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Study of ECG and echocardiography abnormalities in stroke patients and its prognostic significance.

INTRODUCION: Stroke is common life threatening disorder. It is the third leading cause of death in developed countries after cardiovascular disease and cancer. (1) Cerebral infarction is responsible for about 80% of all first ever in a lifetime strokes. For India, community surveys have shown a prevalence rate in range of 200 per 100, 000 persons, nearly 1.5 of all urban hospital admissions, 4.5 of all medical and around 20% of neurological cases. (2) The changes of ECG in CVA were reported in many studies. (3-5) Changes occurring in ECG following stroke were T-wave, U-wave, ST-segment, QT-interval and various arrhythmias. These ECG changes may resemble those of myocardial ischemia or sometime myocardial infarction. Along with ECG changes many studies have shown wall motion abnormalities on 2D echo following stroke, especially with subarachnoid hemorrhage. (6-7) Hence, this study was undertaken to determine ECG and 2D echocardiographic changes in different types of strokes and to know whether such changes have any prognostic significance.

MATERIAL AND METHOD: The material of the study comprised of 100 Patient admitted in a Medical College & Associated Hospital of central India, from May 2009 to Sept. 2011. INCLUSION CRITERIA: Cases of CVA admitted within 72 hours after the onset of stroke were selected for the study, patients admitted beyond 72 hours after onset of stroke were excluded as the incidence of ECG changes beyond this period were infrequent. EXCLUSION CRITERIA: Traumatic cases producing neurological deficits, infections, neoplastic cases producing CVA. CVA cases with known underlying cardiac diseases, which produce ECG and echocardiographic changes.

After admission a detailed history regarding the temporal profile of the stroke including history of risk factors like hypertension, diabetes mellitus, smoking, history of IHD and rheumatic heart disease were obtained. Detailed neurological examination including fundoscopy and cardiovascular examination was carried out in all the cases. The diagnosis of CVA was made on the basis of following criteria:

Temporal profile of clinical syndrome, clinical examination, CT scan of brain.

RESULTS: were analyzed with reference to age, sex and risk factors and clinical examination.

* The above table shows, mortality was higher in patients of stroke with QTc prolonged (45.45) and ST segment depression (45.45%) followed by U waves (40.90) and least was with T-wave inversion (31.8%), but none of them were statistically significant.

DISCUSSION: A hospital based prospective study was done to know whether the ECG and 2D echo changes had any prognostic significance in stroke patients. Increased QTc was seen in 32% of cases in a study Goldstein et al, while in our study it was 41%. T-wave inversion was seen in 15% by Goldstein et al while in this study it was 30%. ST-segment depression was seen in 13% in Goldstein while in the present study it was 20%. U-wave was seen in 28% in Goldstein et al, while in this study it was seen in 53%. Tachycardia was seen in 2% in Goldstein et al while in this study it was 40%. Bradycardia was seen in 8% in Goldstein et al (8), while in the present study it was 2%.

In the present study, LV dysfunction in ischemic stroke was present in 23.53% of cases, which is comparable to the series of Gagliardi et al (1985) and Uma et al (1999) who reported 22% and 26% respectively. Mitral valve abnormality was present in 14% which is comparable to the study by Uma et al (1999) who reported 30% incidence. Aortic wall abnormality in present study was 3% compared to the other studies it varied, Gagliardi et al (1985) and Uma et al (1999) who reported 18.5% and 20% respectively. (9-10)

In infarct group 2D echo was normal in 55.88% (38 out of 68 patients) while LV dysfunction was seen in 23.53% (16 out of 68 patients) and mitral valve abnormality in 20.59% (14 out of 68 patients) and aortic wall abnormality in 4.41% (3 out of 68 patients) and no patients had LA thrombus.

In the hemorrhage group a high number of patients 18 out of 22 i.e., 56.26% had LV dysfunction. None had LA thrombus, mitral valve or aortic valve abnormality and in 25% 2 D echo was normal (8 out of 22). In the either group LV dysfunction was the most common abnormality noticed.

The percentage of normal ECG in patients who survived stroke was 35% (24 out of 78), while 22.72% (5 out of 22) succumbed to stroke, 79% (54 out of 78) of stroke survivors had abnormal ECG, while 77.27% (17 out of 22) of patients who died of stroke had abnormal ECG (p>0.5) and was statistically insignificant.

Among stroke survivors 56.41% (44 out of 78) had normal 2D echo findings while 43.59% (34 out of 78) had abnormal 2D echo study, while among patient who died due to stroke, 90.91% (20 out of 22) had abnormal 2D echo finding, and only 9.09% (2 out of 22) patients had normal echo findings, which was statistically significant (p<0.001).

SUMMARY:

(1) Abnormal ECG changes were more common among hemorrhagic patients (78.12%) compared to infarct patients (67.64%).

(2) ST segment depression (56.26%) and prominent U-waves (56.26%) followed by QTc prolongation were the most common abnormalities in hemorrhage group.

(3) Prominent U-wave was the most common ECG finding (51.47%) among infarct group, followed by QTc prolongation (36.76%) and T-wave inversion (30.88%).

(4) 2D echo abnormalities were more common among hemorrhage group (75%) than in infarct group (44.12%).

(5) LV dysfunction was the most common abnormality noted in both groups i.e., infarct (23.53%) and hemorrhage (56.26%) followed by mitral wall and aortic wall abnormality i.e., 20.59% and 4.41% respectively among infarct group.

(6) None of the ECG changes had much significance on mortality and was statistically insignificant (p>0.05).

(7) LV dysfunction showed significant mortality in stroke patients and was statistically significant (p<0.001).

CONCLUSION: ST segment depression, QTc prolongation and prominent U were the common ECG abnormalities in hemorrhagic strokes while QTc prolongation and prominent U-waves were the common ECG abnormality in ischemic stroke. LV dysfunction was most common 2D echocardiographic abnormality in stroke patients. ECG abnormalities in stroke patients do not have any prognostic significance. While LV dysfunction had prognostic significance in predicting mortality in CVA.

DOI: 10.14260/jemds/2014/2194

REFERENCES:

(1.) Dalal PM. Ischemic Cerebrovascular Diseases in API Textbook of MEDICINE 7th Edition: 2004:796-809.

(2.) Dalal PM. Ischemic Cerebrovascular Diseases in API Textbook of MEDICINE 9th Edition: 2012:1401-1410.

(3.) Byers E. Ashman R, Toth LA.Electrocardiogram with large upright T-and long QT intervals. American Heart Journal; 1947; 719-723.

(4.) Baruch GE, Meyers R, Abldskov J A. A New electrographic pattern observed in cerebrovascular accident. Circulation. 1954; 9:719-723.

(5.) Dimat J, Grob D. Electrocardiographic changes and myocardial damage in patient with acute CVA. Stroke 1977; 8: 448-455.

(6.) Sakka SG, Haettemann E, Reihart K. Acute ventricular dysfunction and SAH. J Neurosurg. Anaesthesiol 1999 Jul;11(3):203-213

(7.) Hatano S. Experience from a multicentre stroke register. A preliminary report, Bulletin WHO 1976; 54:541-543.

(8.) Goldstein DS. The electrocardiogram in stroke: Relationship to patho- physiological type and comparison with tracings. Stroke 1978; 9(4):392.

(9.) Gagliadia et al. Frequency of echocardiographic abnormalities in patient with ischemia of carotid territory- A preliminary report. Stroke 1985; 16 (1):118-121.

(10.) Uma et al. Echocardiography abnormalities in patient with cerebral infarction. JAPI 1999;47:291-293.

A.P.S. Tomar [1], Satish K. Ramteke [2], Ravita Singh [3], Sharmila Ramteke [4]

AUTHORS:

[1.] A. P. S. Tomar

[2.] Satish K. Ramteke

[3.] Ravita Singh

[4.] Sharmila Ramteke

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of Medicine, Chirayu Medical College and Hospital, Bhopal, M. P.

[2.] Associate Professor, Department of Medicine, Chirayu Medical College and Hospital, Bhopal, M. P.

[3.] Post Graduate Student, Department of Conservative dentistry & Endodontics, People's Dental Academy, Bhopal.

[4.] Assistant Professor, Department of Pediatrics, Gandhi Medical College and Hamidia Hospital, Bhopal, M. P.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Satish K. Ramteke, Department of Medicine, Chirayu Medical College and Hospital, Bairagarh, Bhopal, M.P. E-mail: satishh.ramteke@gmail.com

Date of Submission: 14/02/2014.

Date of Peer Review: 15/02/2014.

Date of Acceptance: 26/02/2014.

Date of Publishing: 11/03/2014.
Table 1: Relationship of CVA with ECG & 2D Echo Changes

               Normal          Abnormal

           Total      %      Total     %

ECG          29     29.00     71     71.00
2D Echo      46     46.00     54     54.00

Table 2: Relationship between stroke types and ECG changes

Type of Stroke              ECG Changes

                       Normal        Abnormal

                     No      %      No      %

Ischemic (n-68)      22    32.35    46    67.64
Hemorrhage (n-32)     7     21.8    25    78.12

p > 0.05

Table 3: Relationship between stroke types and 2D Echo changes

Type of Stroke            ECHO Changes

                      Normal        Abnormal

                    No      %      No      %

Ischemic (n-68)     38    55.88    30    44.12
Hemorrhage (n-32)    8    25.00    24    75.00

Table 4: ECG changes in stroke patients

         ECG                  Ischemic (n-68)
       changes
                          Normal         Abnormal

                         No      %      No      %

QTc prolongation         43    63.23    25    36.76
T-wave inversion         47    69.11    21    30.88
ST Segment depression    47    69.11    21    30.88
U waves                  33    48.52    35    51.47
Sinus tachycardia        44    64.70    24    35.29
Sinus bradycardia        68    100.0     0      0

         ECG                 Hemorrhage (n-32)
       changes
                          Normal         Abnormal

                         No      %      No      %

QTc prolongation         16     50.0    16    50.00
T-wave inversion         23    71.87     9    28.13
ST Segment depression    14    43.75    18    56.26
U waves                  14    43.75    18    56.26
Sinus tachycardia        16     50.0    16     50.0
Sinus bradycardia        30    93.75     2     6.25

Table 5: 2D Echo changes in stroke patients

      ECHO changes               Ischemic (n-68)

                             Normal         Abnormal

                            No      %      No      %

LV dysfunction              52    76.47    16    23.53
LA thrombus                 68     100     --      --
Mitral valve abnormality    54    79.41    14    20.59
Aortic valve abnormality    65    95.58     3     4.41
Normal                      30    44.11    38    55.88

      ECHO changes              Hemorrhage (n-32)

                              Normal       Abnormal

                            No      %      No      %

LV dysfunction              14    43.75    18    56.26
LA thrombus                 32    100.0            --
Mitral valve abnormality    32    100.0    --      --
Aortic valve abnormality    32    100.0    --      --
Normal                      24     75.0     8    25.00

Table 6: Mortality in stroke types
and its co-relation with ECG changes

 Type of ECG changes          Ischemic (n-68)

                         Alive (n-59)    Dead (n-9)

                         No      %      No      %

QTc prolongation         21    35.50     4     44.4
T-wave inversion         17    28.80     4     44.4
ST Segment depression    19    32.20     2     22.2
U Wave                   31    52.54     4    44.44

 Type of ECG changes          Hemorrhage (n-32)

                         Alive (n-59)    Dead (n-9)

                         No      %      No      %

QTc prolongation         10    52.63     6    46.15
T-wave inversion          6    31.50     3    23.00
ST Segment depression    10    52.60     8    61.50
U Wave                   13    68.42     5    38.46

Table 7: Mortality in stroke patients
and its correlation with ECG changes

 Type of ECG Changes          Stroke patients

                        Alive (n=78)    Dead (n=22)

                        No     %        No     %

QTc prolongation        31   39.74      10   45.45
T Wave inversion        23   29.48      7    31.8
ST segment impression   29   37.17      10   45.45
U Waves                 44   56.41      9    40.90

Type of ECG Changes     P Value   Chi-square

QTc prolongation          p>0.05       0.23
T Wave inversion          p>0.05      0.044
ST segment impression     p>0.05       0.49
U Waves                   p>0.05       1.65

Table 8: Mortality in stroke types
and its co-relation with 2D Echo changes

     2D Echo Changes                Ischemic

                               Alive          Dead

                            No      %      No      %

LV dysfunction              12    20.33     4    44.40
LA thrombus                 --      --     --      --
Mitral value abnormality    12    20.33     2    22.22
Aortic valve Abnormality     3     5.00     0     0.00
Normal                      38    64.40    --      --

     2D Echo Changes               Hemorrhage

                               Alive          Dead

                            No      %      No      %

LV dysfunction               6    66.66    12      92
LA thrombus                 --      --     --      --
Mitral value abnormality    --      --     --      --
Aortic valve Abnormality    --      --     --      --
Normal                       6    66.20     2    15.38

Table 9: Mortality in stroke patients
and its co-relation with Echo changes

     2D Echo changes            Stroke patients           P Value

                            Alive (n-78)   Dead (n-22)

                            No      %      No      %

LV dysfunction              18    23.00    16    72.72    p>0.001
LA thrombus                 --      --     --      --        --
Mitral valve abnormality    12    15.38     2     9.09     p>0.05
Aortic valve abnormality     3     3.84    --                --
Normal                      44    56.41     2     9.09     p<0.01

([dagger]) Above table shows mortality in patients
of stroke was higher with LV dysfunction (72.72%)
(p<0.001) and was statistically significant followed
by mitral valve abnormality (9.09) (p>0.05).
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Title Annotation:ORIGINAL ARTICLE
Author:Tomar, A.P.S.; Ramteke, Satish K.; Singh, Ravita; Ramteke, Sharmila
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Mar 17, 2014
Words:2095
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