Electrocardiographic screening for chronic obstructive pulmonary disease Biljana Lazovic, MD, PhD1,2; Jelena Milin, MD2; Vladimir Žugić, MD, PhD2,3 1University Clinical Hospital Center Zemun-Belgrade, 2Medical School of Belgrade, 3Clinic for lung disease, Clinical Centre of Serbia ABSTRACT INTRODUCTION RESULTS DISCUSSION INTRODUCTION: Patients with Chronic Obstructive Pulmonary Disease (COPD) often have abnormal electrocardiogram (ECG). Electrocardiographic findings may help in clinical decision making regarding this disease entity. MATERIAL-METHOD:  A hospital based cross-sectional study was conducted in Clinical Hospital Center Zemun, Belgrade. A sample of 836 patients suffered from different respiratory diseasewere included in study consecutively during period 2011-2014. Mean age was 63.3±9,7 (female 70%, male 30%). We analyzed chest radiographs and electrocardiogram changes such as p wave height, QRS axis, duration and voltage, right bundle branch block, left bundle branch block (LBBB), right ventricular hypertrophy (RVH), T wave inversion in leads V1-V3, S1S2S3 syndrome, transition zone in praecordial lead and QT interval and their pulmonary function. RESULTS: Out of 836 patients, we found 220 COPD patients (26.31%). Normal electrocariographic axis had 72,7 % patients, left axis 27,3%, and no patient with right axis. Peaked p wave was observed in 48,2% COPD patients where a duration of QRS complex was abnormal in 99,1%. RVH was found in 0,9%. RBBB in 40,9% while incomplete RBBB in 13,9% patients. Low QRS compex was observed in 50,9% patients.Transitional zone was found in 76,8%, LBBB in 4,1%, S1S2S3 configuration found in 4% and negative T V1-V3 in 2,7%. Emphysema had 52,7 % patients. Mean value of FVC was 57,3± 156, FEV1 46,8±13.5., MEF15.6 (5.6-67.0) l/min. GOLD stadium 2 was verified in 40%, 3 (48,2%) and 4 (11.8%) patients. Artrial fibrillation was found in 33,2 % patients.  CONCLUSION: Duration of QRS complex could be a first electrocardiographic sign of COPD. 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. The various respiratory diseases may secondarily cause changes in the heart, which may be detected by Electrocardiograph (ECG). Several studies 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 precordial leads, sinus tachycardia, Right bundle branch block (RBBB) etc., among COPD patients. However, COPD patients probably are not usually assessed by electrocardiogram in routine medical practice. Therefore, the present study was conducted to evaluate the diagnostic values of ECG changes among COPD patients. Out of 836 patients, we found 220 COPD patients (26.31%). Normal electrocariographic axis had 72,7 % patients, left axis 27,3%, and no patient with right axis. Mean age was 63.3±9,7 (female 70%, male 30%). GOLD stadium 2 was verified in 40%, 3 (48.2%) and 4 (11.8%) patients. Among 836 patients with respiratory disease enrolled in the present study, 220 patients were diagnosed as a COPD patients. The prevalence was higher among female patients. Two thirds patients had normal QRS axis, which is consistent with earlier studies (Phillips et al). GOLD I stadium was not registered, GOLD 4 only about 11,8 %, while GOLD 2 and GOLD 3 were almost about the same. Normal sinus rhythm was recorded in 66.8 % cases, the rest was atrial fibrillation. Scott RC et al¹. reported arrhythmias other than sinus tachycardia to be uncommon in chronic cor pulmonale. About half of COPD patients had peaked P-waves. In previous studies p pulmonale was found in 13.9% to 32,7 patients (Pinto et al.). Low QRS was present in half of patients.T-wave inversion in leads V1 to V3 was found in only 2.7% cases. The case had associated RVH and incomplete RBBB and the inversion could be attributed to them. Pinto et al found T-wave inversion in maximum 18.5% cases. High prevalence of RBBB was registered in 40.9% cases. Shorten QT interval was registered in 99,1% patients. This finding was not reported in such high numbers of patients ever since. Abnormal shortening of the QT interval results from a shortened or absent ST segment. Shortening of the QTc is seldom recognized and, except for a hypercalcemia and digitalis effect, has not played a role in clinical practice. Recently, however, a syndrome of short QT interval was associated with sudden death became recognized as a distinct channelopathy.  Transient zone was observed in 76.8% cases.   Graphicon 1. Cardiac axis Graphicon 2. COPD stadium Peaked p wave was observed in 48,2% COPD patients, where a duration of QRS complex was abnormal in 99,1%. RVH was found in 0,9%. RBBB in 40,9% while incomplete RBBB in 13,9% patients. Low QRS complex was observed in 50,9% patients.Transitional zone was found in 76,8%, LBBB in 4,1%, S1S2S3 configuration found in 4% and negative T V1-V3 in 2,7%. METHODS AND MATERIALS Present hospital based cross-sectional study was conducted during January 2011- March 2014 in Clinical Hospital Center Zemun. Patient sufferes from different respiratory disease were analysed consecutively, in stable condition and supine position. A total of 836 patients were included in the study. 220 patients diagnosed as COPD. Patients underwent pulmonary function test and radiological investigations. Further evaluation was also done by ECG. 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 cardiart various108T/MK-V I machine. Various ECG parameter like rate, axis deviation, P-wave changes, QRS complex, T-wave, ST changes etc. were observed. The axis of P-value and QRS complex was calculated by Cabrera system. Graphicon 3. Electrocardiogra[hic changes in COPD CONCLUSIONS Mean value of FVC was 57,3± 15.6, FEV1 46,8±13.5., MEF 15.6 (5.6-67.0) l/min. Our study came to new conclusion in electrocardiographic changes in COPD patients. Shorten QT interval (less than 400ms, as well as in corrected versions -QTc), which is rare findings in any kind of disese, even in cardiology, as well, could be the first sign of COPD. Electrocardiogram could be a simple screening tool for discovering COPD patient. FVC ( l/min) 57,3 ± 15.6 FEV1( l/min) 46,8 ±13.5 MEF (l/min) 15.6 (5.6-67.0) Figure 2. Shorten QT interval in electrocardiogram REFERENCES Scott RC. The electrocardiogram in pulmonary emphysema and chronic corpulmonale. Amer Heart J. 1961; 61:843 Pinto, Hansoti RC. The ECG changes in chronic corpulmonale. J Assoc Phy India. 1960;8: 213. Phillips RW. The electrocardiogram in cor pulmonale secondary to pulmonary emphysema - A study of 18 cases proved by autopsy. Am Heart J. 1958;56:352 CONTACT E mail: lazovic.biljana@gmail.com Website: https://www.researchgate.net/profile/Biljana_Lazovic1 Figure 1. Lung hiperexpansion and vertical orientation of the heart