Standard Electrocardiographic and Signal-Averaged Electrocardiographic Changes in Congestive Heart Failure

Integrative review of electrocardiographic characteristics in patients with reduced, mildly reduced, and preserved heart failure

INTRODUCTION

Electrocardiographic (ECG) changes in heart failure with reduced, mildly reduced, and preserved ejection fractions can be critical in clinical assessment while waiting to perform echocardiograms or when it is unavailable. This integrative review aimed to identify ECG characteristics among hospitalized patients demonstrating three types of heart failure during acute decompensation.

METHODS

We searched an electronic database of PubMed, Web of Science, EMBASE, Scopus, Google Scholar, and ClinicalTrials.gov using medical subject headings (MeSH) terms and keywords. Sixteen studies were synthesized and reported.

RESULTS

Heart failure with reduced ejection fraction (HFrEF) was more common in men, comorbid with coronary artery diseases and diabetes mellitus, higher BNP/Pro-BNP, wide QRS, and left bundle branch block on ECG. On average, clients with heart failure with preserved ejection fraction (HFpEF) were older and more likely to have a history of atrial fibrillation, valvular heart diseases, hypertension, chronic obstructive pulmonary, and atrial fibrillation (AF) on ECG. Patients with mildly reduced (HFmrEF) were more similar to HFpEF in older patients, comorbid with hypertension, AF and valvular diseases, and AF on ECG.

CONCLUSIONS

ECG characteristics might be related to left ventricular ejection fraction. Demographics, BNP/Pro-BNP, and ECG changes might help differentiate different heart failure types. Therefore, ECG might be a prognostic tool while caring for heart failure patients when highly skilled resources are unavailable. These identified ECG characteristics help generate research hypotheses and warrant validation in future research.

The Effect of Diuresis on the Paced QRS Complexes in Pacing-Dependent Patients with Heart Failure

BACKGROUND

Augmentation of the amplitude of QRS complexes with diuretic therapy for patients with congestive heart failure has been well documented. However, the effect of diuresis on the paced QRS complexes in pacing-dependent patients with heart failure is scarce.

OBJECTIVE

To investigate the effect of diuresis on the paced QRS complexes in pacing-dependent patients with heart failure.

METHOD

Thrity-two consecutive pacing-dependent patients with heart failure were enrolled in this study. Before and after diuresis, the sums of paced QRS amplitude of leads I+II (ΣpQRSI+II ), six limb leads (ΣpQRS6L ), leads V1 -V3 (ΣpQRSV1-V3 ), leads V4 -V6 (ΣpQRSV4-V6 ), leads V1 -V6 (ΣpQRSV1-V6 ), and lead aVR (pQRSaVR ), paced QRS duration (pQRSd ), paced QT intervals (pQT) and the body weight of each patient were measured, then the % changes (Δ%) in paced electrocardiogram (ECG) variables and the Δ% in body weight were evaluated.

RESULTS

Compared with before diuresis, paced ECG variables significantly increased and body weight significantly decreased after diuresis, Δ% in paced QRS amplitude(s) in all ECG variables (ΣpQRSI+II, ΣpQRS6L, ΣpQRSV1-V3 , ΣpQRSV4-V6 , ΣpQRSV1-V6 , and pQRSaVR ) correlated well with Δ% in body weight (r = 0.416, r = 0.849, r = 0.901, r = 0.371, r = 0.837, r = 0.619, and P = 0.018, P < 0.001, P < 0.001, P = 0.037, P < 0.001, P < 0.001), while there was no correlation between Δ% in pQRSd and pQT and Δ% in body weight.

CONCLUSIONS

The changes in amplitude of paced QRS complexes may be useful for the monitoring of therapy of pacing-dependent patients with heart failure.

Protective effect of heme oxygenase-1 on Wistar rats with heart failure through the inhibition of inflammation and amelioration of intestinal microcirculation

BACKGROUND

Myocardial infarction (MI) has likely contributed to the increased prevalence of heart failure (HF). As a result of reduced cardiac function, splanchnic blood flow decreases, causing ischemia in villi and damage to the intestinal barrier. The induction of heme oxygenase-1 (HO-1) could prevent, or lessen the effects of stress and inflammation. Thus, the effect and mechanism thereof of HO-1 on the intestines of rats with HF was investigated.

METHODS

Male Wistar rats with heart failure through ligation of the left coronary artery were identified with an left ventricular ejection fraction of < 45% through echocardiography and then divided into various experimental groups based on the type of peritoneal injection they received [MI: saline; MI + Cobalt protoporphyrin (CoPP): CoPP solution; and MI + Tin mesoporphyrin IX dichloride (SnMP): SnMP solution]. The control group was comprised of rats without coronary ligation. Echocardiography was performed before ligation for a baseline and eight weeks after ligation in order to evaluate the cardiac function of the rats. The bacterial translocation (BT) incidence, mesenteric microcirculation, amount of endotoxins in the vein serum, ileum levels of HO-1, carbon oxide (CO), nitric oxide (NO), interleukin (IL)-10, tumour necrosis factor-α (TNF-α), and the ileum morphology were determined eight weeks after the operation.

RESULTS

The rats receiving MI + CoPP injections exhibited a recovery in cardiac function, an amelioration of mesenteric microcirculation and change in morphology, a lower BT incidence, a reduction in serum and ileac NO and TNF-α levels, and an elevation in ileac HO-1, CO, and interleukin-10 (IL-10) levels compared to the MI group (P < 0.05). The rats that received the MI + SnMP injections exhibited results inverse to the MI (P < 0.05) group.

CONCLUSIONS

HO-1 exerted a protective effect on the intestines of rats with HF by inhibiting the inflammation and amelioration of microcirculation through the CO pathway. This protective effect could be independent from the recovery of cardiac function.

aVR, an index of all ECG limb leads, with clinical utility for monitoring of patients with edematous states, including heart failure

BACKGROUND

Nonreproducibility of precordial electrocardiogram (ECG) leads in serial ECGs has led to emphasis on the limb leads for some applications. Since modern electrocardiographs measure leads I and II and calculate on line the other four limb leads, the former can substitute for the set of six limb leads. Furthermore, based on the mathematical relationship of lead aVR and leads I and II, it was hypothesized that aVR could be used as a representative index of the set of the six limb leads. The aim of this study was to evaluate whether ECG lead aVR could function as an index of all limb leads, in clinical electrocardiography.

METHODS

Automation-derived and manually derived QRS voltage amplitude measurements of all limb leads in ECGs of a series of 100 randomly selected consecutive patients, and ECGs of 36 patients with various edematous states (EDST), congestive heart failure (CHF), or undergoing hemodialysis (HD), and aVR were inter-correlated with the sums of leads I and II (SigmaI&II), and the entire set of the six limb leads (Sigma6LbLds).

RESULTS

Correlation of aVR with SigmaI&II and Sigma6LbLds was excellent (P < 0.00005); also, aVR was found to be a reliable index of the six limb leads in repeat ECGs in the patients with various EDST, CHF, or undergoing HD, in whom changes in aVR correlated with changes in patients' body weight.

CONCLUSION

aVR could be taken as an index of all ECG limb leads in analysis in general, and in monitoring patients with EDST, CHF, and HD in particular.

Augmentation of ECG QRS complexes after fluid removal via a mechanical ultrafiltration pump in patients with congestive heart failure

BACKGROUND

Augmentation of the amplitude of ECG QRS complexes, correlating with loss of weight or fluid volume removed, has been documented in patients with congestive heart failure (CHF).

METHODS

We investigated the effect of an ultrafiltration (UF) pump on the fluid removal and the amplitude of ECG QRS complexes in patients with CHF. Nine patients aged 48.3 +/- 10.4 years with CHF were treated with an UF system, and weights, fluid removed, and sums of the amplitude of QRS complexes (SigmaQRS), were inter-correlated.

RESULTS

UF resulted in removal of 4.62 +/- 1.82 L of fluid, 5.0 +/- 2.9% decrease in the weights (P = 0.002) and 18.1 +/- 16.8% increase in the SigmaQRS (P = 0.012). There was a moderate correlation of % increase in the SigmaQRS and net fluid volume losses (UF + urine - oral intake), (r = 0.67, P = 0.0471, and a poor correlation between % increase in the SigmaQRS and % decrease in weights (r = 0.11, P = 0.77). Correlations of the change in weights after UF with the fluid removed by UF, or with the volume of total fluid loss (including insensible losses) were moderate but barely statistically significant (r = 0.65, P = 0.0559), and (r = 0.65, P = 0.0577), correspondingly.

CONCLUSION

Augmentation of the amplitude of QRS complexes correlates well with net fluid loss in response to UF in patients with CHF, and can be employed as an index of effectiveness of therapy. Also, a model of fluid losses in patients treated for CHF is being proposed.

Low Voltage ECG in Myocarditis: Peripheral Edema as a Plausible Contributing Mechanism

A 24-year-old woman was hospitalized with acute myocarditis that led to multiple organ, including heart, failure, with fluid retention. An echocardiogram showed left ventricular ejection fraction approximately 10%, and her electrocardiogram (ECG) revealed low voltage. She rapidly recovered and was discharged 15 days after admission. On evaluation at 1, 10, and 22 weeks after discharge, she was asymptomatic, with unlimited exercise tolerance. An echocardiogram 11 weeks after discharge from the hospital showed left ventricular ejection fraction of approximately 60%. Correlations of weights with ECG QRS voltage parameters in the hospital revealed r = 0.80 and 0.83, with P = 0.021 and 0.029, suggesting that >or=64% of the attenuation of the QRS potentials could be accounted for by the corresponding gain in weight.

Attenuation of ECG voltage in cirrhotic patients

Two patients with cirrhosis (CIR), ascites (ASC), and peripheral oedema (PEROD) are presented. They were followed for many years, had multiple hospital admissions and clinic evaluations, had repeated laboratory testing, and many ECGs recorded. As their condition worsened, they developed attenuation of the ECG voltage (ATTECGV), which was more pronounced during intervals of increased fluid overload. Attenuation of the ECG voltage was decreased at times of successful diuresis and amelioration of PEROD, while abdominal paracenteses for ASC did not have any influence on the ATTECGV, suggesting that ATTECGV in patients with CIR is due to the associated PEROD, and not to ASC.

The Resting Electrocardiogram in the Management of Patients with Congestive Heart Failure: Established Applications and New Insights

The resting electrocardiogram (ECG) furnishes essential information for the diagnosis, management, and prognostic evaluation of patients with congestive heart failure (CHF). Almost any ECG diagnostic entity may turn out to be useful in the care of patients with CHF, revealing the non-specificity of the ECG in CHF. Nevertheless a number of CHF/ECG correlates have been proposed and found to be indispensable in clinical practice; they include, among others, the ECG diagnoses of myocardial ischemia and infarction, atrial fibrillation, left ventricular hypertrophy/dilatation, left bundle branch block and intraventricular conduction delays, left atrial abnormality, and QT-interval prolongation. In addition to the above well-known applications of the ECG for patients with CHF, a recently described association of peripheral edema (PERED), sometimes even imperceptible by physical examination, with attenuated ECG potentials, could extend further the diagnostic range of the clinician. These ECG voltage attenuations are of extracardiac mechanism, and impact the amplitude of QRS complexes, P-waves, and T-waves, occasionally resulting also in shortening of the QRS complex and QT interval duration. PERED alleviation, in response to therapy of CHF, reverses all above alterations. These fresh diagnostic insights have potential application in the follow-up of patients with CHF, and in their selection for implantation of cardioverter/defibrillator and/or cardiac resynchronization systems. If sought, PERED-induced ECG changes are abundantly present in the hospital and clinic environments; if their detection and monitoring are incorporated in the clinician's "routine," considerable improvements in the care of patients with CHF may be realized.

ECG Changes in Response to Diuresis in an Ambulatory Patient With Congestive Heart Failure

This case report describes an ambulatory patient with congestive heart failure and peripheral edema who lost 18 lb in response to enhanced diuresis over the course of 1 week. The ECG showed increases in the amplitude of P waves, QRS complexes, and T waves; the duration of P waves, QRS complexes, and QT intervals; and the dispersion of P and QT. The clinical implications of these ECG changes are discussed.