Insights into the Importance of the Electrocardiogram in

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Presentation transcript:

Insights into the Importance of the Electrocardiogram in Patients with Acute Heart Failure Pishoy Gouda1, Brian H. Rowe1, Finlay A. McAlister 1, Paul Armstrong1, Mohua Podder1, Justin A. Ezekowitz 1 University of Alberta, Edmonton, Canada Introduction Table 1. ECG Diagnostic Criteria Table 3. Prevalence of ECG characteristics Table 5. Relationship between Unadjusted 1-year mortality and ECG characteristics ECG Criteria PR Interval Prolonged if >200ms QRS Prolonged if >120ms QTc Prolonged if >450ms Atrial Fibrillation Absolutely irregular RR interval with no distinct P waves T wave inversion Drop >0.1mV below the baseline* Left ventricular hypertrophy Either Sokolow Lyons or Cornell criteria** Left bundle branch block QRS >120ms and a R2 peak in leads V5, V6, I, II or aVL Right bundle branch block QRS >120ms and a R2 peak in leads V1 or V2 Q waves Pathological if >40ms and deeper than ¼ the following R wave ST segment +/- 0.1mv or greater in amplitude 40ms following the J point.* Prevalence - N (%) Normal ECG 71 (8) Sinus Rhythm 495 (54) AF 325 (35) RBBB 70 (8) LBBB 124 (13) LVH 219 (24) ST Elevation/Depression 170 (18) T-wave inversion 329 (46) PR >200ms (385 missing) 132 (25) QRS >120ms 334 (36) QTc >450ms 632 (69) * Heart Failure (HF) is a life threatening condition with an estimated prevalence of 2% in the adult population. In Canada, HF is responsible for over 100 000 acute presentations annually with an in hospital mortality rate of up to 10%. The electrocardiogram (ECG) is a component of the standardized diagnostic workup of patients with suspected HF. ECG abnormalities are common among patients with acute HF, however their prognostic relationship remains unclear. * P value <0.05 * * Objective To describe the ECG characteristics of the acute HF population and their associated risks of short term (90 days) and long term (1-year) mortality. *In the absence of LBBB, LVH and paced rhythms **In the absence of LBBB and paced rhythms Table 4. Relationship between Unadjusted 90-day mortality and ECG characteristics Results Methods Table 2. Baseline Characteristics Total ECG Cohort N = 922 Abnormal ECG N = 851 Normal ECG N = 71 P-value Age: med (q1,q3) 77 (67 - 84) 78 (67 - 84) 71 (62 - 82) 0.005 Male: n (%) 503 (55) 475 (56) 28 (39) 0.008 EMS: n (%) 460 (51) 423 (51) 37 (54) 0.650 Prior HF history: n (%) Valvular 182 (20) 171 (20) 11 (16) 0.349 Ischemic 360 (39) 331 (39) 29 (41) 0.746 Hypertensive 436 (47) 395 (46) 41 (58) 0.066 Medical History: CAD 482 (52) 450 (53) 32 (45) 0.206 Device (ICD, CRT, Pacemaker) 158 (17) 154 (18) 4 (6) 0.007 Prior EF (%) Median (q1, q3) 45 (30 - 55) (32.5 - 55) 0.631 First available laboratory readings in ED: median (q1, q3) Troponin (ng/ml) 0.10 (0.01 - 0.10) (0.09 - 0.10) 0.565 BNP (pg/ml) 1023 (590 - 1839) 1047.5 (598 - 1853) 798.5 (488 - 1570) 0.025 Design: Prospective cohort Setting: 4 hospital emergency departments (ED) in Edmonton, Canada. Participants were recruited from June 2009 to November 2012. Participants: 952 patients seen in ED with suspected acute HF were recruited in the Acute Heart Failure – Emergency Management cohort (AHF-EM) Exclusion criteria: severe dementia, hemodialysis dependent, ACS or previous enrollment Of the 952 participants, 922 (97%) had an ECG available. AHF Diagnosis: Based on Boston Criteria, modified to include BNP. ECG Interpretation: The first available ECG for each participant was read by a single investigator at a core lab, with a 1% quality assessment by a second investigator. ECGs were interpreted using modified Minnesota coding guidelines. Statistics: Chi square was used to analyze association of ECG characteristics with all cause mortality. Conclusion * P value <0.05 ECG abnormalities are commonly seen in patients with acute HF. While a completely normal ECG is linked to lower mortality, the presence of RBBB, Q waves and widened QRS are associated with increased risks of mortality. Limitation of this study is the lack of adjustments for key clinical variables (age, sex, creatinine, EF). Further work is required to determine if the ECG, using these cut points or as continuous variables, can be integrated into clinically useful risk models. * Acknowledgments This work was supported by grants from the Canadian Institutes of Health Research and Alberta Innovates Health Solutions.