Ventricular activation time as a marker for diastolic dysfunction in early hypertension

Electrocardiogram as a Tool to Predict Diastolic Dysfunction in the Early Hypertensive Patients and its Comparison in Males and Females

Objectives:

Heart failure with preserved ejection fraction continues to be a major healthcare challenge. Assessment of diastolic dysfunction (DD) is an integral part of the routine cardiologic examination, however little is known about ECG changes in diastolic dysfunction. several resting ECG parameters have been investigated to predict left ventricular diastolic dysfunction (LVDD). The study aims to assess diastolic dysfunction in recently diagnosed hypertensive patients by echocardiography and to find the value of ECG-derived parameters in predicting diastolic dysfunction.

Materials and Methods:

One hundred and fifty hypertensive patients of less than 1-year duration were divided into two groups based on the presence or absence of diastolic dysfunction. ECG parameters such as P wave dispersion, QT and QTc interval, ventricular activation time, Tend P, Tend Q were analyzed in all patients, and correlation was done with echo parameters to assess diastolic dysfunction in both males and females.

Results:

In both men and women a significant correlation was found between p wave dispersion, ventricular activation time, Corrected QT interval, TendP, and, Tend Q in ECG with diastolic dysfunction on bivariate regression analysis. Multivariate regression analysis showed that p wave dispersion had a greater correlation with diastolic dysfunction when compared with other ECG parameters (r=0.88, R2=0.78).

Conclusion:

Analysis of certain ECG parameters especially p wave dispersion is of great value in predicting diastolic dysfunction in both men and women.

Left Ventricular Diastolic Dysfunction Screening by a Smartphone-Case Based on Single Lead ECG

Aims:

To investigate the potential of a signal processed by smartphone-case based on single lead electrocardiogram (ECG) for left ventricular diastolic dysfunction (LVDD) determination as a screening method.

Methods and Results:

We included 446 subjects for sample learning and 259 patients for sample test aged 39 to 74 years for testing with 2D-echocardiography, tissue Doppler imaging and ECG using a smartphone-case based single lead ECG monitor for the assessment of LVDD. Spectral analysis of ECG signals (spECG) has been used in combination with advanced signal processing and artificial intelligence methods. Wavelengths slope, time intervals between waves, amplitudes at different points of the ECG complexes, energy of the ECG signal and asymmetry indices were analyzed. The QTc interval indicated significant diastolic dysfunction with a sensitivity of 78% and a specificity of 65%, a Tpeak parameter >590 ms with 63% and 58%, a T value off >695 ms with 63% and 74%, and QRSfi > 674 ms with 74% and 57%, respectively. A combination of the threshold values from all 4 parameters increased sensitivity to 86% and specificity to 70%, respectively (OR 11.7 [2.7-50.9], P < .001). Algorithm approbation have shown: Sensitivity—95.6%, Specificity—97.7%, Diagnostic accuracy—96.5% and Repeatability—98.8%.

Conclusion:

Our results indicate a great potential of a smartphone-case based on single lead ECG as novel screening tool for LVDD if spECG is used in combination with advanced signal processing and machine learning technologies.

Electrocardiography in Hypertensive Patients without Cardiovascular Events: A Valuable Predictor Tool?

Background

Hypertension is an important risk factor of cardiovascular (CV) disease. An early diagnosis of target organ damage could prevent major CV events. Electrocardiography (ECG) is a valuable clinical technique, with wide availability and high specificity, used in evaluation of hypertensive patients. However, the use of ECG as a predictor tool is controversial given its low sensitivity. This study aims to characterise ECG features in a hypertensive population and identify ECG abnormalities that could predict CV events.

Methods

We studied 175 hypertensive patients without previous CV events during a follow-up mean of 4.0 ± 2.20 years. ECGs and pulse wave velocity were performed in all patients. Clinical characteristics and ECG abnormalities were evaluated and compared between the patients as they presented CV events.

Results

Considering the 175 patients (53.14% male), the median age was 62 years. Median systolic blood pressure was 140  mmHg and diastolic blood pressure was 78 mmHg. Median PWV was 9.8 m/s. Of the patients, 39.4% were diabetic, 78.3% had hyperlipidaemia, and 16.0% had smoking habits. ECG identified left ventricular (LV) hypertrophy in 29.71% of the patients, and a LV strain pattern was present in 9.7% of the patients. Twenty-nine patients (16.57%) had a CV event. Comparative analyses showed statistical significance for the presence of a LV strain pattern in patients with CV events (p=0.01). Univariate and multivariate analysis confirmed that a LV strain pattern was an independent predictor of CV event (HR 2.66, 95% IC 1.01–7.00). In the survival analysis, the Kaplan–Meier curve showed a worse prognosis for CV events in patients with a LV strain pattern (p=0.014).

Conclusion

ECG is a useful daily method to identify end-organ damage in hypertensive patients. In our study, we also observed that it may be a valuable tool for the prediction of CV events.

An Electrocardiographic Characterization of Left Bundle Branch Area Pacing-Induced Right Ventricular Activation Delay: A Comparison With Native Right Bundle Branch Block

Background

Left bundle branch area pacing (LBBAP) induces delayed RV activation and is thought to be harmless, since the electrocardiographic signature is reminiscent to native RBBB. However, to what extent the delayed RV activation during LBBAP truly resembles that of native RBBB remains unexplored.

Methods

This study included patients with incomplete RBBB (iRBBB), complete RBBB (cRBBB) and patients who underwent LBBAP. Global and right ventricular activation times were estimated by QRS duration and R wave peak time in lead V1 (V1RWPT) respectively. Delayed RV activation was further characterized by duration, amplitude and area of the terminal R wave in V1.

Results

In patients with LBBAP (n = 86), QRS duration [120 ms (116, 132)] was longer compared to iRBBB patients (n = 422): 104 ms (98, 110), p &lt; 0.001, but shorter compared to cRBBB (n = 223): 138 ms (130, 152), p &lt; 0.001. V1RWPT during LBBAP [84 ms (72, 92)] was longer compared to iRBBB [74 ms (68, 80), p &lt; 0.001], but shorter than cRBBB [96 ms (86, 108), p &lt; 0.001]. LBBAP resulted in V1 R′ durations [42 ms (28, 55)] comparable to iRBBB [42 ms (35, 49), p = 0.49] but shorter than in cRBBB [81 ms (68, 91), p &lt; 0.001]. During LBBAP, the amplitude and area of the V1 R′ wave were more comparable with iRBBB than cRBBB. V1RWPT during LBBAP was determined by baseline conduction disease, but not by LBBAP capture type.

Conclusion

LBBAP-induced delayed RV activation electrocardiographically most closely mirrors the delayed RV activation as seen with incomplete rather than complete RBBB.

Artificial Intelligence-Enabled Electrocardiography Predicts Left Ventricular Dysfunction and Future Cardiovascular Outcomes: A Retrospective Analysis

BACKGROUND: The ejection fraction (EF) provides critical information about heart failure (HF) and its management. Electrocardiography (ECG) is a noninvasive screening tool for cardiac electrophysiological activities that has been used to detect patients with low EF based on a deep learning model (DLM) trained via large amounts of data. However, no studies have widely investigated its clinical impacts. OBJECTIVE: This study developed a DLM to estimate EF via ECG (ECG-EF). We further investigated the relationship between ECG-EF and echo-based EF (ECHO-EF) and explored their contributions to future cardiovascular adverse events. METHODS: There were 57,206 ECGs with corresponding echocardiograms used to train our DLM. We compared a series of training strategies and selected the best DLM. The architecture of the DLM was based on ECG12Net, developed previously. Next, 10,762 ECGs were used for validation, and another 20,629 ECGs were employed to conduct the accuracy test. The changes between ECG-EF and ECHO-EF were evaluated. The primary follow-up adverse events included future ECHO-EF changes and major adverse cardiovascular events (MACEs). RESULTS: The sex-/age-matching strategy-trained DLM achieved the best area under the curve (AUC) of 0.9472 with a sensitivity of 86.9% and specificity of 89.6% in the follow-up cohort, with a correlation of 0.603 and a mean absolute error of 7.436. In patients with accurate prediction (initial difference < 10%), the change traces of ECG-EF and ECHO-EF were more consistent (R-square = 0.351) than in all patients (R-square = 0.115). Patients with lower ECG-EF (≤35%) exhibited a greater risk of cardiovascular (CV) complications, delayed ECHO-EF recovery, and earlier ECHO-EF deterioration than patients with normal ECG-EF (>50%). Importantly, ECG-EF demonstrated an independent impact on MACEs and all CV adverse outcomes, with better prediction of CV outcomes than ECHO-EF. CONCLUSIONS: The ECG-EF could be used to initially screen asymptomatic left ventricular dysfunction (LVD) and it could also independently contribute to the predictions of future CV adverse events. Although further large-scale studies are warranted, DLM-based ECG-EF could serve as a promising diagnostic supportive and management-guided tool for CV disease prediction and the care of patients with LVD.

Electrocardiographic Features of Left Ventricular Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction: A Systematic Review

Background: Electrocardiographic features are well-known for heart failure with reduced ejection fraction (HFrEF), but not for left ventricular diastolic dysfunction (LVDD) and heart failure with preserved ejection fraction (HFpEF). As ECG features could help to identify high-risk individuals in primary care, we systematically reviewed the literature for ECG features diagnosing women and men suspected of LVDD and HFpEF. Methods and Results: Among the 7,127 records identified, only 10 studies reported diagnostic measures, of which 9 studied LVDD. For LVDD, the most promising features were T-end-P/(PQ*age), which is the electrocardiographic equivalent of the passive-to-active filling (AUC: 0.91-0.96), and repolarization times (QTc interval ≥ 350 ms, AUC: 0.85). For HFpEF, the Cornell product ≥ 1,800 mm*ms showed poor sensitivity of 40% (AUC: 0.62). No studies presented results stratified by sex. Conclusion: Electrocardiographic features are not widely evaluated in diagnostic studies for LVDD and HFpEF. Only for LVDD, two ECG features related to the diastolic interval, and repolarization measures showed diagnostic potential. To improve diagnosis and care for women and men suspected of heart failure, reporting of sex-specific data on ECG features is encouraged.

Left ventricular hypertrophy in athletes: How to differentiate between hypertensive heart disease and athlete’s heart

Athlete’s heart is typically accompanied by a remodelling of the cardiac chambers induced by exercise. However, although competitive athletes are commonly considered healthy, they can be affected by cardiac disorders characterised by an increase in left ventricular mass and wall thickness, such as hypertension. Unfortunately, training-induced increase in left ventricular mass, wall thickness, and atrial and ventricular dilatation observed in competitive athletes may mimic the pathological remodelling of pathological hypertrophy. As a consequence, distinguishing between athlete’s heart and hypertension can sometimes be challenging. The present review aimed to focus on the differential diagnosis between hypertensive heart disease and athlete’s heart, providing clinical information useful to distinguish between physiological and pathological remodelling.

Echocardiographic predictors of interatrial block in patients with severe chronic kidney disease

BACKGROUND

Interatrial block (IAB), defined as a conduction delay between the right and left atrium, is manifested on the electrocardiogram as a prolonged P-wave duration. Large number of studies recently have been published regarding the prevalence of IAB and its associations with the risk of atrial fibrillation and ischemic stroke. Cardiovascular diseases are the leading causes of mortality in chronic kidney disease (CKD). In this study, we aimed to investigate echocardiographic predictors of IAB in patients with severe CKD.

METHODS

This study enrolled a total of 155 patients [male: 95 (61.3%), mean age: 56.3 ± 12.8 years] with severe CKD (glomerular filtration rate < 30 mL/min). All patients were evaluated by electrocardiography and transthoracic echocardiography. IAB was defined as P wave duration of ≥ 120 ms on electrocardiography.

RESULTS

Electrocardiography revealed IAB in 54 patients. The baseline demographic characteristics of the patients were similar in both groups with and without IAB. Left atrial diameter (LAD), left ventricular end-systolic and end-diastolic diameters, interventricular septal thickness, posterior wall thickness, left ventricular mass, left ventricular mass index (LVMI), and the prevalence of left ventricular hypertrophy were found to be significantly increased in patients with IAB. Increased LAD (OR = 1.119; 95% CI 1.019-1.228; p = 0.019) and LVMI (OR = 1.036; 95% CI 1.003-1.070; p = 0.031) were found to be independent predictors of IAB.

CONCLUSION

A significant association exists between the presence of IAB and echocardiographic parameters related to left ventricular hypertrophy and left atrial dilatation. Presence of IAB may be an additional and easy diagnostic marker for risk stratification of patients with severe CKD.

Blood pressure-related electrocardiographic findings in healthy young individuals

Purpose: Elevated blood pressure induces electrocardiographic changes and is associated with an increase in cardiovascular disease later in life compared to normal blood pressure levels. The purpose of this study was to evaluate the association between normal to high normal blood pressure values (90-139/50-89 mmHg) and electrocardiographic parameters related to cardiac changes in hypertension in healthy young adults.Methods: Data from 1449 volunteers aged 18-30 years collected at our centre were analyzed. Only subjects considered healthy by a physician after review of collected data with systolic blood pressure values between 90 and 139 mmHg and diastolic blood pressure values between 50 and 89 mmHg were included. Subjects were divided into groups with 10 mmHg systolic blood pressure increment between groups for analysis of electrocardiographic differences. Backward multivariate regression analysis with systolic and diastolic blood pressure as a continuous variable was performed.Results: The mean age was 22.7 ± 3.0 years, 73.7% were male. P-wave area, ventricular activation time, QRS-duration, Sokolow-Lyon voltages, Cornell Product, J-point-T-peak duration corrected for heart rate and maximum T-wave duration were significantly different between systolic blood pressure groups. In the multivariate model with gender, body mass index and cholesterol, ventricular rate (standardized coefficient (SC): +0.182, p < .001), ventricular activation time in lead V6 (SC= +0.065, p = .048), Sokolow-Lyon voltage (SC= +0.135, p < .001), and Cornell product (SC= +0.137, p < .001) were independently associated with systolic blood pressure, while ventricular rate (SC= +0.179, p < .001), P-wave area in lead V1 (SC= +0.079, p = .020), and Cornell product (SC= +0.091, p = .006) were independently associated with diastolic blood pressure.Conclusion: Blood pressure-related electrocardiographic changes were observed incrementally in a healthy young population with blood pressure in the normal range. These changes were an increased ventricular rate, increased atrial surface area, ventricular activation time and increased ventricular hypertrophy indices on a standard 12 lead electrocardiogram.

Conventional and new electrocardiographic criteria for hypertension-mediated cardiac organ damage: A narrative review

Hypertension-mediated organ damage (HMOD) is frequently observed in hypertensive patients at different cardiovascular (CV) risk profile. This may have both diagnostic and therapeutic implications for the choice of the most appropriate therapies. Among different markers of HMOD, the most frequent functional and structural adaptations can be observed at cardiac level, including left ventricular hypertrophy (LVH), diastolic dysfunction, aortic root dilatation, and left atrial enlargement. In particular, LVH was shown to be a strong and independent risk factor for major CV events, namely myocardial infarction, stroke, congestive heart failure, CV death. Thus, early identification of LVH is a key element for preventing CV events in hypertension. Although echocardiographic assessment of LVH represents the gold standard technique, this is not cost-effective and cannot be adopted in routine clinical practice of hypertension. On the other hand, electrocardiographic (ECG) assessment of HMOD relative to the heart is a simple, reproducible, widely available and cost-effective method to assess the presence of LVH, and could be preferred in large scale screening tests. Several new indicators have been proposed and tested in observational studies and clinical trials of hypertension, in order to improve the relatively low sensitivity of the conventional ECG criteria for LVH, despite high specificity. This article reviews the differences in the use of the main conventional and the new 12 lead ECG criteria of LVH for early assessment of asymptomatic, subclinical cardiac HMOD in a setting of clinical practice of hypertension.

The relationship between R wave peak time and left ventricular mass index in patients with end-stage renal disease on hemodialysis

PURPOSE

Cardiovascular complications have been reported to be the main cause of mortality in patients with end-stage renal disease (ESRD). Although left ventricular hypertrophy is the most common clinical presentation of cardiac remodeling, cardiovascular complications may also include disturbances of the heart conduction system. The R wave peak time (RWPT) has been previously associated with left ventricular hypertrophy and myocardial ischemia. In this study, we aimed to investigate the relationship between RWPT and echocardiographic parameters in patients with ESRD.

METHODS

This study enrolled 66 patients (29 females, age 57.2 ± 12.8 years) with ESRD, and 72 controls (37 females, age 55.3 ± 10.1 years) with similar risk factors. All patients underwent electrocardiography and transthoracic echocardiography. The RWPT was defined as the interval between the onset of the QRS complex and the peak of the R or R' wave.

RESULTS

There was no significant difference in terms of clinical and demographic parameters between ESRD patients and controls. Left ventricular ejection fraction was similar between the groups. However, left atrial diameter, interventricular septal thickness, posterior wall thickness, left ventricular mass (LVM) and left ventricular mass index (LVMI) were significantly higher in patients with ESRD. Among electrocardiographic parameters, P wave and QRS complex durations and RWPT were significantly higher in patients with ESRD. Prolonged RWPT, increased LVM and LVMI were identified as associates of ESRD. Furthermore, RWPT correlated well with LVM and LVMI.

CONCLUSION

The present study demonstrated that RWPT prolonged significantly in patients with ESRD. Furthermore, prolonged RWPT has been associated with increased LVM and LVMI.

Noninvasive assessment of left-ventricular diastolic electromechanical coupling in hypertensive heart disease

BACKGROUND

There is a need to stratify patients who may develop heart failure because of the current "heart failure pandemic". We hypothesized that noninvasive assessment of diastolic electromechanical coupling by electrocardiography and Doppler echocardiography may be clinically useful for risk stratification of hypertensive patients who may develop heart failure.

METHODS

We measured the time from the peak to end of the T wave (TpTe) as an electrophysiological parameter, and peak early diastolic mitral flow (E) and lateral annular (e') velocities as mechanical parameters in 109 patients with hypertension. Relationships between these parameters and their association with the prognosis were evaluated.

RESULTS

The e' was inversely correlated with TpTe (p < 0.001) and QTc (p < 0.014), whereas E/e' was positively correlated with TpTe (p < 0.001) and QTc (p < 0.001). The TpTe predicted patients with E/e' > 12. There were 24 cardiovascular events during follow-up (57 ± 20 months), and Kaplan-Meier analysis showed that outcome was worse (p = 0.003) in patients with higher E/e' than lower E/e'; however, there was no difference between patients with longer TpTe (≧72 ms) and shorter TpTe (< 72 ms).

CONCLUSION

The correlation of TpTe with e' and E/e' in hypertensive patients suggests that these parameters reflect diastolic ventricular electromechanical coupling. The E/e' predicted outcome, and an elevated E/e' should be suspected when TpTe is prolonged (> 72 ms). Noninvasive evaluation of diastolic electromechanical coupling is clinically useful in patients with hypertension for predicting their outcome.

Effect of Coronary Slow Flow on Intrinsicoid Deflection of QRS Complex

Coronary slow flow is a rare, clinically important entity observed in acute coronary syndrome. The pathophysiological mechanism is not fully elucidated. We investigated patients with chest pain who had angiographic features consistent with the coronary slow flow. One hundred ten patients were included. Electrocardiography, echocardiography, and angiography results were retrospectively noted. The mean age was 56.4. Fifty-eight were male, and fifty-two were female. The control group consisted of patients with normal angiography. Patients had higher diastolic blood pressure, lower mean ejection fraction, higher average left ventricular end-diastolic diameter, and higher mean left atrial size than the control group (p=0.009, p=0.017, p=0.041, andp < 0.001, resp.). Patients had higher average V1 ID, V6 ID, P wave dispersion, TFC LAD, TFC Cx, TFC RCA, and TFC levels than the control group. A significant linear positive relationship was found between the V1 ID and the TFC LAD, TFC Cx, TFC RCA, and TFC; also between the V6 ID and the TFC LAD, TFC Cx, TFC RCA, and TFC. Angiographic and electrocardiographic features are suggestive and diagnostic for the coronary slow flow syndrome. Although when regarded as a benign condition, coronary slow flow should be diagnosed, followed up, and treated as many of laboratory features suggest ischemic events.

Evaluation of the Tp-Te Interval, QTc and P-Wave Dispersion in Patients With Coronary Artery Ectasia

Background

Coronary artery ectasia (CAE) is defined as a diffuse dilatation of the diameter of the ectatic segment of the coronary artery, 1.5 times greater than that of the adjacent segment. The Tp-Te interval, P-wave and QTc dispersions are relatively new electrocardiographic markers associated with an increased risk of developing arrhythmias. Despite CAE increasing in prevalence in recent years, there is a sparsity of data available about its arrhythmogenic effect. The aim of the study was to evaluate QTc, P-wave dispersion and Tp-Te and Tp-Te/QT ratio in patients with CAE.

Methods

A retrospective comparative study was designed for consecutive age- and sex-matched patients. Twenty patients with isolated CAE (group 1) and 20 control subjects (group 2), with normal coronary arteries, were included. All patients presented with chest pain and coronary angiogram was indicated. Outcome measures included Tp-Te interval, Tp-Te/QT ratio, QTc dispersion and P-wave dispersion. Measurement of electrocardiogram (ECG) parameters was conducted using standardized digital online software. Descriptive and inferential statistics were performed.

Results

Mean Tp-Te (95.5 ± 9.01 ms) and Tp-Te/QT ratio (0.22 ± 0.02) were significantly prolonged in CAE group (Tp-Te: 84 ± 5.62 ms, P = 0.00009; Tp-Te/QT ratio: 0.20 ± 0.01, P = 0.00004). In addition, QTc (31.2 ± 3.71 ms) and P-wave dispersion (31.9 ± 5.46 ms) were significantly increased in comparison to the control group (QTc: 27.6 ± 2.82 ms, P = 0.00532 and 20 ± 3.77 ms, P = 0.00003 respectively). However, there was no difference in ventricular activation time (VAT) between groups.

Conclusions

CAE ECGs were found to be associated with increased Tp-Te, Tp-Te/QT ratio, QTc intervals and P-wave dispersions. This may suggest that CAE existence has a pro-arrhythmogenic nature.

The association between electrocardiographic R wave peak time and coronary artery disease severity in patients with non-ST segment elevation myocardial infarction and unstable angina pectoris

BACKGROUND

We aimed to evaluate possible association between QRS duration (QRSD), R wave peak time (RWPT), and coronary artery disease severity identified using the SYNTAX score (SS) in patients with unstable angina pectoris (USAP) or non-ST segment elevation myocardial infarction (NSTEMI).

METHOD

A total of 176 USAP/NSTEMI patients were enrolled in the study.

RESULTS

The high SS group (>22, n:45) patients had a higher prevalence of diabetes mellitus (DM); presence of ST segment depression ≥0.5 mm and 1 mm; ST segment elevation in the AVR lead (AVRSTE); longer QRSD and RWPT; and lower left ventricular ejection fraction (LVEF) than the low SS group (≤22, n: 131). The LVEF, AVRSTE, and RWPT (OR: 1.035, 95% CI: 1.003-1.067; p = 0.030) were independent predictors of high SS.

CONCLUSION

The present study demonstrated that RWPT and AVRSTE could be used as predictors of high SS.

Relationship between R-wave peak time and no-reflow in ST elevation myocardial infarction treated with a primary percutaneous coronary intervention

OBJECTIVES

Coronary no-reflow (NR) is observed in nearly half of ST segment elevation myocardial infarction (STEMI) patients who undergo a primary percutaneous coronary intervention (pPCI) despite epicardial coronary vessel patency. Several methods used to define NR include thrombolysis in myocardial infarction grade, corrected thrombolysis in myocardial infarction frame count, myocardial blush grade, ST-segment resolution, contrast echocardiography, and MRI. The aim of our study was to evaluate the relationship between NR and R-wave peak time (RWPT) measured from infarct-related artery leads METHOD: We enrolled 282 consecutive STEMI patients treated with pPCI in Kafkas University Hospital from January 2014 to January 2015. After exclusion, the remaining 233 patients were included in the study population RESULTS: Patients were divided into two groups according to the development of NR. We observed that increased preprocedural (31 (27-37) vs 27 (21-30) p<0,001) and postprocedural RWPT(35±7 vs 22±6 p<0,001) was associated with the development of NR and preprocedural RWPT(OR: 1.254 95% CI: 1.104-1.425 p<0,001) was found to be independent predictor of NR. The association between postprocedural RWPT and angiographic NR was statistically noninferior to that between ST-segment resolution % and NR(difference between area under curves: 0.0232, p= 0.38) CONCLUSION: the present study is the first to report a significant correlation between NR and RWPT in STEMI patients treated with primary pPCI.

Tp-Te interval predicts heart rate reduction after fingolimod administration in patients with multiple sclerosis

BACKGROUND

FTY720 (Fingolimod) is an immunosuppressive drug, which provides favourable effects in patients with multiple sclerosis (MS), albeit it induces heart rate (HR) and blood pressure (BP) reductions. Therefore, we tested potential factors able to predict HR response in MS patients treated with fingolimod.

METHODS

We analysed patients with MS followed at our Neurology Outpatient Clinic from May 2013 to June 2015. All patients underwent BP measurements and 12-lead ECG before and 6-h after drug administration. At these time intervals, conventional and new ECG indexes for cardiac damage, including Tp-Te interval, were measured. Univariate and multivariate analyses were performed to test the outcome of HR reduction more than median difference between baseline and final observations.

RESULTS

69 outpatients with MS (46 males, age 35.1±9.4years, BP 119.0±12.7/73.0±9.3mmHg, HR 73.5±11.4bpm) were included. No relevant adverse reactions were reported. Fingolimod induced progressive systolic (P=0.024) and diastolic (P<0.001) BP, as well as HR (P<0.001) reductions compared to baseline. Prolonged PQ (150.4±19.5 vs. 157.0±19.5ms; P<0.001), QT (374.9±27.0 vs. 400.0±25.8ms; P<0.001), Tp-Te (1.8±0.3 vs. 1.9±0.3mm; P=0.021), and reduced QTc (414.4±24.4 vs. 404.5±24.5ms; P<0.001) intervals were also recorded at final observation. Baseline HR, QT and Tp-Te intervals provided prognostic information at univariate analysis, although Tp-Te interval resulted the best independent predictor for HR reduction at multivariate analysis [0.057 (0.005-0.660); P=0.022].

CONCLUSIONS

This study firstly demonstrates that prolonged Tp-Te interval may identify those MS patients treated with fingolimod at higher risk of having significant, asymptomatic HR reduction during clinical observation.

R-Peak Time: An Electrocardiographic Parameter with Multiple Clinical Applications

In the 12-lead electrocardiogram (ECG), the time from the onset of the QRS complex (Q or R wave) to the apex or peak of R or to R' (when present), using indirect or semidirect surface unipolar precordial leads, bipolar limb leads or unipolar limb leads, is called ventricular activation time (VAT), R wave peak time (RWPT), R-peak time or intrinsicoid deflection (ID). The R-peak time in a specific ECG lead is the interval from the earliest onset of the QRS complex, preferably determined from multiple simultaneously recorded leads, to the peak (maximum) of the R wave or R' if present. Irrespective of the relative height of the R and R' waves, the R-peak time is measured to the second peak. The parameter corresponds to the time of the electrical activation occurring from the endocardium to the epicardium as reflected by the recording electrode located at a variable distance on the body surface, depending on the lead type: a unipolar precordial lead, a bipolar or unipolar limb lead. In normal conditions, the R-peak time for the thinner-walled right ventricle is measured from lead V1 or V2 and its upper limit of normal is 35 ms. The R-peak time for the left ventricle (LV) is measured from leads V5 to V6 and 45 ms is considered the upper limit of normal. In this manuscript, we review the clinical applications of this parameter.

A Novel Electrocardiographic T-Wave Measurement (Tp-Te Interval) as a Predictor of Heart Abnormalities in Hypertension: A New Opportunity for First-Line Electrocardiographic Evaluation

The aim of the study was to evaluate the role of conventional and new markers of early cardiac organ damage (OD) on 12-lead electrocardiography (ECG) in 25 outpatients with newly diagnosed untreated essential hypertension compared with 15 normotensive, otherwise healthy individuals. Each participant underwent ECG, echocardiographic, and blood pressure (BP) measurements. Conventional and new ECG indexes for cardiac OD (Tp-Te interval, ventricular activation time, and P-wave analysis) were also measured. Clinic and 24-hour ambulatory BP levels as well as left ventricular mass indexes were significantly higher in hypertensive than in normotensive patients. No significant differences were found between the two groups for ECG and echocardiographic markers of OD. Only Tp-Te interval was higher in hypertensive than in normotensive individuals (3.06 mm vs 2.24 mm; P<.0001), even after adjustment for anthropometric and clinical parameters. Preliminary results of this study demonstrated prolonged Tp-Te interval in newly diagnosed, untreated hypertensive outpatients compared with normotensive individuals.