Prevalence of Major Electrocardiographic Abnormalities in Patients with Hypertension in a Primary Care Clinic in Hong Kong

Background Hypertension is strongly associated with cardiovascular events. Studies have shown that electrocardiographic (ECG) abnormalities were associated with increased risks for cardiovascular events. However local data is limited. The objectives of this study were: (1) to determine the prevalence of major electrocardiographic abnormalities in patients with hypertension in primary care in Hong Kong, and (2) to determine the association of major electrocardiographic abnormalities with patients’ socio-economical background, cardiovascular disease and cardiovascular risk factors. Methods This was a cross-sectional study. Subjects were hypertensive patients aged between 18 to 80 who were enrolled in the Risk Assessment and Management Programme (RAMP) in a general outpatient clinic in Hong Kong. Outcome measures were prevalence of probable ischaemic heart disease (IHD), complete left bundle branch block (LBBB), left ventricular hypertrophy (LVH) and atrial fibrillation (AF) in patients with hypertension. The Pearson Chi-square test, independent t-test and Mantel-Haenszel test were used to measure the association between socioeconomic characteristics and cardiovascular risk factors, and ECG abnormalities. Results 504 hypertensive patients aged 18 to 80 were recruited in a general outpatient clinic. 6.3% had probable IHD, 0.4% had complete LBBB, 4.0% had LVH and 1.0% had AF. Probable IHD was associated with smoking (P = 0.032), hypercholesterolaemia (P = 0.037) and higher 10-year CV risk (P = 0.04). Complete LBBB was associated with smoking (P = 0.021) and hypercholesterolaemia (P = 0.022). LVH was associated with male gender (P = 0.001) and longer duration of hypertension (P = 0.035). AF was not significantly associated with any of the clinical or sociodemographic parameters. Conclusions This study showed that a significant proportion of patients with hypertension at the primary care setting in Hong Kong had probable ischaemic heart disease, left ventricular hypertrophy and atrial fibrillation. This finding is consistent with both overseas data and historic data in Hong Kong. The detection of electrocardiographic abnormalities is helpful in hypertension management by improving risk stratification.

Electrocardiographic Characteristics and Their Correlation with Echocardiographic Alterations in Fabry Disease

Fabry disease (FD) is an X-linked disorder with α-galactosidase A deficiency. Males (>30 years) and females (>40 years) often present with cardiac manifestations, predominantly left ventricular hypertrophy (LVH). The aim of this study was to evaluate electrocardiographic (ECG) characteristics within FD patients to identify gender related differences, and to additionally explore the association of ECG parameters with structural and functional alterations on transthoracic echocardiography (TTE). Retrospective cross-sectional analysis of 45 FD patients with contemporaneous ECG and TTE was performed and compared to age and gender matched healthy controls. FD patients demonstrated alterations in several ECG parameters particularly in males, including prolonged P-wave duration (91 vs. 81 ms, p = 0.022), prolonged QRS duration (96 vs. 84 ms, p < 0.001), increased R-wave amplitude in lead I (8.1 vs. 5.7 mV, p = 0.047), increased Sokolow–Lyon index (25 vs. 19 mV, p = 0.002) and were more likely to meet LVH criteria (31% vs. 7%, p = 0.006). FD patients with impaired basal longitudinal strain (LS) on TTE were more likely to meet LVH criteria (41% vs. 0%, p = 0.018). Those with more advanced FD (increased LV wall thickness on TTE) were more likely to meet LVH criteria but additionally demonstrated prolonged ventricular depolarization (QRS duration 101 vs. 88 ms, p = 0.044). Therefore, alterations on ECG demonstrating delayed atrial activation, delayed ventricular depolarization and evidence of LVH were more often seen in male FD patients. Impaired basal LS, a TTE marker of early cardiac involvement, correlated with ECG abnormalities. Increased LV wall thickness on TTE, a marker of more advanced FD, was associated with more severe ECG abnormalities.

Prevalence And Risk Factors of Electrocardiogram Abnormalities In Patients With Rheumatoid Arthritis: A Machine Learning Study With Follow-Up Data

OBJECTIVES: Electrocardiogram (ECG) abnormalities could predict some subsequent cardiovascular events. Cardiac involvement is a major extra-articular manifestation in rheumatoid arthritis (RA). We aimed to determine the prevalence of three major ECG abnormalities in RA patients, discover the associated ECG abnormalities associated with machine learning (ML) approaches, and then examine these preselected factors in the follow-up patients with traditional Cox regression. METHODS: Consecutive RA patients’ records were retrieved from the hospital database; about one-third of patients had follow-up data. Abnormal ECGs with clinical significance were grouped into non-specific ST-segment/T-wave changes, QT interval prolongation, and QRS-T angle increase. Machine learning approaches assessed the associated factors of these abnormalities. The top-important factors selected by the most optimal ML would be used to construct Cox regression models. RESULTS: Two hundred twenty-six patients were enrolled for the first step cross-sectional study. Non-specific ST-T changes (27%) were the most prevalent abnormalities among patients with abnormal ECGs. Random forest models had the best performance in the discovery of associated factors for three outcomes. Cox regression validated that rheumatoid factor and low-density lipoprotein were common risk factors within those three abnormalities. Hypertension, ESR, and serum immunoglobulin G were influential factors for non-specific ST-T changes, prolonged QT interval, and increased QRS-T angle specifically. CONCLUSION: Non-specific ST-T changes were the most common abnormalities seen in ECGs of RA patients. Our finding suggests that rheumatoid factor, LDL, hypertension, and inflammatory indicators are important risk factors for these ECG abnormalities.

398 Right ventricular cardiogenic shock induced by propafenone intoxication: a case report

Aims Propafenone is a Class 1C antiarrhythmic drug recommended in the treatment of supraventricular or ventricular tachycardia and paroxysmal atrial fibrillation (AF). Most common cardiological features associated with propafenone intoxication include heart failure and conduction disturbances while other clinical findings range from nausea and vomiting to seizures and coma. Methods We report a case of atypical presentation of propafenone intoxication occurred in 88-year-old woman who presented at Emergency Department with severe ECG abnormalities and prevalent acute right ventricular with massive tricuspidalic regurgitation and cardiogenic shock. The patient underwent urgent coronary angiography that revealed a stable 90% coronary plaque that was treated with a single stent and then brought to Intensive Care Unit where she was successfully treated with inotropic and mechanical circulatory support (intra-aortic balloon pump, IABP). Results The patient progressively achieved hemodynamic stability with complete ECG normalization and biventricular function recovery. Conclusions Our case further expands the vast spectrum of presentations of Class 1c antiarrhythmic drugs overdose. In an emergency setting it is difficult to rule out other causes of cardiogenic shock but propafenone toxicity needs to be suspected in every case of hemodynamic instability in patients in chronical treatment. Patients in chronical treatment with propafenone who have kidney or liver dysfunction might be at higher risk of drug accumulation: in such cases, the real utility of propafenone must be evaluated before therapy initiation.

148 ECG abnormalities in COVID-19 pneumonia: acute pericarditis, silent cad, or both? A case report

Aims We report the case of a hypertensive 70 year-old man, who presented to the Emergency Department (ED) with fever, dry cough, malaise, dyspnoea. A nasopharyngeal swab for SARS-CoV-2 test was done, being positive. Methods and results Chest TC demonstrated ground glass bilateral pneumonia. Laboratory test showed WBC 10680/mmc, CRP 20 mg/l, TnT 0.03 ng/l, NTproBNP 147 ng/l. The liver and kidney function were within normal values. ECG was normal. He was treated with high flow oxygen (cPAP), enoxaparin, dexamethasone, doxycycline. After an initial improvement, dyspnoea got worse in 8th day, with the evidence of a new rise of inflammatory markers (PCR 95 mg/l, IL6 49 pg/ml) and the clinical new onset of cardiac rubbings on medical examination. The ECG revealed a sinus rhythm with T wave inversion everywhere. TnT remained normal. Echocardiography revealed a normal ventricular function, without segmentary alterations, absence of valvular disease. A mild pericardial effusion was evidenced, without signs of tamponade. We treated the patient with tocilizumab, after exclusion of other active infective foci. The clinical response was good, the patient was progressively weaned by oxygen and he was discharged asymptomatic. After 15 days, for ECG alterations persistence, despite no signs of ACS, a Coronary TC was done and a subcritical multivessel coronary artery disease was demonstrated: a subcritical IVA stenosis and a calcific MO. Conclusions In conclusion we report a successful treatment of COVID pneumonia likely complicated by acute pericarditis, and we observe that in these patients hypoxemia and cytochine storm possibly bring out silent vascular diseases, otherwise neglected.

544 Two cases of constrictive pericarditis temporally associated with mRNA-1273 COVID-19 vaccination

Aims The SARS-CoV-2 pandemic has led to the development of the mRNA vaccines in humans which are well tolerated, safe, and highly efficacious; however, post-marketing surveillance is revealing potential rare cardiac adverse effects as acute pericarditis. We herein report two cases of symptomatic constrictive pericarditis following administration of the second dose of mRNA-1273 (Moderna) SARS-CoV-2 vaccine. Methods and results Case summary: A 75 years old male with history of hypertension and COPD presented to our Hospital approximately one month after the second dose of mRNA-1273 SARS-CoV-2 Vaccine with dyspnoea and leg oedema. Routine analysis resulted normal, no increasing of inflammatory markers or ECG abnormalities. Echocardiogram showed circumferential fibrinous pericardial effusion without tamponade and typical features of constrictive pericarditis: annulus reversus, ventricular interdependence, expiratory diastolic flow reversal in hepatic vein, inferior vena cava plethora. Pleural ultrasound showed bilateral pleural effusion that was sampled and showed a transudate fluid. Tumoral marker and a CT Scan, autoimmunity panel, blood tests for bacteraemia and Quantiferon were negative. Cardiac magnetic resonance imaging confirmed thickening of pericardium. A 68 years old male with history of ischaemic heart disease with previous CABG, hypertension, dyslipidaemia and chronic kidney disease presented with palpitations and mild legs swelling. Approximately, 2 months before he received the second dose of mRNA-1273 SARS-CoV-2 vaccine. Routine blood examinations resulted normal, ECG showed a right bundle branch block. Echocardiogram showed a mild enlargement of LV with normal systolic function, a moderate primary mitral regurgitation and a circumferential pericardial effusion, showing signs of constrictive syndrome. CT Scan demonstrated pericardium thickness. Constrictive pericarditis may represent a subacute complication of an asymptomatic exudative acute pericarditis. Although cases of acute pericarditis have been reported after SARS-CoV-2 vaccine, to our knowledge, the association with constrictive pericarditis has not been described. The temporal link between vaccination and symptoms development as the biological plausibility of autoimmune or cross-reaction response to vaccination in predisposed subjects could suggest a possible correlation as an adverse event, even if causality could not be established. Conclusions We present two cases of constrictive pericarditis occurring after mRNA-1273 SARS-CoV-2 vaccination, aiming further data to confirm a causal role.

Clinical values of resting electrocardiography in patients with known or suspected chronic coronary artery disease: a stress perfusion cardiac MRI study

Background Electrocardiography (ECG) is an essential investigation in patients with chronic coronary artery disease (CAD). However, evidence regarding the diagnostic and prognostic value of ECG in this population is limited. Therefore, we sought to determine whether baseline ECG abnormalities were associated with myocardial ischemia and cardiac events in patients with known or suspected chronic CAD. Methods Consecutive patients with known (n = 146) or suspected chronic CAD (n = 349) referred for adenosine stress cardiac magnetic resonance (CMR) between 2011 and 2014 were enrolled. Resting ECGs were classified as major, minor, and no abnormalities. Predictors of myocardial ischemia on CMR and major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, hospitalization for heart failure and late revascularization (> 180 days after CMR) were evaluated. Results Average age was 69 ± 11 years (51% men). One hundred and eighty-five patients (37.4%) had major and 154 (31.1%) had minor ECG abnormalities. In patients with suspected CAD, myocardial ischemia was presented in 83 patients (23.8%). Multivariable analysis demonstrated major ECG abnormality as the strongest predictor of myocardial ischemia (HR 2.51; 95% CI 1.44–4.36; p = 0.001). Adding ECG to clinical pretest probability models improved the prediction of myocardial ischemia in ROC analyses (p = 0.04). In the whole cohort (n = 495), 91 MACE occurred during the median follow-up period of 4.8 years. Multivariable analysis showed that diabetes mellites, history of heart failure, prior revascularization, left ventricular ejection fraction, ischemia, and major ECG abnormality were independent predictors of MACE. Conclusion Abnormal resting ECG is common in patients with known or suspected chronic CAD. ECG had important diagnostic and prognostic values in this population.

Electrocardiographic abnormalities and psychotropic polypharmacy in schizophrenia and schizoaffective disorders

Background: Sudden cardiac death (SCD) is a significant cause for increased mortality in people with schizophrenia and schizoaffective disorders. Cardiac arrhythmia is one cause of SCD. Electrocardiographic (ECG) abnormalities predictive of arrhythmias are associated with antipsychotic drug use. Method: This chart audit examined the types and frequency of ECG abnormalities (ECG-Abs) in 169 patients with schizophrenia and schizoaffective disorder in a long-stay inpatient unit. We examined the association of ECG-Abs with demographic details and psychotropic drug prescription using chi-square test, Fisher’s Exact test, independent two-sample t-test, Pearson’s correlation, and one-way ANOVA. Results: Eighty-eight patients (52.1%) recorded at least one ECG-Ab, and 20.7% had two or more ECG-Abs. The use of multiple antipsychotics, with or without other psychotropic drugs, did not associate significantly with the presence or number of ECG-Abs. Conclusion: A significant proportion of patients with schizophrenia and schizoaffective disorder have ECG-Abs other than prolonged QTc interval, which can predispose them to cardiac arrhythmias. The abnormalities were not limited to patients on psychotropic polypharmacy. ECG evaluation is indicated for all patients and should consider various electrical abnormalities to identify arrhythmia risk.

Electrocardiographic abnormalities in COVID-19 patients visiting the emergency department: a multicenter retrospective study

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be associated with myocardial injury. Identification of at-risk patients and mechanisms underlying cardiac involvement in COVID-19 remains unclear. During hospitalization for COVID-19, high troponin level has been found to be an independent variable associated with in-hospital mortality and a greater risk of complications. Electrocardiographic (ECG) abnormalities could be a useful tool to identify patients at risk of poor prognostic. The aim of our study was to assess if specific ECGs patterns could be related with in-hospital mortality in COVID-19 patients presenting to the ED in a European country. Methods From February 1st to May 31st, 2020, we conducted a multicenter study in three hospitals in France. We included adult patients (≥ 18 years old) who visited the ED during the study period, with ECG performed at ED admission and diagnosed with COVID-19. Demographic, comorbidities, drug exposures, signs and symptoms presented, and outcome data were extracted from electronic medical records using a standardized data collection form. The relationship between ECG abnormalities and in-hospital mortality was assessed using univariate and multivariable logistic regression analyses. Results An ECG was performed on 275 patients who presented to the ED. Most of the ECGs were in normal sinus rhythm (87%), and 26 (10%) patients had atrial fibrillation/flutter on ECG at ED admission. Repolarization abnormalities represented the most common findings reported in the population (40%), with negative T waves representing 21% of all abnormalities. We found that abnormal axis (adjusted odds ratio: 3.9 [95% CI, 1.1–11.5], p = 0.02), and left bundle branch block (adjusted odds ratio: 7.1 [95% CI, 1.9–25.1], p = 0.002) were significantly associated with in-hospital mortality. Conclusions ECG performed at ED admission may be useful to predict death in COVID-19 patients. Our data suggest that the presence of abnormal axis and left bundle branch block on ECG indicated a higher risk of in-hospital mortality in COVID-19 patients who presented to the ED. We also confirmed that ST segment elevation was rare in COVID-19 patients.