Utility of electrocardiogram in the assessment and monitoring of pulmonary hypertension (idiopathic or secondary to pulmonary developmental abnormalities) in patients≤18 years of age

Prognostic biomarkers in pediatric pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a progressive life-threatening disease of the pulmonary vasculature. Despite the introduction of targeted therapies, prognosis remains poor. In pediatric PAH, reliable prognostic biomarkers are needed to inform clinicians on disease progression and risk of mortality, in order to be able to assess the need for escalation of medical therapy, consider surgical options such as Pott's shunt and listing for (heart)-lung transplantation. This review provides an overview of prognostic biomarkers that are considered to carry potential for the clinical management of pediatric PAH. These include conventional physiological biomarkers [resting heart rate, heart rate variability (HRV), a child's growth], biomarkers of functional status [World Health Organization functional class, 6-minute walk distance (6MWD), parameters derived from cardiopulmonary exercise testing (CPET), daily physical activity level], electrocardiographic biomarkers, circulating serum biomarkers (natriuretic peptides, uric acid, neurohormones, inflammatory markers, and novel circulating biomarkers), and multiple hemodynamic biomarkers and imaging biomarkers [echocardiography and cardiac magnetic resonance (CMR)]. In recent years, many potential prognostic biomarkers have become available for the management of PAH in children. As the available prognostic biomarkers reflect different aspects of the disease process and functional implications, a multi-marker approach appears the most useful for guiding therapy decisions and improve outcome in pediatric PAH.

Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment

Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.

Electrocardiogram signs of right ventricular hypertrophy may help identify pulmonary hypertension in patients with dilated cardiomyopathy

Objective

To the authors' knowledge, limited data are available regarding the association between Electrocardiogram (ECG) signs of right ventricular hypertrophy (RVH) and pulmonary hypertension (PH) in patients with dilated cardiomyopathy (DCM). We aimed to assess the accuracy of the recommended ECG criteria of RVH for predicting PH in patients with DCM.

Methods

According to the definition of PH (mPAP ≥ 25 mm Hg), 35 patients with DCM were divided into 2 groups: DCM with PH (n = 22) and DCM without PH (n = 13). Right heart catheterization was performed in all patients. Seventeen parameters of RVH recommended by the AHA/ACCF/HRS for diagnosis of RVH on ECG were determinded.

Results

The following parameters were correlated with mPAP: R_V1 > 6 mm, S_V5 > 10 mm, R:S_V6 < 0.4, R_V1 + S_{V5 or V6} > 10.5 mm and P_II amplitude. The following parameters were significantly different between DCM patients with and without PH: S in V₅ (S_V5) > 10 mm, S in V₆ (S_V6) > 3 mm, R:S ratio in V₅ (R:S_V5) < 0.75, R_V1 + S_{V5 or V6} > 10.5 mm, S > R inI, S > R inII and R:S _V1 > R:S _V3, although results were no longer significant after correcting for multiple comparisons. High specificity (92.3-100%), lowsensitivity (31.8-50%), high positive predictive value, and low negative predictive value of established parameters of RVH were noted for predicting PH in patients with DCM.

Conclusion

Several ECG signs of RVH may be useful for in the diagnosis PH in patients with DCM.

Impact of the Right Ventricular Sokolow-Lyon Index in Children with Idiopathic Pulmonary Arterial Hypertension

Right ventricular (RV) hypertrophy is regarded as the adaptation on chronic RV pressure load in pulmonary hypertension. As the RV Sokolow-Lyon index (RVSLI) is an electrocardiographic marker of RV hypertrophy, we hypothesized that RVSLI might be able to reflect RV pressure load. Therefore, the purpose of this study was to characterize the diagnostic impact of the RVSLI in children with idiopathic pulmonary arterial hypertension (IPAH) in order to assess disease severity and to evaluate its value for the prediction of worse outcome. Forty-two children (aged 3-17 years) with IPAH were included in this retrospective study. The follow-up after baseline examination was 59 ± 17 months. Receiver-operating characteristic (ROC) curves and Kaplan-Meier analysis were used to discriminate a cut-off value of RVSLI and to assess its predictive value regarding morbidity and mortality. In 12/42 patients (29%) severe cardiovascular events (defined as death, lung transplantation, or Potts shunt) were observed (time to event 20 ± 22 months). Patients with an event showed higher RVSLI values (3.6 ± 1.2 mV vs. 2.6 ± 1.6 mV; p < 0.05). ROC analysis discriminated an RVSLI of 2.1 as the best cut-off value (area under the ROC curve: 0.79, sensitivity: 0.91, specificity: 0.70, p < 0.05) to detect patients with high-risk PAH (mPAP/mSAP ratio > 0.75). Relative risk for a severe event with an index > 2.1 mV was 1.76 (95% CI 1.21-3.20). Relative risk for death with RVSLI > 2.1 mV was 2.01 (95% CI 1.61-4.80). Our study demonstrates a strong relationship between RVSLI and disease severity in children with IPAH. An RVSLI > 2.1 mV at the time of first diagnosis is a predictor for patients at risk for cardiac events. As an adjunct to the usual diagnostic assessment this parameter may therefore contribute to the initial prognostic estimation.

Characteristics of Infants With Congenital Diaphragmatic Hernia Who Need Follow-Up of Pulmonary Hypertension

OBJECTIVES

Pulmonary hypertension is one of the main causes of mortality and morbidity in patients with congenital diaphragmatic hernia. Currently, it is unknown whether pulmonary hypertension persists or recurs during the first year of life.

DESIGN

Prospective longitudinal follow-up study.

SETTING

Tertiary university hospital.

PATIENTS

Fifty-two congenital diaphragmatic hernia patients admitted between 2010 and 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pulmonary hypertension was measured using echocardiography and electrocardiography at 6 and 12 months old. Characteristics of patients with persistent pulmonary hypertension were compared with those of patients without persistent pulmonary hypertension. At follow-up, pulmonary hypertension persisted in four patients: at 6 months old, in three patients (patients A-C), and at 12 months old, in two patients (patients C and D). Patients with persistent pulmonary hypertension had a longer duration of mechanical ventilation (median 77 d [interquartile range, 49-181 d] vs median 8 d [interquartile range, 5-15 d]; p = 0.002) and hospital stay (median 331 d [interquartile range, 198-407 d) vs median 33 d (interquartile range, 16-59 d]; p = 0.003) than patients without persistent pulmonary hypertension. The proportion of patients with persistent pulmonary hypertension (n = 4) treated with inhaled nitric oxide (100% vs 31%; p = 0.01), sildenafil (100% vs 15%; p = 0.001), and bosentan (100% vs 6%; p < 0.001) during initial hospital stay was higher than that of patients without persistent pulmonary hypertension (n = 48). At 6 months, all patients with persistent pulmonary hypertension were tube-fed and treated with supplemental oxygen and sildenafil.

CONCLUSIONS

Less than 10% of congenital diaphragmatic hernia patients had persistent pulmonary hypertension at ages 6 and/or 12 months. Follow-up for pulmonary hypertension should be reserved for congenital diaphragmatic hernia patients with echocardiographic signs of persistent pulmonary hypertension at hospital discharge and/or those treated with medication for pulmonary hypertension at hospital discharge.

Prevalence and predictive value of electrocardiographic abnormalities in pulmonary hypertension: evidence from the Pan-African Pulmonary Hypertension Cohort (PAPUCO) study

Background

Pulmonary hypertension (PH) is prevalent in Africa and is still often diagnosed only at an advanced stage, therefore it is associated with poor quality of life and survival rates. In resource-limited settings, we assessed the diagnostic utility of standard 12-lead electrocardiograms (ECG) to detect abnormalities indicating PH.

Methods

Sixty-five patients diagnosed with PH were compared with 285 heart disease-free subjects. The prevalence and diagnostic performance of ECG features indicative of PH and right heart strain were calculated.

Results

Compared to the control group, all abnormalitieswere more frequent in the PH cohort where no patient hada completely normal ECG. The most prevalent (cases vscontrol) ECG abnormalities were: pathological Q wave inat least two contiguous peripheral leads (47.7 vs 6.7%), leftventricular hypertrophy (38.5 vs 9.8%) and p-pulmonale(36.9 vs 20.7%) (all p < 0.05). The sensitivity of ECG criteriafor right heart strain ranged between 6.2 and 47.7%, whilespecificity ranged between 79.3 and 100%. Negative predictivevalue ranged between 81.5 and 88.9% and positive predictivevalue between 25 and 100%. Positive predictive value waslowest (25%) for right bundle branch block and QRS rightaxisdeviation (≥ 100°), and highest (100%) for QRS axis ≥+100° combined with R/S ratio in V1 ≥ 1 or R in V1 > 7 mm.

Conclusion

When present, signs of PH on ECG strongly indicated disease, but a normal ECG cannot rule out disease. ECG patterns focusing on the R and S amplitude in V1 and right-axis deviation had good specificity and negative predictive values for PH, and warrant further investigation with echocardiography.