but poor for semiautomated measurement of RV mass and left-ventricle (LV) end-diastolic volume (EDV). Thus, for an RCT (power, 80%; significance level, 5%) analyzing ''outcome'' indices (RVEDV, LVEDV, RV ejection fraction, and RV mass; anticipated change: 10 mL, 10 mL, 3%, and 10 g, respectively) manually, 34 patients are required compared to 78 if analysis is semiautomated. RV mass was repeatable if the interventricular septum was divided between ventricles or if wholly apportioned to the LV. Limits of agreement between manual and semiautomated analyses were unsatisfactory for RV measures and interobserver reproducibility was worse for semiautomated than manual analysis. Conclusion:Manual is more robust than semiautomated analysis and at present should be favored in RCTs in PAH as it leads to lower sample size requirements.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Measuring the heart in pulmonary arterial hypertension (PAH): Implications for trial study size

Bradlow

Hughes

Keenan

et al. 2009

Magnetic Resonance Imaging

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“…While these findings were published in an era before effective therapy was available, they have generally (but not universally) been validated in more recent studies of patients at diagnosis or initiation of therapy [19,[33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50]. Importantly, PAH patients with more severe cardiac dysfunction or history of heart failure at baseline continue to have a higher risk of death than those with less severe heart failure despite treatment with new therapies [33,34,36,38,41,45,46,48,49]. Improvement in these characteristic hemodynamic abnormalities after therapy has been associated with better survival [19,34,49].…”

Section: Potential Surrogate and Intermediate End Points In Pah Hemodmentioning

confidence: 94%

Surrogate End Points in Pulmonary Arterial Hypertension: Assessing the Response to Therapy

Snow¹,

Kawut²

2007

Clinics in Chest Medicine

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Pulmonary arterial hypertension (PAH) is a rare disease which is characterized by increased pulmonary vascular resistance and right heart failure. Recent discoveries in disease pathophysiology have been translated into effective therapies tested in clinical trials. The studies which have led to the regulatory board approval of therapies for PAH have focused on surrogate and intermediate end points, thought to reflect quantity and quality of life, respectively. However, validation of many of these surrogates is incomplete. It is also unknown which indicators of function or long-term survival should be used to formulate decisions regarding addition, discontinuation, or combination of therapies. Identification of suitable end points would therefore not only help investigators design appropriate clinical trials, but also assist clinicians in caring for patients with PAH. Hemodynamic, cardiac imaging, plasma biomarkers, and exercise testing hold some promise as potential surrogate end points for PAH. Functional status and quality of life assessments may also have important roles. Future studies should validate the most promising surrogate markers, so that patients, clinicians, subjects, and investigators may benefit from the advantages they confer on clinical care and on clinical trials.The past several years have yielded an explosion of randomized clinical trials (RCTs) of several new medical therapies for pulmonary arterial hypertension (PAH). The hopes for these and all treatments for potentially fatal diseases are 1) to improve how a patient feels or functions and/ or 2) to prolong survival. While simply stated, the assessment of progress towards these goals may be quite complex [1][2][3][4][5][6].New PAH therapies have gained regulatory board approval based on studies with intermediate and surrogate end points as primary outcomes, believed to reflect the impact of these drugs on quality of life (QOL) and survival, respectively. While hemodynamic, plasma, cardiac imaging, exercise, functional, and QOL parameters are promising candidates, the reliability and validity of these measures are not clearly established. In addition, there are no RCTs addressing the use of such end points in guiding management decisions in PAH, such as changing, intensifying, escalating, or combining therapies. Despite this lack of evidence, clinicians who

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“…In contrast, much less known aspect of pressure overload of RV is its impact on electrocardiographic (ECG) changes. ECG findings consistent with pulmonary hypertension and RV ischemia and strain, including complete and incomplete right bundle branch block (RBBB), ST-segment changes and T-wave inversions, the S1Q3T3 pattern, and nonsinus rhythm, had been observed more frequently in patients with RV pressure load (7)(8)(9).…”

Section: Introductionmentioning

confidence: 99%

Role of electrocardiographic changes in discriminating acute or chronic right ventricular pressure overload

Can¹,

Özveren²,

Biteker³

et al. 2013

Anadolu Kardiyol Derg

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Objective: Pulmonary embolism (PE) and severe pulmonary stenosis (PS) are two distinct conditions accompanied by increased pressure load of the right ventricle (RV). Despite major advances in our understanding of the mechanisms of RV adaptation to the increased pressure, substantial gaps in our knowledge remain unsettled. One of much less known aspect of pressure overload of RV is its impact on electrocardiographic (ECG) changes. In this study, we aimed to study whether acute and chronic RV overload are accompanied by different ECG patterns. Methods: Thirty-eight patients with PE underwent ECG monitoring were compared with 20 matched patients with PS in this observational retrospective study. ECG abnormalities suggestive of RV overload were recorded and analyzed in both groups. Logistic regression analysis was used to define the predictors of chronic RV overload. Results: Among the ECG changes studied, premature atrial contraction (OR-12.2, 95% CI, 1.3-107, p=0.008), right axis deviation (OR-20.4, 95% CI 4.2-98, p<0.001), indeterminate axis (OR-0.11, 95% CI 0.02-0.44, p=0.001 0.11), incomplete right bundle branch block (OR-4.2, 95% CI, 1.1-15.4, p=0.02), late R in aVR (OR-8.4, 95% CI 2.1-33.2, p=0.001), qR in V1 lead (OR-8.3, 95% CI 1.2-74.8, p=0.03) were found to be the independent predictors of chronic RV pressure overload. Conclusion: Our data indicate that the ECG changes that attributed to the acute RV pressure loading states may be more prevalent in chronic RV overload as compared with acute RV overload. (Anadolu Kardiyol Derg 2013; 13: 344-9) Key words: Right ventricular pressure load, electrocardiography, disease process, regression analysis Original Investigation Özgün Araşt›rma 344ÖZET Amaç: Sağ ventrikül (SV) fonksiyonu birçok kardiyopulmoner hastalıklarda klinik sonlanım olarak önemli rol oynar. Pulmoner emboli (PE) ve ciddi pulmoner darlık (PD) SV basınç yüklenmesi ile seyreden iki ayrı hastalıktır. SV' nin artmış basınç yüklenmesine karşı verdiği uyum mekanizmaları iyi bilinmesine karşın hala bazı tanımlanmamış boşluklar devam etmektedir. SV basınç yüklenmesinin elektrokardiyografik (EKG) olarak nasıl bir deği-şiklik yaptığı pek bilinmemektedir. Çalışmamızdaki amaç akut ve kronik basınç yüklenmesini EKG olarak ayrımının yapılabileceğini araştırmaktır. Yöntemler: Bu retrospektif gözlemsel çalışmamıza 20 PD ve 38 PE tanısı kesinleşmiş hasta dahil edildi. SV yüklenmesini gösterdiği daha önceki çalışmalarda kabul edilmiş EKG kriterleri her iki grupta araştırıldı. Logistic regression analysis was used to define the predictors of chronic RV overload. Bulgular: Bakılan EKG değişikliklerinden, prematür atriyal atım (OR-12.2, %95 CI, 1.3-107, p=0.008), sağ aks deviasyonu (95)(96)(97)(98) p=0.001), indetermine aks (OR-0.11, %95 CI 0.02-0.44, p=0.001), inkomplet sağ dal bloğu (OR-4.2, %95 CI, 1.1-15.4, p=0.02), aVR de geç R dalgası (OR-8.3, %95 CI 1.2-74.8, OR-8.4, %95 CI 2.1-33.2 p=0.001), V1' de qR dalgası (OR-8.3, %95 CI 1.2-74.8 p=0.02) SV kronik basınç yüklenmesini gös-teren bağımsız prediktörle...

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The Prognostic Role of the ECG in Primary Pulmonary Hypertension

Cited by 136 publications

References 24 publications

Measuring the heart in pulmonary arterial hypertension (PAH): Implications for trial study size

Measuring the heart in pulmonary arterial hypertension (PAH): Implications for trial study size

Surrogate End Points in Pulmonary Arterial Hypertension: Assessing the Response to Therapy

Role of electrocardiographic changes in discriminating acute or chronic right ventricular pressure overload

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