Non-invasive screening for pulmonary hypertension in idiopathic pulmonary fibrosis.

BACKGROUND: Pulmonary hypertension (PH) is a common complication of idiopathic pulmonary fibrosis (IPF) that is associated with poor prognosis. Noninvasive screening for PH in IPF patients is challenging and a combination of several noninvasive determinations can improve discrimination. METHODS: We included 235 IPF patients who underwent right heart catheterization (RHC) as part of the lung transplant evaluation. We measured electrocardiographic (ECG) and echocardiographic variables as well as the pulmonary artery (PA) and ascending aorta (AA) diameters on chest CT. We recorded results of arterial blood gases (ABG), pulmonary function (PFT) and 6-min walk tests (6MWT). RESULTS: Several variables were predictors of PH in IPF patients in univariable models including a lower arterial oxygenation and 6MWT distance; worse right ventricular (RV) function, rightward deviation of the QRS axis and a higher FVC/DLCOc ratio, PA/AA diameter ratio, and estimated RV systolic pressure. In multivariable analysis, a worse RV function and higher PA/AA ratio remained predictors of PH (c-index 0.75 (0.65-0.84)). Similarly, a worse RV function, a higher PA/AA ratio and a rightward QRS axis deviation were independent predictors of precapillary PH (c-index 0.86 (0.76-0.92)). A combination of PA/AA diameter ratio <1.1, a QRS axis <90° and normal RV function showed a negative predictive value of 85% for precapillary PH. CONCLUSIONS: There are significant differences in ECG, echocardiographic, chest CT, PFT and ABG parameters between IPF patients with and without PH. However, these noninvasive tests alone or combination have limited discrimination ability for PH screening in IPF.

Electrocardiographic differences between COPD patients evaluated for lung transplantation with and without pulmonary hypertension.

INTRODUCTION: Pulmonary hypertension (PH) is an indicator of poor prognosis in COPD patients; particularly in those with mean pulmonary artery pressure ≥ 40 mm Hg. Electrocardiography (ECG) might be useful for screening of this condition. METHODS: Retrospective study of COPD patients evaluated for lung transplantation in whom we analyzed the 12-lead ECG performed closest to the time of right heart catheterization. RESULTS: We included 142 patients. PH was present in 90 patients (63%) and 16 (11%) had a mean PAP ≥ 40 mmHg. The PR interval was longer in PH patients (151 (29) versus 139 (22) ms, p = 0.01) and T wave axis had a left shift (56.9 (32) versus 68.7 (19) degrees, p = 0.006). PR interval was longer (178.5 (35) versus 142.2 (23) ms, p = 0.001), T wave axis had a leftward deflection (63.6 (24) versus 42.8 (46) degrees, p = 0.005) and S wave in lead I was larger (0.19 (0.13) versus 0.12 (0.12) mV, p = 0.03) in patients with mean PAP ≥ 40 mmHg. A PR interval > 137 ms and S wave in DI > 0.02 mV had a sensitivity of 100% and a specificity of 59.5% to identify COPD patients with a mean PAP ≥ 40 mmHg. CONCLUSION: There are significant ECG differences between advanced COPD patients with and without PH; however the ECG is an inadequate tool to differentiate between the groups. A prolonged PR interval suggests the presence of severe PH.

Electrocardiography at diagnosis and close to the time of death in pulmonary arterial hypertension.

BACKGROUND: Scarce information exits on the electrocardiographic (ECG) characteristics of pulmonary arterial hypertension (PAH) patients close to their death and whether observed abnormalities progress from the time of PAH diagnosis. METHODS: We analyzed the characteristics of the ECG performed at initial diagnosis, during the course of the disease and close to the time of death on consecutive PAH patients followed at our institution between June 2008 and December 2010. RESULTS: We included 50 patients with PAH (76% women) with mean (SD) age of 58 (14) years. Median heart rate (83 vs 89 bpm, P = 0.001), PR interval (167 vs 176 ms, P = 0.03), QRS duration (88 vs 90 ms, P = 0.02), R/S ratio in lead V1 (1 vs 2, P = 0.01), and QTc duration (431 vs 444 ms, P = 0.02) significantly increased from the initial to the last ECG. In addition, the frontal QRS axis rotated to the right (97 vs 112 degrees, P = 0.003) and we more commonly observed right bundle branch block (5% vs 8%, P = 0.03) and negative T waves in inferior leads (31% vs 60%, P = 0.004). No patient had normal ECG at the time of death. CONCLUSIONS: Significant changes progressively occur in a variety of ECG parameters between the time of the initial PAH diagnosis and close to death.