Role of 2d Echocardiography as a Predictor of Pulmonary Hypertension and its Outcome

ORIGINAL ARTICLE

Role of 2d Echocardiography as a Predictor of Pulmonary Hypertension and its Outcome

1* 2 3 4 Vaishali Patel , Jigna patel , Asha Vagadiya , Arpita Solanki

1 Assistant professor, medicine Department, 3Tutor, Physiology Department, 4Tutor, Ophthalmology Department, Medical college, Vadodara, 2Assistant professor, Physiology Department, medical college, Bhavnagar

ABSTRACT BACKGROUND: Pulmonary hypertension is most often diagnosed in advanced stages because of nonspecific nature of early symptoms and signs. Although clinical assessment is essential when evaluating patients of pulmonary hypertension as pulmonary hypertension is progressive disease with relative poor prognosis even in modern era. So here in present study we have tried to study value/role/importance of 2D Echocardiography in assessing progress, treatment options and outcome of pulmonary hypertension. MATERIAL AND METHODS: The study was carried out at medicine Department of civil hospital Ahmedabad during May 2007 to November 2009. 50 cases of pulmonary hypertension were selected and enrolled on the basis of signs and symptoms of right sided heart failure among screened 880 patients. Apart from detailed history, clinical assessment and routine blood investigations, all patients were sent for basic electrocardiogram, chest x ray PA view and 2Dechocardiography.All Data were analyzed using Microsoft excel software. RESULTS: In our study, the common x-ray chest findings suggestive of pulmonary hypertension were enlarge pulmonary artery segment (48%), hyperinflation of lungs (42%) and cardiomegaly (40%).The common ECG findings were P pulmonale in 49 patients (98%) Right axis deviation of P axis 40 (80%), Right axis deviation of QRS axis 26(52%) and Right Ventricular hypertrophy 24(48%).2D Echocardiography findings were RA dilatation & RV dilatation in 50 (100%) patients. Mild PAH in 12 (24%) Moderate PAH in 27 (54%) and severe PAH in 11 (22%). CONCLUSION: 2D echocardiography plays important role in early detection,assessing outcome, monitoring efficacy of specific therapeutic interventions for pulmonary hypertension and detecting preclinical stages of diseases./detailed echocardiographic assessment is performed in all patients of pulmonary hypertension.

Keywords: Echocardiography, Pulmonary hypertension

INTRODUCTION MATERIAL AND METHODS Pulmonary hypertension is a spectrum of In our study, 50 cases of pulmonary diseases involving pulmonary vasculature hypertension were selected and enrolled on and is defined as an elevation in pulmonary the basis of signs and symptoms of arterial pressures (mean pulmonary artery pulmonary hypertension among screened pressure >22 mm Hg). Pulmonary 880 patients during two and half years of hypertension is characterized by symptoms study course in medicine Department. of dyspnea, fatigue, chest pain and syncope. Patients were selected on the basis of As Pulmonary hypertension is chronic symptoms (dyspnea , cough, fatigue, chest progressive disease, carries a high mortality pain, syncope) ,Signs of Right Ventricular rate with most common cause of death being failure (Enlarged neck veins, Raised JVP, decompensated right heart failure if left Hepatomegaly, Hepatojugular reflux, untreated. A Delay in diagnosis results in Ascites ,Pedal edema, Loud P2, Right obvious delay in initiation of appropriate parasternal heave , Tricuspid murmur) and treatment.1 So in this review we discuss the other signs of chronic respiratory diseases. diagnostic and prognostic role of Apart from routine General examination echocardiography in pulmonary including physical parameters, anemia, hypertension. cyanosis, clubbing, edema feet, neck veins etc., systemic examination (specially *Corresponding Author: respiratory and cardiovascular system) was Dr. Vaishali Patel Assistant done of each patient. General investigations professor, Medicine including complete hemogram, Random Department, Medical Blood sugar, Renal function test, Liver college, fuction test, urine examination were sent. In Vadodara addition, Chest X-ray PA view,

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Role of 2d Echocardiography as a Predictor of Pulmonary Hypertension and its Outcome Electrocardiography, 2D Echocardiography Table.3 2D Echocardiography wise and Pulmonary function test of each patient distribution in pulmonary hypertension was done for diagnosis of pulmonary cases hypertension. Depending upon history and 2 D Echo findings No. of Percentage Patients examination some special investigation were RA dilatation 50 100% also sent (e.g. sputum examination, S. RV dilatation 50 100% Antinuclear antibody, S. Thyroid stimulating Mild PAH (RVSP 30- 12 24% 50 mm Hg) Hormone, S. Calcium).All Data were Moderate PAH (RVSP 27 54% analyzed using Microsoft excel software. 50-70 mm Hg) RESULTS Severe PAH (RVSP>70 11 22% mm Hg) Among 880 patients who presented with signs and symptoms of pulmonary In present study, all patients have RA dilatation and RV dilatation with normal left hypertension reviewed, 50 patients (5.68%) atria, ventricles and ejection fraction. In had been diagnosed as cases of pulmonary present study, Mild PAH was observed in hypertension 24%, Moderate PAH was observed in 54% Table 1shows x ray chest wise distribution and Severe PAH was observed in 22%. of pulmonary hypertension cases Tricuspid No. of Percentage X-ray Chest Findings No. of Percentage Regurgitation Patients Patients Mild TR 13 26% Enlarged Pulmonary 24 \48% Moderate TR 29 58% Artery Segment Severe TR 8 16% Hyperinflation of lungs 21 42% In present study, Mild TR was observed in Cardiomegaly 20 40% Consolidation 10 20% 13 patients (26%), Moderate TR was Honey Comb appearance 3 6% observed in 29 patients (58%) and Severe In present study, chest X-ray findings were TR was observed in 8 patients (16%) on the enlarged pulmonary artery segment (48%), basis of 2D Echocardiography finding. Hyperinflation of lungs (42%), DISCUSSION Cardiomegaly of RV type (40%), 50 patients of pulmonary hypertension were Consolidation (20%) and Honey Comb studied on basis of clinical features, x-ray Appearance (6%). chest, Electrocardiography And 2D Table.2 Electrocardiographic wise Echocardiography. In present study, chest distribution in pulmonary hypertension X-ray findings were enlarged pulmonary cases artery segment (48%), Cardiomegaly (40%) ECG Findings Present in Percentage and Hyperinflation of lungs (42%). They are No. of comparable with study of K.V. Krishna Patients 2 P pulmonale 49 98% swami .The common x-ray chest findings Right Axis Deviation 40 80% suggestive of pulmonary hypertension were of P axis enlarge pulmonary artery segment (48%), Right Axis Deviation 26 52% hyperinflation of lungs (42%) and of QRS axis Right Ventricular 24 48% cardiomegaly (40%).The incidence of Hypertrophy Hyperinflation of lungs (42%) was higher in RBBB 1 2% present study as compared to study of K.V. S1Q3T3 pattern 1 2% Krishna swami (16.8%).The reason for this In present study, the commonest ECG discrimination in results may be because of finding was P pulmonale (98%). The other common ECG findings were Right Axis in K.V. Krishna swami study, there were Deviation of P axis (80%), and Right Axis more numbers of Pulmonary Tuberculosis, Deviation of QRS axis (52%), Right while in present study there were more Ventricular Hypertrophy (48%). The other number of Chronic Bronchitis/Emphysema less common ECG findings were RBBB in causation of Pulmonary hypertension, so (2%) and S1Q3T3 pattern 1(2%) patients. incidence of Hyperinflation of lungs in X- ray chest findings was higher. In Electrocardiography, P. Pulmonale was observed in 98% patients. The common

ECG findings were P pulmonale in 49 54 Int J Res Med. 2016; 5(1);53-56 e ISSN:2320-2742 p ISSN: 2320-2734

Role of 2d Echocardiography as a Predictor of Pulmonary Hypertension and its Outcome patients (98%) Right axis deviation of P axis overload ,most patients present with 40 (80%), Right axis deviation of QRS axis enlarged right side chambers, right 26(52%) and Right Ventricular hypertrophy ventricular hypertrophy, increased 24(48%). P. Pulmonale was observed in interventricular septal thickness, an Kilpatrick et.al. study3 60%, Padmavati et.al. abnormal interventricular septum and study4 75%, P. Wood et.al5 85%, Michael reduced global right ventricular systolic et.al6 79% and S.C. Kapoor et.al7 97% function ,ultimately leading to right heart Present study is comparable with failure and death.12 S.C.Kapoor and P. Wood studies. P. CONCLUSION Pulmonale is due to right atrial overload. In As compared to X-ray chest and ECG, 2D present study, right axis deviation of P. wave Echocardiography can detect pulmonary was observed in 80% patients. In Caird and hypertension earlier, even when findings on Wilkon et.al study8 it was 79%,in Michael X-ray chest and ECG are absent. Utility of et. Al6 it was 79% and in Kilcoyne et.al. 2D Echocardiography is to rule out other study9 it was 71% .Present study co-relates causes of right sided heart failure like with above studies. Right axis deviation of p congenital, valvular, hypertensive, ischemic wave is because of right atrial hypertrophy. heart diseases and cardiomypathy.. So in Right axis deviation of QRS axis was modern era, 2D Echocardiography is present in 52% patents in present study. It investigation of choice for early detection of was observed 50% in Coelho study10, 50% pulmonary hypertension. As an imaging in Caird & Wilkon study8 and 63% in modality 2D echocardiography has Kilcoyanestudy9.Present study co-relates advantage of being widely available, with above studies. Right axis deviation of noninvasive, cost effective and safe. It plays QRS axis is a sign of right ventricular important role in the screening, early dilatation and hypertrophy. In present study, detection, diagnosis and Prognosis of Right Ventricular Hypertrophy was observed pulmonary hypertension. However in 48% while in Padmavati et.al. study4 it 3DEchocardiography offers promise in its was 78% and in Kapoor et.al 7 It was ability to minimize geometric limitations of 59%.Present study, correlates with the 2Dimentional assessment of chamber size kapoor study, while statistical difference in and thus quantify volume and pressure the ECG incidence of Right Ventricular relationship in right ventricle. Thus despite Hypertrophy in the present series may be the current utility of Echocardiography, because of large number of patients in study there remains vast area to explore in the of Padmavati. In present study, RBBB was noninvasive assessment of pulmonary observed in 1 patient (2%). Present study is hypertension. comparable with study of Kapoor et. al. In REFERENCES Present study, 2D Echocardiography 1. Harrison's, Principle of Internal Medicine: findings were RA dilatation & RV dilatation 19th edition 2015; vol. 2, page no. 1655. in 50 (100%) patients. Mild PAH in 12 2. K.V.Krishnaswamiet. al, pulmonary (24%) Moderate PAH in 27 (54%) and hypertension in chronic pulmonary severe PAH in 11 (22%). In present study, diseases: Indian Journal of Tuberculosis, all patients have RA dilatation and RV 1979; Vol. XXVII, No.2, page no 57-62. dilatation. Same findings were noted in 3. Kilpatrick J.A., Electrocardiography Himelmanet. el study11. In present study, changes in chronic pulmonary 24% had mild PAH, 54% had moderate hypertension PAH and 22% had severe PAH. In 4. Padmavati S. and Rizada V., pulmonary hypertension there is pre Electrocardiogram in chronic pulmonary capillary pulmonary hypertension due to hypertension :British Heart Journal, relative blood flow obstruction proximal to 1972; 34, page no. 658. the lung capillary bed and elevated 5. Wood P., Electrocardiography pulmonary vascular resistance. this results in appearance in acute and chronic Right ventricular pressure overload .Because pulmonary heart diseases: British Heart of chronic right ventricular pressure Journal, 1948; 10, page no. 87.

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Role of 2d Echocardiography as a Predictor of Pulmonary Hypertension and its Outcome 6. Michael MC Goon, David Gutterm on, 9. Kilcoyne MM., Davis A.L. and Ferrer Clinical study of screening, early M.I., A dynamic ECG concept useful in detection and diagnosis of pulmonary the diagnosis of pulmonary hypertension hypertension from chest journals 2007 :Circulation, 1970; 42, page no. 903. Vol. 126/1/14 pages. 10. Coelho H., Amram S.S., ECG alteration 7. Kapoor S.C., pulmonary hypertension in in chronic pulmonary Pulmonary Tuberculosis: Indian hypertension:American Journal of Journal of Tuberculosis, 1950; Vol VI Cardiology, 1962; 10, page no. 20. no.2, page no. 50-64 11. Himelman et al, Improved recognition of 8. Caird P.I. and Wilkon, The pulmonary hypertension in patients with electrocardiography in chronic bronchitis COPD: American Journal of Medicine, with generalized obstructive lung May 1988; Vol. 84, page no. 891-897. diseases and its relation to ventilatory 12. Journal of the American society of functions: American Journal of Echocardiography Jan’13,vol 26; Cardiology, 1962; 10, page no. 5 Number1

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