Electrocardiographic Differences between COPD Patients Evaluated for Lung Transplantation With and without Pulmonary Hypertension

Figures & data

Table 1.   ECG findings described in patients with emphysema

Author, Year, Reference	Included patients with cor-pulmonale	ECG signs
Selvester, 1965 (27)	Substudy excluded patients with cor-pulmonale	1- Rightward deviation of the P wave axis. 2- Low QRS voltage in the limb leads and in V6. 3- Posterior and superior displacement of the QRS axis in the precordial leads or rightward / indeterminate / leftward QRS axis deviation in the limb leads.
Spodick, 1959 (42)	Probably yes	1- Large P wave in inferior limb leads. 2- Rightward deviation of the P wave axis. 3- Rightward deviation of the QRS axis.
Wasserburger, 1959 (43)	Probably yes	1- Large P waves in inferior limb leads. 2- Prominent atrial T waves in inferior limb leads. 3- Vertical cardiac positioning (inverted P and T waves in aVL and low QRS voltage in lead I). 4- Rightward deviation of the QRS axis. 5- Low QRS voltage in left precordial leads.

Table 2.   Patient characteristics

	All patientsMean (SD) or n (%)	No PHMean (SD) or n (%)	PHMean (SD) or n (%)	p
n	142	52 (37)	90 (63)
Age (year)	59 (7)	59 (7)	59 (7)	0.95
Male gender	84 (59)	27 (52)	57 (63)	0.18
FVC (% of predicted)	55 (17)	56 (19)	55 (15)	0.73
FEV1 (% of predicted)	22 (13)	23 (13)	22 (12)	0.5
O2 at rest (L/min)	2 (2)	2 (3)	3 (2)	0.023
O2 with exercise (L/min)	6 (3)	6 (3)	7 (4)	0.022
Lung allocation score^23	33 (5)	32 (1)	34 (6)	0.06
Hemodynamic data
-Systolic ABP (mm Hg)	137 (19)	130 (14)	140 (20)	0.08
-Diastolic ABP (mm Hg)	83 (13)	79 (13)	85 (13)	0.2
-RA pressure (mm Hg)	9 (5)	7 (3)	10 (5)	<0.001
-Systolic PAP (mm Hg)	41 (12)	31 (5)	46 (12)	<0.001
-Diastolic PAP (mm Hg)	20 (7)	14 (4)	23 (6)	<0.001
-Mean PAP (mm Hg)	26 (7)	21 (3)	30 (7)	<0.001
-PAOP (mm Hg)	13 (5)	10 (4)	15 (5)	<0.001
-CO (L/min)	5 (1)	5 (1)	6 (2)	0.02
-CI (L/min/m^2)	3 (1)	3 (1)	3 (1)	0.26
-PVR (Wood Units)	3 (1)	2 (1)	3 (1)	<0.001
Echocardiographic data
•Left ventricular EF (%)	57 (5)	57 (8)	57 (5)	0.99
•RVSP (mm Hg)	43.6 (19)	37.3 (8)	46.6 (22)	0.005
•TAPSE (cm)	1.7 (0.5)	1.9 (0.5)	1.6 (0.4)	0.04
•RV dysfunction
-Missing	7 (5)	6 (12)	1 (1)	0.06
-Normal	103 (73)	38 (73)	65 (72)
-Mild	24 (17)	8 (15)	16 (18)
-Moderate	3 (2)	0 (0)	3 (3)
-Mod-severe	3 (2)	0 (0)	3 (3)
-Severe	1 (1)	0 (0)	1 (1)
•RV Dilation
-Missing	17 (12)	8 (15)	9 (10)	0.6
-Normal	83 (59)	32 (62)	51 (57)
-Mild	33 (23)	9 (17)	24 (27)
-Moderate	8 (6)	3 (6)	5 (6)
-Severe	1 (1)	0 (0)	1 (1)
CT thorax
•PA diameter (cm)	2.7 (0.5)	2.4 (0.3)	2.9 (0.5)	<0.001
•PA / Ao diameter	0.81 (0.1)	0.72 (0.1)	0.85 (0.1)	<0.001
Medications
-Beta Blocker	16 (11)	5 (10)	11 (12)	0.66
-CCB	36 (25)	11 (21)	25 (28)	0.49
-Antiarrhythmic	6 (4)	2 (4)	4 (4)	0.74
-Digoxin	6 (4)	2 (4)	4 (4)	0.735

Abbreviations: ABP: arterial blood pressure, Ao: aorta, CCB: calcium channel blockers, CI: cardiac index, CO: cardiac output, CT: computed tomography, EF: ejection fraction, FVC: forced-vital capacity, FEV1: forced expiratory volume in 1 sec, PA: pulmonary artery, PAOP: pulmonary artery occlusion pressure, PAP: pulmonary artery pressure, PVR: pulmonary vascular resistance, RA: right atrium, RV: right ventricle, TAPSE: tricuspid annular plane systolic excursion.

Figure 1.  Electrocardiographic characteristics of COPD patients without and with PH.Panel A corresponds to the ECG of a COPD patient without PH (mean PAP 17 mm Hg, heart rate 81 bpm, PR interval 124 ms, QRS complex duration 76 ms, QTc interval 401 ms, QRS axis + 37° and T wave axis + 70°). Panel B shows the ECG of a COPD patient with PH (mean PAP 65 mmHg, heart rate 63 bpm, PR interval 216 ms, QRS complex duration 84 ms, QTc interval 409 ms, QRS axis + 72° and T wave axis – 22°). In the ECG of the COPD patient with PH (panel B) the PR interval (PR) is longer, the P wave (P) in V1 and the S wave in lead I are of larger amplitude. In addition, there are negative T waves in the inferior leads (*).

Table 3.   Electrocardiographic variables

	All patientsMean (SD) or n (%)	No PHMean (SD) or n (%)	PHMean (SD) or n (%)	p
n	142	52 (37)	90 (63)
Time from RHC to ECG (months)	–0.5 (–8–0)	–3.5 (–11–0)	0 (–6–0)	0.05
Heart rate (bpm)	85 (16)	86 (16)	85 (16)	0.83
P wave axis (degrees)	73 (19)	76 (15)	72 (22)	0.19
P wave amplitude V1 (mV)	0.08 (0.05)	0.07 (0.04)	0.08 (0.05)	0.14
P wave amplitude lead II (mV)	0.17 (0.08)	0.17 (0.08)	0.17 (0.08)	0.73
PR interval (ms)	146 (27)	139 (22)	151 (29)	0.01
QRS complex duration (ms)	89 (14)	88 (14)	90 (14)	0.32
QRS axis (degrees)	61 (33)	63 (32)	60 (34)	0.66
R wave amplitude lead V1 (mV)	0.16 (0.2)	0.14 (0.1)	0.17 (0.2)	0.25
R/S ratio lead V1	0.42 (0.6)	0.4 (0.6)	0.4 (0.6)	0.74
R wave amplitude lead I (mV)	0.34 (0.2)	0.3 (0.2)	0.37 (0.2)	0.03
S wave amplitude lead I (mV)	0.13 (0.1)	0.11 (0.1)	0.14 (0.1)	0.58
R wave amplitude lead V6 (mV)	0.81 (0.4)	0.75 (0.3)	0.85 (0.4)	0.12
RBBB	6 (4)	3 (6)	3 (3)	0.49
IRBBB	21 (15)	3 (6)	18 (20)	0.02
ST segment depression in leads V1-V3	2 (1)	0 (0)	2 (2)	0.28
T wave axis (degrees)	61.3 (30)	68.7 (19)	56.9 (32)	0.006
Negative T wave in leads V1-V3	73 (51)	24 (46)	49 (54)	0.34
Negative T wave in inferior leads	11 (8)	4 (8)	7 (8)	0.99
QTc interval (ms)	431 (413–446)	434 (409–452)	431 (414–446)	0.57

Abbreviations: bpm: beats-per-minute, ECG: electrocardiogram, IRBBB: incomplete right bundle branch block, RBBB: right bundle branch block, RHC: right heart catheterization.

Figure 2.  Hierarchical binary recursive partitioning algorithm to predict the presence of PH in COPD patients.The model correctly classified 64 out of 90 (71.1%) PH patients, and 39 out of 52 (75%) patients without PH. The model precision was 83.1% with an AUC by ROC of 0.74.

Table 4.   Electrocardiographic variables in COPD patients with mean PAP < 40 or ≥ 40 mmHg

	Mean PAP < 40 mmHgMean (SD) or n (%)	Mean PAP ≥ 40 mmHgMean (SD) or n (%)	p
n (%)	126 (89)	16 (11)
P wave amplitude in V1	0.73 (0.04)	0.12 (0.08)	0.04
PR interval (ms)	142.2 (23)	178.5 (35)	0.001
QRS complex duration (ms)	88.6 (13)	95.8 (15)	0.048
S wave amplitude in lead I	0.12 (0.12)	0.19 (0.13)	0.03
T wave axis	63.6 (24)	42.8 (46)	0.005
Negative T waves in the inferior leads	7 (5.6)	4 (25)	0.02

Abbreviations: PAP: pulmonary artery pressure.

Figure 3.  Hierarchical binary recursive partitioning algorithm to predict mean PAP ≥ 40 mmHg in COPD patients.The model correctly classified the 16 COPD patients (100%) with mean PAP ≥ 40 mmHg and 75 out of 126 (59.5%) patients who had a mean PAP < 40 mmHg. The model precision was 24% with an AUC by ROC of 0.80. Abbreviations: mPAP: mean pulmonary artery pressure.

Table 5.   Electrocardiographic variables in COPD patients with PH and a PVR < 3 or ≥ 3 Wood Units

	PVR < 3 WU Mean (SD) or n (%)	PVR ≥ 3 WU Mean (SD) or n (%)	p
n (%)	51 (57)	39 (43)
P axis (degrees)	67 (25)	77 (15)	0.02
QRS axis (degrees)	53 (40)	70 (21)	0.02
R wave amplitude in lead I (mV)	0.4 (0.2)	0.3 (0.10)	0.007
R wave amplitude in lead V6 (mV)	0.9 (0.4)	0.8 (0.4)	0.05

Abbreviations: WU: Wood Units.

Figure 4.  Hierarchical binary recursive partitioning algorithm to predict PAOP > 15 mmHg in COPD patients.The model correctly classified 21 out of 42 COPD patients (50%) with a PAOP > 15 mmHg and 77 out of 97 (79.4%) patients who had a PAOP ≤ 15 mmHg. The model precision was 51.2% with an AUC by ROC of 0.65. Abbreviations: PAOP: pulmonary artery occlusion pressure.

Selvester RH, Rubin HB. New criteria for the electrocardiographic diagnosis of emphysema and cor pulmonale. Am Heart J 1965; 69:437–447.

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Spodick DH. Electrocardiographic studies in pulmonary disease. II. Establishment of criteria for the electrocardiographic inference of diffuse lung diseases. Circulation 1959; 20:1073–1074.

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Wasserburger RH, Kelly JR, Rasmussen HK, The electrocardiographic pentalogy of pulmonary emphysema. A correlation of roentgenographic findings and pulmonary function studies. Circulation 1959; 20:831–841.

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