Electrocardiographic changes in COPD - Smt. NHL Municipal ...

Research Article Electrocardiographic changes in COPD Hina Banker*, Anita Verma** *

Tutor , Dept of Physiology, GMERS Medical College, Gandhinagar Associate Professor**, Dept of Physiology, Smt. NHL Muni Medical College, Ahmedabad

ABSTRACT Introduction: Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous clinical syndrome found in 6–8% of the entire population. In human being, the respiratory and circulatory systems are so intimately related that changes in one, sooner or later may cause changes in the other. In COPD patients, functional and structural changes of the respiratory system deeply influence cardiovascular function. Methodology: Cross-sectional study was conducted in patients of chronic obstructive pulmonary disease admitted in medical ward & emergency ward. Out of 100 cases, 30 were females and 70 were males. Most of the patients were diagnosed clinically and after radiological investigation & ECG. Discussion: Maximum number of patients belonged to 51-60 years. 65% cases showed right axis deviation. 35% showed p pulmonale, 70% showed right axis deviation. In 65% cases position of heart was vertical. In 22% cases low voltage QRS complex was seen. 62% cases dominant S wave in lead V5-V6. Conclusion: Most common findings in ECG of patients with chronic obstructive pulmonary disease were indicating right axis deviation, clockwise rotation of heart, vertical position of heart. Key words: Chronic obstructive pulmonary disease, Electrocardiogram. AIMS & OBJECTIVE 1. To study various Electrocardiographic (ECG) changes in patients of chronic obstructive pulmonary disease. 2. To find out the incidence of various ECG changes in patients of COPD. INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous clinical syndrome found in 6–8% of the entire population1. In human being, the respiratory and circulatory systems are so

intimately related that changes in one, sooner or later may cause changes in the other. In COPD patients, functional and structural changes of the respiratory system deeply influence cardiovascular function2. Cardiac arrhythmia and sudden death are common and important causes of mortality in patients with COPD. Several factors such as abnormal autonomic control of cardiopulmonary function may contribute to the development of arrhythmias in these patients3 4. Varied prevalence of COPD among adult population is reported in India5,6. Several studies7,8,reported changes in the activity of heart including P-wave axis and amplitude, rightward displacement of QRS and T-axis, reduction of amplitude of QRS complex in limb and primordial leads, sinus tachycardia, Right bundle branch block (RBBB) etc., among COPD patients. In clinical practice, COPD is defined by its characteristically low airflow on lung function tests.9 The natural course of COPD is characterized by occasional sudden worsening of symptoms called acute exacerbation, most of which are caused by infections or air pollution. A complication of advanced COPD is cor-pulmonale, a strain on the heart due to the extra work required by the heart to pump blood through the affected lungs. COPD causes cor-pulmonale through severe inter related mechanisms, including hypoventilation, hypoxemia from ventilation perfusion mismatch and destruction of perfused surface area. Various Causes of COPD are smoking, occupational exposures, air pollution, genetic susceptibility (alpha 1 antitrypsin deficiency). In COPD, the greatest reduction in airflow is during expiration, as pressure in the chest tends to compress rather than expand the airways. COPD influences the electrical events of the heart in following basic respects10. The voluminous lung has an insulating effect and thereby diminishing the transmission of electrical potential to the registering electrode. The heart descends to lower position due to lowering of diaphragm. This will alter the position of heart relative to the conventional precordial electrode positions. The right ventricle and right atrium

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becomes compromised due to a reduction of pulmonary vascular bed. This will result in right ventricle hypertrophy and dilatation as well as right atrial enlargement. The typical ECG changes in COPD are: (1) prominent P waves in leads II, III and aVF; (2) rightward shift of the QRS axis in the frontal plane; (3) poor progression of the R wave in the precordial leads; (4) low voltage of the QRS complexes especially in the left precordial leads, and (5) the "lead I sign" In patients with COPD, the frontal plane P, QRS and T wave axes are not infrequently directed at around +90. However, they are directed either precisely or almost perpendicular to the standard lead I axis. As a result, lead I reflect either absent or very low amplitude P, QRS, T wave complexes giving the appearance of a minimally disturbed baseline. This ECG phenomenon is known as the "lead I sign". The "lead I sign" is a highly specific ECG marker of chronic obstructive pulmonary disease (COPD) and has been very rarely documented in any other condition. In 1965, Fowler and co-workers reported 15 patients with severe pulmonary emphysema with cor pulmonale, & found, 5 patients (33%) showed the "lead I sign"11. These authors proposed very strict arbitrary criteria for the diagnosis of the "lead I sign" consisting of isoelectric P wave in lead I combined with a very small QRS complex of less than 1.5 mm total deflection and a T wave of less than 0.5 mm in lead I. Various ECG changes in COPD and their possible mechanism:10 - (1) Low voltage graph (QRS complex < 5mm in standard leads). Due to insulating effect of hyper inflated lungs and lowered position of the heart (tubular) with respect to electrodes. (2)Right axis deviation of QRS with clockwise rotation. This is due to rotation of the heart on horizontal and frontal plane. (3)Right atrial (P pulmonale) and right ventricular hypertrophy (Decreased voltage of R in leads V1 and V2 with R: S>1). This is secondary to development of pulmonary hypertension and subsequent development of cor pulmonale. (4)Poor progression of R wave in chest leads from V1 to V6. Hyper inflated lungs push down the heart with respect to electrodes, which record low voltage. There is clockwise rotation shifting the transition zone leftwards resulting in poor voltage in precordial

leads. (5)SI, SII, SIII pattern. This indicates marked shifting of QRS axis to north- west region. I.e. right superior quadrant. (6) The T wave may be inverted in lead V1 or V2 due to RVH. Due to varied effect of hyper inflated lungs, axis deviation and right ventricular enlargement (7) There may be generalized ST depression with T wave inversion. This is due to global hypoxemia. (8) Arrhythmias: Supraventricular arrhythmias are more common than ventricular arrhythmias. These are due to generalized myocardial ischemia due to global hypoxia. METHODOLOGY Present hospital based cross-sectional study was conducted during July 2009 to November 2011 at Ahmedabad. 100 cases of chronic obstructive pulmonary disease admitted in medical ward & emergency ward taken up for this study, Out of which 30 were females and 70 were males. Inclusion criteria: (a) All the patients were of above 30 years of age. (b)The presence of chronic obstructive pulmonary disease having ECG findings Exclusion criteria: (a) The presence of congenital, valvular, infective, as well as cardiomyopathy of the heart. Most of the patients were diagnosed clinically and after radiological investigation. A 12 lead ECG including 3 bipolar limb leads, 3 unipolar limb leads and 6 unipolar precordial leads was performed. All necessary precautions desired in ECG were observed. ECG was done by single channel BPL cardiac various 108T/MK-V I machine. Various ECG parameters like rate, axis deviation, P-wave changes, QRS complex, Twave, ST changes etc. were observed. The axis of Pvalue and QRS complex was calculated by hex axial reference system. RESULT A total 100 patient of COPD were studied, out of which there were 30 females and 70 males. TABLE-I: Distribution of Patients according to age Age in 31-40 41-50 51-60 > 60 Years Total 16 25 35 24 Patients Out of 100 patients maximum i.e. 35 belonged to 5160 years.

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Fig 2: Symptoms and Number of the patients.

Number of patients 80 70 60 50 40 30

number of patients

20 10 0

ECG changes (%) 100 90 80 70 60 50 40 30 20 10 0

65

70

65

64

58 38

35 20 5

38 22

21 12

10

In most of the cases, cough and breathlessness were the common symptoms. Whereas right axis deviation, clockwise rotation of heart, vertical position of the heart was the commonly observed findings.

16 8

11

16

DISCUSSION A study of Electro cardiogram (ECG) in 100 patients primarily suffering from chronic obstructive pulmonary disease (COPD) is done. The Airway obstruction and Emphysema existed to a variable degree in these patients and an attempt has been made to assess the influence of these factors

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on electrical activity of Heart. Among 100 patients with COPD, maximum number of patients belonged to 51-60 years; Mean age of COPD patients was significantly higher than that of patients suffering from other respiratory diseases, which is comparable with previous study.12 In our study 65% of cases showed right axis deviation, in P wave axis. There is no case showing left axis deviation. Remaining 35% of cases showed normal p wave axis. In previous studies it was 50%, 76%. 12 Thus our results are comparable with the results of previous studies. In present study, 35% patients showed P pulmonale (Tall and peaked p wave in lead II, III, aVF), Amplitude of p wave >2.5mm. In previous studies P pulmonale was reported in 32%, 35.7%, 37%..Right axis deviation of QRS complex was seen in 70% of the case in previous studies. 12 In the present study, the left axis deviation of QRS is not observed in any of the cases, while previous study reported it to be present in 14% of cases. In present study 65% of cases showed vertical position and other 20% of cases showed semi vertical position. 10% of cases showed intermediate position and 5% of cases showed horizontal position. In previous studies 72% & 66% showed vertical position ,.12 In present study clockwise rotation of the heart was observed in 64% of cases. Counter clockwise was not present in any of the cases. Dominant ‘R’ in lead aVR found in 38% in present study & 44% of previous study. R/S ratio in lead V 1 is less than 1 in 38% of cases. In previous 2 different studies it was reported to be 20% & 44%. 12 In present study, R/S ratio in lead V6 less than 1,Was found in 62% of cases, in the previous study the incidence of same was reported to be 74%.In present study 12% of cases showed incomplete RBBB in their ECG. In previous study, it was found to be 7% of cases. In this study 21% of cases showed abnormal ST-T changes.12 QS Pattern seen in 16% of cases. In previous study, the incidence of same was reported in 11% of cases. In present study QRS complex less than 5mm in lead I, suggestive of low voltage ECG, was seen in 22% of cases & was reported to be 80%in previous studies. 12

CONCLUSION Chronic obstructive pulmonary disease, a broad spectrum of respiratory diseases represents a worldwide problem. Classical right ventricular hypertrophy is less commonly observed than expected. When classical pattern was not present then, the features suggesting right ventricular hypertrophy are the combination of right axis deviation, R/S ratio in lead V1 >1, Dominant ‘R’ in aVR , abnormal ST – T changes, and p pulmonale. P pulmonale is perhaps the less common findings. Other less commonly observed changes are the right bundle branch block, low voltage QRS, SI SII SIII, and arrhythmia. Most common findings in ECG of patients with COPD are right axis deviation, clockwise rotation of heart, vertical position of heart. References: 1. Murray CJ, Lopez AD: Alternative projections of mortality and disability by cause 1990- 2020: Global Burden Disease Study. Lancet , 1997; 349: 1498-1504. 2. Young RP, et al: COPD prevalence is increased in lung cancer, independent of age, sex, and smoking history”. Eur . Respir. J. (2009) 34 (2): 380–6. 3. Flick MR, Block AJ.:Nocturnal vs. Diurnal cardiac arrhythmias in patients with chronic obstructive pulmonary disease. Chest, 1979, 75: 8-11. 4. Stewart AG, Waterhouse JC, Howard P: The QTc interval, autonomic neuropathy and mortality in hypoxaemic COPD. Respir Med 1995;89:79- 84. 5. Malik SK .: Profile chronic bronchitis in North India: the PGI experience (1972- 1985) Lung India. 1986; 4: 89-100. 6. Bhattacharya SN, Bhatnagar JK, KumarS, Jain PC.: Chronic bronchitis in rural population. Indian J Chest Dis 1975; 17:1-7. 7. Carid FI and Wilcken DEL.: ECG in chronic bronchitis with generalized Obstructive lung disease- Its relation to ventilatory Junction. Am J Card 1962;10:5. 8. Calatayud JB, Abad JM, Khoi NB et al : P wave changes in chronic obstructive pulmonary disease. Amer Heart J 1970; 79: 444. 9. Nathell, L: Nathell M : Malmberg, P: Larsson, K. (2007) . “COPD diagnosis related to different guidelines and spirometry techniques:. Respiratory research 8 : 89. 10. S N Chugh, practical electrocardiography, second edition, 2009; pp. 165- 166. 11. Kumar P, Clark M (2005). Clinical Medicine (6th ed.) Elsevier Saunders. Pp.900 ISBN 0702027634 12. Chappell AG. The electrocardiogram in chronic bronchitis and emphysema. Brit Heart J 1996;28;517 13. Shah C et al.Electrocardiographic changes in COPD in Indians,Indian journal of apllied basic med.sciences.Vol10b,2018,10-13. 14. Chazan R,Drosea W.Electocardiographic changes in patients with air way obstruction.Pol.Arch.>ed.wewn 1992;87;237-241 15. R I agrawal,dineshkumar,Gurpreet,D K Agrawal,G S chhabra.Diagnostic values of ECG in COPD.Lung India 2008;25:78-81

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