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SYNOPSIS OF DISSERTATION FOR RAJIV GANDHI UNIVERSITY OF

HEALTH SCIENCES, KARNATAKA

1. Name of the Candidate and address DR FAHMI ABDUL SALAM

(in block letters) YECHEES; MUZHATHADAM; THANA

KANNUR-670012; KERALA

2. Name of the Institution A J INSTITUTE OF MEDICAL SCIENCE

KUNTIKANA, MANGALORE 575004.

3. Course of study and subject M D GENERAL MEDICINE

4. Date of admission to course 10TH MAY 2010

“Electrocardiographic and
5. Title of topic Echocardiographic changes in Chronic
Obstructive Pulmonary Disease and Cor
Pulmonale”

6.0 Brief Resume of the intended Work :

6.1 Need for the study :
Chronic Obstructive Pulmonary Disease (COPD) is defined as a disease state characterized by airflow limitation
that is not fully reversible. In India COPD is the second most common lung disorder after pulmonary tuberculosis
and remains a major public health problem. Global Initiative for Chronic Obstructive Lung Disease (GOLD)
estimates suggest that COPD will rise from the sixth to the third most common cause of death worldwide by 2020.
However, COPD patients probably are not usually assessed be electrocardiogram (ECG) in routine medical
practice particularly in developing countries like India. Therefore, the present study was conducted to evaluate the
diagnostic values of ECG and ECHO findings among COPD patients and predicting right heart disease.
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6.2 Review of Literature :

 1Anton Vonk-Noordegraaf et al had conducted a study on the structural and functional cardiac changes in
25 clinically stable COPD patients with normal PaO2 and without signs of right ventricular failure and had
concluded that concentric right ventricular hypertrophy is the earliest sign of right ventricular pressure
overload in patients with COPD and this structural adaptation of the heart does not alter right ventricular
and left ventricular systolic function

 Chronic Cor Pulmonale (CCP) is a strong predictor of death in chronic obstructive pulmonary disease
(COPD). However, a study was done by 2 Raffaele Antonelli Incazi et al to assess the prognostic role of
individual ECG signs of CCP and of the interaction between these signs and abnormal arterial blood gases.
To the conclusion, some ECG signs of CCP and alveolar-arterial oxygen gradient more than 48mmHg
during oxygen therapy qualified as a simple and inexpensive tool for targeting subsets of COPD patients
with severe or very severe short term prognosis

 Electrocardiographic (ECG) findings may help in clinical decision making regarding this disease
(COPD) entity. 3 R.L. Agarwal et al had conducted a hospital based cross-sectional study to evaluate the
extent and diagnostic values of ECG changes among COPD patients suffering from broad spectrum of
respiratory diseases. Results showed that ECG changes were found less sensitive but highly specific and
suggests that COPD patients should be screened electrocardiographically in addition to other clinical
investigations

 An electrocardiographic study has been made of 112 hospital out-patients suffering from chronic bronchitis
by 4 A.G. Chappell and his study showed that rightward deviation of the P axis occurred in 32 (29%)
patients, P pulmonale in 11(10%), right ventricular hypertrophy in 11 (10%), and left axis deviation in 8
(7%). Less common abnormalities included small secondary r waves in right precordial leads, right and left
bundle-branch block, indeterminate mean QRS axes, and S1S2S3 syndrome. Rightward deviation of the P
axis, P pulmonale, and right ventricular hypertrophy were confined to patients with severe airways
obstruction, and the presence or absence of widespread emphysema assessed radiographically did not
appear to influence these electrocardiographic abnormalities.
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 Two patients with co-existing cardiac disease and chronic obstructive pulmonary disease are described by
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J.W.Yip et al. The first patient had Wolff-Parkinson-White syndrome and the second patient had extensive
anterior Q wave myocardial infarction. In addition to the distinctive ECG patterns of their cardiac
abnormalities, both patients also showed the "lead I sign" which is a highly specific marker of chronic
obstructive pulmonary disease. These two patients suggest that even in the presence of cardiac disease, the
diagnosis of chronic obstructive pulmonary disease should be strongly suspected when the "lead I sign" is
present

 Ultrasound imaging has continuously developed over recent years, leading to the development of several
novel echocardiographic indexes. Among these, of particular interest are those that focus on pulmonary
hemodynamic, because they not only improve both sensitivity and specificity in the echocardiographic
evaluation of pulmonary pressures (systolic, mean, and diastolic), but can also be used to estimate other
pulmonary hemodynamic parameters, such as pulmonary vascular resistance, pulmonary capillary wedge
pressure, and pulmonary capacitance and impedance. Such parameters can provide important diagnostic
and prognostic information in patients with heart failure, chronic obstructive pulmonary disease, and
pulmonary arterial hypertension and in every patient with suspected pulmonary impairment. In this review,
the authors 6Alberto Milano et al had presented a comprehensive overview of the echocardiographic
indexes involved in pulmonary hemodynamic evaluation and discussed the applications of these indexes in
the clinical setting.
 Right ventricular (RV) dysfunction determines prognosis in patients with chronic pulmonary disease.
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Malcolm I. Burgess et al examined the relative prognostic potential of measures of systolic, diastolic, and
global RV function in 87 patients with chronic pulmonary disease. Univariate analysis demonstrated that
both clinical and echocardiographic variables predicted survival. In the multivariate model both RV end-
diastolic diameter index and velocity of late diastolic filling were independent predictors of survival.
Receiver operator characteristic analysis demonstrated that a composite model combining these 2 measures
provided the most powerful prognostic information. Echocardiographic indices of RV function identify
patients with pulmonary disease at high risk and provide incremental prognostic information over and
above that supplied by clinical data.
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6.3 Objectives of the study :

1. To study ECG changes in COPD

2. To compare ECG changes of Cor Pulmonale with Echocardiography findings
3. To find the significance of ECG change of Cor Pulmonale in predicting right heart disease

7.0 Material and Methods :

7.1 Source of data :
Study will be done at A J Institute of Medical Sciences
The study period is from December 2010 to December 2011.

7.2 Method of Collection of data :

Inclusion Criteria:

1. All the patients should be more than 18 years of age

2. All the patients should be proven to have COPD

3. Electrocardiogram and Echocardiography to be done in all the patients

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Exclusion Criteria:

1.Patients with bronchial asthma , post pulmonary TB or other cardiac illness were excluded

7.3 Does the study require any investigations or interventions to be conducted on patients
or other humans or animals? If so please describe briefly.
YES
1. Complete blood count

2. Sputum for AFB

3. Chest X-ray

4. Pulmonary Function Test

5. ECG

6. Echocardiography

7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES
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8.0 References :

1) Anton Vork-Noordegraaf, J. Timmarcus, Sebastiaan Holverda, Bea Roseboom, Peter E. Postmus. Early
changes of cardiac structure and function in COPD patients with mild Hypoxemia.
Chest 2005; 127 1898-1903 DOI 10. 1378/ chest 127.6.1898.

2) Raffaele Antonelli Incalzi, Leonello Fuso, Marino De Rosa, Anteo Di Napoli, Salvatore Basso, Gabriella
Pagliari and Riccardo Pistelli. Electrocardiographic Signs of Chronic Cor Pulmonale : A Negative
Prognostic Finding in Chronic Obstructive Pulmonary Disease. Circulation 1999;99;1600-1605.

3) R.L. Agarwal, Dinesh Kumar, Gurpreet, D.K Agarwal, G.S Chabra. Diagnostic Values of
Electrocardiogram in Chronic Obstructive Pulmonary Disease. Lung India 2008; 25: 78-81

4) The Electrocardiogram in chronic bronchitis and emphysema. A G Chappell. Br Heart J 1966 28: 517-
522 DOI.10.1136/hrt.28.4.517.

5) J W Yip, B L Chia, W C Tan. The ECG "Lead I Sign" in Cardiac Disease - An Indicator of Coexisting
Obstructive Pulmonary Disease.Singapore Med J 1999; Vol. 40(04).

6) Alberto Milan, Corrado Magnino, Franco Veglio. Echocardiographic Indexes for the Non-Invasive
Evaluation of Pulmonary Hemodynamics. Journal of American Society of Echocardiography,Volume23,
Issue3, Pages 225-239 (March 2010).

7) Malcolm I. Burgess, Nesrin Mogulkoc, Rowland J. Bright Thomas, Paul Bishop, Jim J. Egan, Siman G.
Ray. Comparison of echocardiographic markers of right ventricular function in determining prognosis in
chronic pulmonary disease. Journal of American Society of Echocardiography, Volume15, Issue6, Pages
633-639 (June 2002).