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A CORRELATIONAL STUDY OF ELECTROCARDIOGRAM FINDINGS WITH SEVERITY OF COPD IN A TERTIARY CARE CENTRE.

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of chronic morbidity and mortality throughout the world. It accounts for a substantial number of visits to general physician, emergency department, hospital admissions and also a cause for frequent absence from work. (1)

Across the world, tobacco smoking is the leading risk factor for COPD. (4) Both active and passive smoking account for respiratory symptoms. Occupational exposure to organic and inorganic dusts, chemical agents and fumes are other risk factors for COPD.t (5,6) There is growing evidence that indoor air pollution from biomass cooking and heating in poorly ventilated dwellings is an important risk factor for COPD. (2)

Cough is often the first and most common symptom of COPD. Cough may be productive or unproductive.!3) Cough with sputum production is present in about 30% of patients. These symptoms may vary from day to day. Breathlessness, wheezing and chest tightness are other accompanying symptoms. Fatigue, weight loss and anorexia are other problems seen in patients with severe and very severe COPD. Spirometry gives an objective measurement of airflow limitation. (2) On the basis of GOLD criteria, COPD is graded into 4 grades (Mild, Moderate, Severe and Very Severe disease) according to spirometric parameters. (4)

The major morbidity of COPD is due to its effect on cardiovascular system, which is mainly due to pulmonary arterial hypertension ultimately leading to cor pulmonale. Cor pulmonale is an important cause of mortality in patients with COPD. (5) Since the electrocardiogram is a very simple and convenient bedside investigation, it would be of great importance if a high degree of correlation is established between ECG and spirometric studies (which indicate the severity of COPD).

Aim and Objective of the study

To study correlation between ECG changes and spirometric parameters in patients with COPD.

MATERIALS AND METHODS

Type of Study

A prospective observational study from 2016 August to 2017 August.

Place of Study

Department of Medicine, K. D. Medical College, Mathura.

Inclusion Criteria

Adult males and females aged more than 35 years with a history suggestive of chronic obstructive pulmonary airway disease were selected at random from the Outpatient Department of KDMCHRC, Mathura for the present study.

The diagnosis of chronic obstructive pulmonary disease is made by symptoms in history and confirmed by physical examination, radiographic examination and lung spirometry for airway obstruction by spiroanalyser.

Exclusion Criteria

Cases excluded from the present study are those with a primary diagnosis of bronchial asthma, lung cancer, known left ventricular dysfunction, poorly controlled hypertension, significant valvular disease and known coronary artery diseases (Angina, Ischaemic changes in resting ECG or documented history of myocardial infarction).

Cases with non-visualisation or poor visualisation of only one or few parameters being studied in the presence of recordable readings of the other parameters are included. Patients with active pulmonary Koch's or history of old pulmonary Koch's were excluded from the study.

Study Protocol

After recruitment for the study, a thorough physical examination was done and routine investigations were carried out. The patients were subjected to the spirometric examination. The patients who were diagnosed as having chronic obstructive pulmonary disease as per GOLD guidelines with FEV1/FVC 0.7 or less are further divided into 4 groups

Group I--Patients having FEV/FVC 0.7 or less, but having a FEV1 of more than 80% of predicted value.

Group II--Patients selected fulfil the above criteria and belong to moderate COPD based on predicted FEV1 (50-80% of predicted value).

Group III--Patients selected fulfil the above criteria and belong to severe COPD based on predicted FEV1 (30-50% of predicted value).

Group IV--Patients selected fulfil the above criteria and belong to very severe COPD based on predicted FEV1 (< 30% of predicted value).

Electrocardiographic Assessment

A standard 12-lead electrocardiography obtained for each using a portable ECG machine. The following ECG changes were detected and correlated with spirometric test

a. P-pulmonale pattern (P-wave amplitude > 2.5 mm) in leads II, III, avF;

b. Right axis deviation of QRS complex (beyond + 90 degrees).

c. Right ventricular hypertrophy.

d. Right bundle branch block.

e. Low voltage QRS complexes.

f. Polymorphic p-wave.

Statistical Method

The data was entered in SPSS version 22 for generating reports and distribution curves of the study population. Chi-square test was used to see how strongly ECG changes were related with spirometric findings of COPD patients. A p-value of less than 0.05 was considered as significant.

RESULTS

This paper deals with relationship of ECG changes with spirometric parameters in COPD patients.

The study includes 50 (N= 50) patients diagnosed as COPD in our tertiary care centre. Out of 50 patients, 43 were male and 7 were female patients.

Maximum number of patients i.e. 27 belonged to 51-60 years of age group.

As per GOLD criteria mild group included 2 COPD patients, moderate group 14 COPD patients, severe group consisted of 23 COPD patients and very severe group consisted of 11 COPD patients. Further, the patients in each subgroup were studied for ECG changes.

In the current study, the most frequent ECG change observed was P-pulmonale (68%) and the least common change was Right Ventricular Hypertrophy.

In the present study, it was observed that the most frequent ECG changes were P-pulmonale and Right Axis Deviation of QRS complex seen in grade II and III severity, which is statistically significant. However, RVH pattern, RBBB and low voltage were seen less commonly and thus were statistically not significant. Table 3 denotes that more ECG changes were seen in COPD patients with low FEV1/FVC % values (probably due to increase in residual volume with reduction in FEV1/FVC ratio).

DISCUSSION

A prospective observational study of COPD patients was done with the aim to study correlation between ECG changes and spirometric parameters in patients with COPD. Among 50 patients with COPD, maximum number of patients i.e. 27 belonged to 51-60 years of age group. Similar finding was reported in study by Banker et al in Gandhinagar. (6)

In the present study most common symptom was cough at the time of presentation followed by cough with sputum production, which is comparable to the study by Jain NK et al. (7)

In the current study, the most frequent ECG change observed was P-pulmonale (68%) and the next common change was Right Axis Deviation of QRS Complex (beyond +90 degrees). This is in accordance with findings of studies conducted by Gupta et al (2015) (8) and VK Singh et al (1989), (9) which states that p-wave axis > +90[degrees] is a common ECG abnormality.

On the contrary a study by Kamdar DJ et al (2017) in Gujarat(2) reported that P-pulmonale was observed only in 20% of the COPD patients. A study by Chappell AG(10) reports that 70% of cases showed right axis deviation of QRS complex (Beyond +90 degrees).

In the present study, it was observed that the most frequent ECG changes were P-pulmonale and Right Axis Deviation of QRS complex seen in grade II and III severity, which is statistically significant. However, RBBB and low voltage were seen less commonly and thus were statistically not significant. Similar findings were reported by Gupta et al (2015) in RajasthanM and by R Ramakrishna et al in Guntur.P)

The current study also shows that COPD patients with low FEV1/FVC % values have more ECG changes in comparison to those with higher FEV1/FVC % values. And as the severity of airflow obstruction increases (fall in FEV1), ECG changes also becomes more common. A study by VK Singh et al (1989) (9) and Gupta et al (2015) (8) also suggested significant negative correlation between the FEV1/FVC values and the incidence of various electrocardiographic features.

CONCLUSION

Chronic obstructive pulmonary disease, a broad spectrum of respiratory diseases represents a worldwide problem. Diagnosis of COPD is established on the basis of history and spirometric examination. Forced expiratory volume in the first second (FEV1) along with forced vital capacity (FVC) and FEV1/FVC ratio are important parameters in diagnosing and assessing the severity of the patients with COPD.

The most frequent ECG change observed is P-pulmonale and Right Axis Deviation of QRS complex seen in grade II and III severity. So, ECG can be considered as an alternative parameter when spirometry is not available.

REFERENCES

[1] Rachakonda R, Beri S, Kalyankumar PV. Study of ECG and echocardiographic findings in COPD patients in a tertiary care centre. J Evolution Med Dent Sci 2016;5(24):1276-80.

[2] Kamdar DJ, Patel DK. A study of the clinical profile of 50 patients of COPD with correlation between clinical, radiological and spirometric evaluation. Int J Res Med Sci 2017;5(5):1802-7.

[3] Cho SH, Lin HC, Ghoshal AG, et al. Respiratory disease in Asia-Pacific region: cough as the key symptom. Allergy Asthma Proc 2016;37(2):131-40.

[4] BMJ Best Practice. Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. 2017. (Cited April 4, 2018). https://bestpractice.bmj.com/topics/en-us/7/criteria

[5] Rachaiah NM, Rachaiah JM, Krishnaswamy RB. A correlative study of spirometric parameters and ECG changes in patients with chronic obstructive pulmonary disease. Int J Biol Med Res 2012;3 (1):1322-6.

[6] Banker H, Verma A. Electrocardiographic changes in COPD. NHL Journal of Medical Sciences 2013;2(2):558.

[7] Jain J, Apte S, Soni P, et al. A study of correlation between the ECG changes with the duration and severity of chronic obstructive pulmonary disease. Journal of Evolution of Medical and Dental Sciences 2014;3(7):1739-44.

[8] Gupta D, Agrawal P, Kothari RP, et al. Electrocardiographic changes in chronic obstructive pulmonary disease-correlation with air flow limitation. IOSR Journal of Dental and Medical Sciences 2015;14(9):49-52.

[9] Singh VK, Jain SK. Effects of airflow limitation on the electrocardiogram in chronic obstructive pulmonary disease (COPD). Indian J Chest Dis & All Sci 1989;31(1):1-8.

[10] Chappell AG. The electrocardiogram in chronic bronchitis and emphysema. Brit Heart J 1996;28 (4):517-22.

Saurabh Singhal (1), Gagandeep Kaur (2), Varun Sisodia (3)

(1) Assistant Professor, Department of General Medicine, KDMCHRC, Mathura, Uttar Pradesh, India.

(2) Assistant Professor, Department of Community Medicine, KDMCHRC, Mathura, Uttar Pradesh, India.

(3) Assistant Professor, Department of General Surgery, KDMCHRC, Mathura, Uttar Pradesh, India.

'Financial or Other Competing Interest': None.

Submission 15-05-2018, Peer Review 07-06-2018, Acceptance 14-06-2018, Published 25-06-2018.

Corresponding Author:

Saurabh Singhal, D/B/301, Radha Valley, Mathura, Uttar Pradesh, India.

E-mail: singhalsaurabh83@gmail.com

DOI: 10.14260/jemds/2018/675

Caption: Figure 1. Demonstrates the distribution of patients according to Symptoms Exhibited. The most common Symptom was Cough followed by Sputum Production
Table 1. ECG Changes in COPD Patients

ECG Changes            Criteria    Number     %
                                  (n = 50)

P-pulmonale             Absent       16      32.0
                       Present       34      68.0

Right axis deviation    Absent       19      38.0
of QRS Complex         Present       31      62.0
(Beyond +90 degrees)

Right Ventricular       Absent       40      80.0
Hypertrophy (RVH)      Present       10      20.0

Right bundle branch     Absent       34      68.0
block (RBBB)           Present       16      32.0

Low voltage of QRS      Absent       24      48.0
complex                Present       26      52.0

Polymorphic p-wave      Absent       44      88.0
                       Present       6       12.0

Table 2. Correlation of ECG changes with Spirometry Severity Grade

ECG Changes   Criteria     No.     Spirometry-Severity Grade
                         (n= 50)   Grade-2    Grade-3     Grade-4

P-pulmonale   Absent       16         13          2           1
                                   (81.25%)   (12.50%)     (6.25%)
              Present      34         3          22           9
                                   (8.82%)    (64.70%)    (26.47%)

Right axis    Absent       19         15          3           1
deviation                          (78.94%)   (15.78%)     (5.26%)
of QRS        Present      31         1          21           9
complex                            (3.22%)    (67.77%)    (29.03%)

RVH           Absent       40         15         18           7
                                   (37.50%)   (45.00%)    (17.50%)
              Present      10         1           6           3
                                   (10.00%)   (60.00%)    (30.00%)

RBBB          Absent       34         14         17           3
                                   (41.17%)   (50.00%)     (8.82%)
              Present      16         2           7           7
                                   (12.50%)   (43.75%)    (43.75%)

Low           Absent       24         2          15           7
voltage                            (8.33%)    (62.50%)     (2.16%)
of QRS        Present      26         14          9           3
complex                            (53.84%)   (34.61%)    (11.53%)

Polymorphic   Absent       44         15         18          11
p-wave                             (34.1%)     (41.0%)     (25.0%)
              Present       6      1(16.6%)   5 (83.4%)   0 (00.0%)

ECG Changes   Criteria   P value

P-pulmonale   Absent     < .00001

              Present

Right axis    Absent     < .00001
deviation
of QRS        Present
complex

RVH           Absent       .235

              Present

RBBB          Absent       .008

              Present

Low           Absent       .002
voltage
of QRS        Present
complex

Polymorphic   Absent       .317
p-wave
              Present

Table 3. Correlation of ECG changes with FEV1/FVC Ratio

ECG            Criteria    No.              FEV1/FVC           P
Changes                   (n=50)     51-60        61-70      value

P-pulmonale     Absent      16     13 (56.2%)   2 (43.7%)    .000
               Present      34     11 (41.2%)   23(58.8%)

Right axis      Absent      19     17 (89.5%)   2 (10.5%)
deviation of
QRS            Present      31     12 (38.7%)   19 (61.3%)   .000
complex

RVH             Absent      40     24 (60.0%)   16 (40.0%)   1.00
               Present      10      6(60.0%)     4(40.0%)

RBBB            Absent      34     22 (64.7%)   12 (35.3%)   0.56
               Present      16      9(56.2%)     7(43.7%)

Low voltage     Absent      24     18 (75.0%)   8 (33.3%)
of QRS         Present      26     11(42.3%)    13 (50.0%)   0.09
complex

Polymorphic     Absent      44     13 (29.5%)   31 (70.5%)
p-wave         Present      6      1 (16.6%)    5 (83.4%)    0.50
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Title Annotation:Original Research Article; chronic obstructive pulmonary disease
Author:Singhal, Saurabh; Kaur, Gagandeep; Sisodia, Varun
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Jun 25, 2018
Words:2192
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