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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 149-153

Study of electrocardiographic and two-dimensional echocardiography changes in patients of intracerebral hemorrhage and its outcome in terms of mortality


1 Department of Medical Oncology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
2 Department of Medicine, Dr D Y Patil Medical College, Pune, Maharashtra, India

Date of Submission27-Dec-2019
Date of Decision28-Sep-2020
Date of Acceptance08-Dec-2020
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Sachin Kisan Shivnitwar
Department of Medicine, Dr D Y Patil Medical College Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-4534.322615

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  Abstract 


Aims of the Study: The aim was to study the electrocardiographic and two-dimensional echocardiography (2D ECHO) changes in patients of intracerebral hemorrhage and its outcome in terms of mortality. Materials and Methods: Patients admitted to medicine ward and intensive care unit selected for the study. Their electrocardiography (ECG), 2D ECHO, and outcome noted. Results: Mortality was higher in patients of intracerebral bleed having ECG and 2D ECHO changes than those with normal ECGs and 2D ECHO. Conclusion: ECG and 2D ECHO abnormalities are common in patients of intracerebral hemorrhage, and these have prognostic significance in predicting mortality in patients of intracerebral hemorrhage. Thus, every patient of intracerebral hemorrhage should undergo ECG and 2D ECHO examination for the evaluation of cardiac dysfunction occurring in these patients.

Keywords: Electrocardiography, intracerebral hemorrhage, two-dimensional echocardiography


How to cite this article:
Narayankar AS, Shivnitwar SK. Study of electrocardiographic and two-dimensional echocardiography changes in patients of intracerebral hemorrhage and its outcome in terms of mortality. J Datta Meghe Inst Med Sci Univ 2021;16:149-53

How to cite this URL:
Narayankar AS, Shivnitwar SK. Study of electrocardiographic and two-dimensional echocardiography changes in patients of intracerebral hemorrhage and its outcome in terms of mortality. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 23];16:149-53. Available from: http://www.journaldmims.com/text.asp?2021/16/1/149/322615




  Introduction Top


Cerebrovascular accident (CVA) or stroke is the most common life-threatening disorder. It is the third leading cause of death in developed countries after cardiovascular disease and cancer.[1]

A stroke, or cerebrovascular accident, is defined as an abrupt onset of a neurological deficit that is attributable to a focal vascular cause. Thus, the definition of stroke is clinical, and laboratory studies, including brain imaging, are used to support the diagnosis. Intracranial hemorrhage is caused by bleeding directly into or around the brain; it produces neurologic symptoms by producing a mass effect on the brain structures, from the toxic effects of extravasated blood itself, or by increasing intracranial tension.

Many studies have shown CVA associated with electrocardiography (ECG) changes and wall motion abnormalities of two-dimensional echocardiography (2D ECHO). The changes of ECG in CVA were reported in many studies.[2],[3],[4] Changes occurring in ECG following stroke were changes in T-wave, U-wave, ST-segment, QT-interval, and various arrhythmias, these ECG changes may resemble those of myocardial ischemia or sometimes myocardial infarction.

Along with ECG changes, many studies have shown wall motion abnormalities on 2D ECHO following a stroke, especially with subarachnoid hemorrhage.[5],[6]

This study was undertaken to determine ECG and 2D echocardiographic changes in patients of intracerebral hemorrhage and to know the outcome of patients in terms of mortality.

An increase in sympathetic activity has been proposed as a causative factor in the genesis of cardiac abnormalities. This has been supported by the presence of a high level of plasma norepinephrine in such patients. The myocardial damage could be the cause of ischemic changes observed in surface ECG and various arrhythmias.[7]

There are two primary theories regarding the etiology of ECG changes seen following the central nervous system (CNS) insult. The first is that damage occurs to neurologic structures that have direct connections to the autonomic nervous system. Stimulation or destruction of these structures causes augmentation or inhibition of one or both divisions of the autonomic nervous system, resulting in ECG changes without permanent effects on the myocardium.[8] The second is that the neurologic disease creates an imbalance between sympathetic and parasympathetic outputs favoring sympathetic dominance. The relative excess of sympathetic stimuli leads to an increase in plasma catecholamine levels that triggers ECG changes. These systemic effects develop more slowly but are also long lasting and cause damage to the myocardium.

The interactions between the CNS and the cardiovascular system create a complex network with direct neural and several humoral pathways connecting these two vital organ systems firmly together.[8]


  Materials and Methods Top


One hundred patients with spontaneous nontraumatic intracerebral hemorrhage were selected from the medical ward and intensive care unit.

Patient eligibility

Inclusion criteria

  1. All proved cases of nontraumatic intracerebral bleed confirmed by computed tomography (CT) scanning on admission were eligible for this study
  2. Age >18 years.


Exclusion criteria

  1. Patients with a history of ischemic heart disease
  2. Patients with congenital heart disease
  3. Patients with a history of valvular heart disease
  4. Patients with a history suggestive of cardiomyopathy
  5. Patients with electrolyte imbalance
  6. Patients who do not consent to participate in the study and patients who were unable to understand the issues of the study. In patients with a depressed level of consciousness, informed consent was asked from a relative. If relatives did not give consent for participation of the patient, or if relatives were unable to understand the issues of the study, we did not include the patient.


Ethical clearance was taken from the ethics committee of hospital.

The diagnosis of CVA was made based on the following criteria:

  • Temporal profile of clinical syndrome
  • Clinical examination
  • CT scan of the brain.


A 12 lead ECG and 2D ECHO were done within.

Each case was subjected to 12-lead ECG and 2D echo, and the following criteria were applied in their analysis:

Electrocardiography criteria in the study

  • Heart rate <60/min was regarded as bradycardia, and heart rate exceeding 100/min was regarded as tachycardia
  • ST-segment depression of 0.5 mm or elevation of >1 mm were taken abnormally
  • T-wave was considered abnormal when the inversion of T-waves, in which it should have been upright, i.e., I, II, V3-V6 may be variable in III, aVL, V, and V2
  • QTc prolongation: The QT interval is measured from the beginning of the QRS complex to the end of T-wave, the rate corrected QTc is obtained by dividing the actual QT by the square root of the RR-interval (both measured in seconds). QTc is taken as prolonged if it is more than 0.44 m-s
  • U-wave was taken as significant when exaggeration of U-wave voltage was noted when appeared in more than 2 leads when appeared in leads, in which it was not normally seen (other than V3-V4)
  • RVH: R-waves in right chest leads and the R-wave may be taller than the S-wave in lead Vl; persistent S-wave seen in V5-V6
  • Left ventricular hypertrophy (LVH): If the sum of the depth of the S-wave in lead V, and the height of the R-wave in either lead V5 or V6 exceeds 35 mm, an R-wave of 1 1-13 mm or more in lead aVL is another criterion for LVH.


Echocardiographic criteria in the study

Philips iE33 2D echo with color Doppler machine was used:

  • Left ventricular (LV) ejection fraction was used to assess LV systolic function. Doppler indices (A > E across the mitral valve) were used to look for LV diastolic dysfunction
  • EF was calculated using the Fractional shortening method
  • Mitral valve opening using planimetry was used to look for mitral stenosis apart from this valve thickening and doming of anterior mitral leaflet and paradoxical motion of posterior mitral leaflet were used
  • Flow across the aortic valve was used to look for aortic stenosis (AS), including an opening (severe AS if AVO <8 mm)
  • Color imaging and Doppler were utilized for any regurgitation
  • 2D imaging was used to rule out cardiac thrombus.



  Results Top


The presence of LVH was the most common ECG finding in our patients (36%), followed by ST depression (35%). Other findings were tachycardia (33%), QTc prolongation (30%), and T-wave inversion (28%). Bradycardia was observed in 3% of patients and U waves in 2%.

As shown in [Table 2], it is evident that the most common abnormal 2D ECHO finding in our patients was LV dysfunction (48%) followed by LVH (38%). Four patients had global hypokinesia.
Table 1: Electrocardiography findings in patients

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Table 2: Two-dimensional echocardiography findings in patients

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[Table 3] shows that percentage mortality in patients of intracerebral bleed in our study was 43.
Table 3: Outcome

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[Table 4] shows that mortality was higher in patients of intracerebral bleed having ECG changes than those with normal ECGs.
Table 4: Mortality in stroke patients and its co-relation with electrocardiography changes

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Statistically significant ECG changes (i.e., P < 0.05) were noted in patients who had tachycardia and ST depression.

[Table 5] shows that mortality was higher in patients of intracerebral bleed having 2D ECHO abnormalities than those with normal 2D ECHO studies.
Table 5: Mortality in intracerebral bleed patients and its co-relation with 2-dimensional echocardiography findings

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Statistically significant 2D ECHO abnormalities were noted in patients having LV dysfunction, LVH and the presence of Global hypokinesia (i.e., P < 0.05) [Table 1].


  Discussion Top


A hospital-based prospective study was done to know the mortality in intracerebral hemorrhage patients and its relation with ECG and 2D ECHO changes.

ECG abnormalities were seen in 78% of our patients. Similar results were obtained in studies conducted by Tomar et al.[9] and Purushothaman et al.[10] who reported ECG abnormalities in 78.2% and 76.89% of intracerebral hemorrhage patients.

Findings suggestive of LVH was seen in 36% of our patients. This finding was not reported by Tomar et al. and Purushothaman et al. It was the most common abnormal ECG finding seen in our study.

ST depression on ECG was seen in 35% of our patients, whereas it was seen in 56.26% and 23.81% of patients in Tomar et al. and Purushothaman et al. study, respectively.

Tachycardia was seen in 33% of our patients and 50% of patients included in Tomar et al. study and 21.43% of patients included in Purushothaman et al.'s study.

QTc prolongation was present in 30% of our patients and 50% of Tomar et al. and 19.05% of Purushothaman et al.'s study patients.

T-wave inversion was seen in 28% of our patients. T-wave inversion was reported in 28.13% and 33.33% patients by Tomar et al. and Purushothman et al., respectively.

Abnormal 2D ECHO findings were present in 77% of our patients. Similar abnormal findings were seen in 75% of cases in Tomar et al. and 46% of cases in Amin et al. (2008)[11] study.

LV dysfunction was the most common (48%) abnormal finding in our patients which is comparable to 56.26% cases of LV dysfunction reported in this study by Tomar et al.

Amin et al. (2008)[11] studied 2D ECHO findings in stroke patients, including 41 patients of intracerebral hemorrhage. LV dysfunction was present in 2% of patients.

Amin et al.'s study showed the presence of LVH in 24% of patients, which is comparable with 38% cases in our study. Aortic regurgitation was seen in 7% of patients of our study, whereas it was seen in 15% of patients in Amin et al.'s study.

The percentage of mortality in patients of intracerebral bleed in our study was 43.

Mortality was higher in patients of intracerebral bleed having ECG changes than those with normal ECGs. However, only statistically significant ECG changes (i.e., P < 0.05) were tachycardia and ST depression.

Mortality was higher in patients of intracerebral bleed having 2D ECHO abnormalities than those with Normal 2D ECHO studies. However, only statistically significant 2D ECHO abnormalities were LV dysfunction, LVH, and the presence of global hypokinesia (i.e., P < 0.05).


  Conclusion Top


ECG and 2D ECHO abnormalities are common in patients of intracerebral hemorrhage, and these have prognostic significance in predicting mortality in patients of intracerebral hemorrhage. Thus, every patient of intracerebral hemorrhage should undergo ECG and 2D ECHO examination for the evaluation of cardiac dysfunction occurring in these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dalai PM. Cerebrovascular Disorders. API Textbook of Medicine. 9th ed. Jaypee Brothers Medical Pub: 2012. p. 796-809.  Back to cited text no. 1
    
2.
Byer E, Ashman R, Toth LA. Electrocardiograms with large upright T-waves and long QT intervals. Am Heart J 1947;33:796-806.  Back to cited text no. 2
    
3.
Burch GE, Meyers R, Abildskov JA. A new electrocardiographic pattern observed in cerebrovascular accidents. Circulation 1954;9:719-23.  Back to cited text no. 3
    
4.
Dimant J, Grob D. Electrocardiographic changes and myocardial damage in patients with acute CVA. Stroke 1977;8:448-55.  Back to cited text no. 4
    
5.
Davies KR, Gelb AW, Manninen PH, Boughner DR, Bisnaire D. Cardiac function in aneurysmal SAH – A study of electrocardiographic and echocardiographic abnormalities. Br J Anesthe 1991;67:58-63.  Back to cited text no. 5
    
6.
Sakka SG, Huettemann E, Reinhart K. Acute left ventricular dysfunction and SAH. J Neurosurg Anesthesiol 1999;11:209-13.  Back to cited text no. 6
    
7.
Norris JW, Froggatt GM, Hachinski VC. Cardiac arrhythmias in acute stroke. Stroke 1978;9:392.  Back to cited text no. 7
    
8.
Davis TP, Alexander J, Lesch M. Electrocardiographic changes associated with acute cerebrovascular disease: A clinical. Reve Prog Cardiovas Dis 1993;36:245-60.  Back to cited text no. 8
    
9.
Tomar AP, Ramteke SK, Singh R, Ramteke S. Study of ECG and echocardiographic abnormalities in stroke patients and its prognostic significance. J Evol Med Dent Sci 2014;3:2693-8.  Back to cited text no. 9
    
10.
Purushothaman S, Salmani D, Prarthana KG, Bandelkar SG, Varghese S. Study of ECG changes and its relation to mortality in cases of cerebrovascular accidents. J Nat Sci Biol Med 2014;5:434-6.  Back to cited text no. 10
    
11.
Amin H, Aronow WS, Lleva P, McClung JA, Desai H, Gandhi K, et al. Prevalence of transthoracic echocardiographic abnormalities in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Arch Med Sci 2010;6:40-2.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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