|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2015 | Volume
: 15
| Issue : 2 | Page : 160-165 |
|
Electrocardiographic changes in patients of postcerebrovascular accident in rural population of Eastern India
Abhijit Kanrar1, Arunima Chaudhuri1, Arpita Ghosh1, Debasis Adhya1, Pallav Das2, Suranjan Banerjee1
1 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
2 Department of Physical Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| Date of Web Publication | 6-May-2015 |
Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1319-6308.156351
Background: Disorders of the central nervous system cause a wide array of cardiovascular disorders. Aims: The present study was conducted to study the pattern of electrocardiogram (ECG) changes associated with acute stroke in recovery phase among patients without cardiovascular diseases in a rural population of a developing country. Materials and Methods: The present study was conducted in a tertiary care hospital of eastern India in a time span of 1 year. Study group consisted of hundred postcerebrovascular accident (CVA) patients during recovery stage and age and gender matched hundred subjects with no history of CVA or cardiac dysfunction in present or past were chosen as control. Results: Average heart rate of controls was 76.58 ± 6.31 per min and in stroke it was 69.74 ± 12.03 per min. The P value was significant (<0.01). Axis, P-R interval, ST segment, Q-Tc intervals were significantly worse in patients suffering from stroke as compared to normal. Average heart rate of ischemic stroke patients was 71.36 ± 12.17 per min and in the haemorrhagic stroke was 65.12 ± 10.52 per min. The P value was significant (0.02* < 0.05). There was no significant difference in other ECG parameters among the two groups of stroke patients. Conclusion: The major ECG abnormalities are S-T segment depression, prolonged corrected Q-T interval and abnormalities in heart rate and rhythm following CVA and are nearly identical in ischemic and haemorrhagic CVA. The patients of acute CVA in developing countries need to be treated with proper follow-up considering the neurological as well as cardiological complications. ناكس يف ةسارد - ةيومدلا ةيعولأا ةباصإ دعب ىضرملا دنع بلقلا ةيبرهك ططخم يف تاريغتلا. دنهلا يقرش يف ةيفيرلا قطانملا
. ةيئاعولا ةيبلقلا تابارطضلاا نم ديدعلا يزكرملا يبصعلا زاهجلا تابارضا ببست :ثحبلا ةيفلخ
ةطبترملاو بلقلل ىئابرهكلا طيطختلا يف تلريغتلا طمن ةفرعم ةساردلا هذه فده ناك :ةساردلا فده نم ددع يف كلذ ةيومدلا ةيعولأاو بلقلل ضارعأ نود يفاعتلا ةلحرم يف ةداحلا ةيغامدلا ةتكسلاب.ةيمانلا نادلبلا يف ةيفيرلاا قطانملا ناكس
ةينمز ةرتفل دنهلا يقرش يف ةيثلاثلا ةياعرلا ىفشتسم يف ةساردلا هذه تيرجأ :ةساردلا قرط داوملا ةيئاعولا تلالاتعلاا نوناعي ىضرملا نم ةئام نم ةساردلا ةعومجم تنوكتو .ةدحاو ةنس ىلإ تدتما للاتخا وأ ةباصلإل اوضرعتي مل صخش ةئام نم ةطباض ةعومجمو شاعنلإا ةلحرم للاخ غامدلل.يضاملا وأ رضاحلا يف بلقلا يف يفيظو
ةيغامدلا ةتكسلا ةعومجم يفو ةقيقد لكل ةطباضلا ةعومجملا يف بلقلا تابرض لدعم ناك :جئاتنلا 71.36=12,17 ةيغامدلا ةتكسلا ىضرمل بلقلا تابرض طسوتم ناكو 76.58 =6.51 12.03 طيطختلا يف ركذي قرف يأ ةساردلا رهظن ملو 10.52 ةيفزنلا ةيغامدلا ةتكسلاو ةقيقد لكل 69-74.ةيغامدلا ةتكسلا يتعومجم ىدل بلقلل ىئابرهكلا
ىف تابارطضا مهل ثدحي ام اريثك غامدلل ةيئاعولا تلالاتعلاا نوناعي نيذلا ىضرملا نا :جاتنتسلاا كلذ عضو ىغبني هيلعو ةيغامدلا تابونلا كلتب مهيباصا دعب ةرشابم بلقلا تابرض ىفو بلقلا طيطخت.ةيمانلا لودلا ىف ةصاخ نابسحلا ىف
Keywords: Developing country, electrocardiographic changes, stroke
How to cite this article:
Kanrar A, Chaudhuri A, Ghosh A, Adhya D, Das P, Banerjee S. Electrocardiographic changes in patients of postcerebrovascular accident in rural population of Eastern India. Saudi J Sports Med 2015;15:160-5 |
How to cite this URL:
Kanrar A, Chaudhuri A, Ghosh A, Adhya D, Das P, Banerjee S. Electrocardiographic changes in patients of postcerebrovascular accident in rural population of Eastern India. Saudi J Sports Med [serial online] 2015 [cited 2023 Dec 8];15:160-5. Available from: https://www.sjosm.org/text.asp?2015/15/2/160/156351 |
| Introduction | |  |
Cerebrovascular accidents (CVAs), the second most frequent cause of death world-wide, accounts for 6.2 million deaths. Between 1990 and 2010 the number strokes have decreased by approximately 10% in the developed countries and increased by 10% in the developing countries. [1],[2],[3],[4],[5] Stroke is the term used to describe episodes of focal brain dysfunction due to focal ischemia or haemorrhage. The incidence of first stroke is around 1.5/1000/year, and of transient ischemic attack 0.6/1000/year. About 22% of all strokes are recurrent events. [1],[2],[3],[4],[5]
Cardiovascular abnormalities are common after a stroke. Studies have evaluated electrocardiogram (ECG) changes and rhythm disturbances in ischemic stroke patients without primary heart disease to distinguish abnormalities specifically associated with acute stroke. Disorders of the central nervous system cause a wide array of cardiovascular system dysfunction ranging from ECG changes and transient myocardial dysfunction to sudden cardiac death. ECG changes are present in 60-90% of patients with intra-parenchymal or subarachnoid bleed and in about 5-20% of patients with acute ischemic stroke. [6],[7],[8],[9] The underlying basis is disordered repolarization process. The possible mechanism is through disturbances in autonomic regulation and massive stimulation of the sympathetic nervous system. Moreover studies have shown that the frontal lobe, insular cortex and amygdala play an important role in regulating the heart rate via autonomic nerves.
Experimental studies even revealed that the left stellate ganglion influences the posterior wall of the ventricles and the right stellate ganglion has influence over the anterior ventricular walls. [10],[11] The ECG abnormalities most frequently noted are ischemic changes are 35%, prolongation of QT interval 45% and disturbances in rate and rhythm 25%, which include atrial fibrillation, premature atrial and ventricular complexes, supra-ventricular- and ventricular-tachycardias, torsedes de point is or polymorphic ventricular tachycardias. [5],[6],[7],[8],[9] Stroke induced ECG changes are evanescent, resolving over a period of days to months.
The present study was conducted to study the pattern of ECG changes associated with acute stroke in recovery phase among patients without cardiovascular diseases in a rural population of a developing country.
| Materials and methods | | |
The present study was conducted in a tertiary care hospital of eastern India in a time span of 1 year after taking institutional ethical clearance and informed consent of the patients. Study group consisted of hundred post-CVA patients during recovery stage and age and gender matched 100 subjects with no history of CVA or cardiac dysfunction in present or past were chosen as control.
Inclusion criteria
Hundred patients of CVA in the recovery stage (within 2 weeks of attack) who had no prior cardiac abnormalities, without any past history of CVA or any associated systemic infections. Age of the study group was 45 years and above.
Exclusion criteria
Patients having evidence of previous ischemic heart disease, congenital heart disease valvular cardiac disease, electrolyte imbalance, systemic infections or prior history of stroke, unconscious subjects and patients suffering from stroke due to traumatic injury were excluded.
A detailed history regarding the clinical profile of stroke including risk factors like hypertension, diabetes mellitus, dyslipidemia, history of cardiac diseases and smoking was taken. Detailed neurological examination was done. The following investigations were carried: Complete blood count, Fasting blood sugar, lipid profile, serum electrolytes, urea creatinine, computerised tomography (CT) scan of brain.
Electrocardiogram recording was done after 3-5 days from the day of attack and not later than and 14 days.
Cerebrovascular accident patients were divided into two groups: Patients with ischaemic stroke and patients with haemorrhagic stroke.
Electrocardiogram criteria applied for analysis of data
Heart rate: Sinus bradycardia <60 beats/min; sinus tachycardia >100 beats/min; PR interval >0.2 s: Considered as prolonged; QRS width >0.1 s: Considered as wide; ST segment depression of 0.5 mm or elevation of 1 mm: Considered abnormal; QT interval was measured and corrected for the heart rate. The normal Q-Tc is 0.35-0.43 s. The corrected QT (QTc) >0.43 s was taken under consideration; T wave negative in lead II and V4-V6 and presence of very deep, widely splayed T wave inversions were considered as abnormal. [12]
Right ventricular hypertrophy: Tall R wave in lead V1, equal to or larger than the S wave in that lead; right axis deviation; T wave inversion in V1-V4 chest leads.
Left ventricular hypertrophy: The voltage of the S wave in lead V1 plus the voltage of the R wave in lead V5 or V6 often exceeded 35 mm; high voltage R wave (11-13 mm or more) seen lead aVL when the QRS axis is horizontal; inverted T waves in leads with tall R waves; left axis deviation.
The computer software Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.) was used to analyze the data. P value was considered as statically significant when it was <0.05* and statistically highly significant when P < 0.01**.
| Results | | |
Hundred cases of acute CVA patients, admitted to the Burdwan Medical College, Burdwan, were selected in recovery stage for the study. A noncontrast CT scan of brain was used to define the stroke type. Hundred age and gender matched subjects were included in the study as control group.
Out of 100 CVA patients in the study group 64 were male and 36 were female. There were male preponderance compared to the female making the male-female ratio 1.78:1. Out of 100 CVA patients in the study group the mean age was 68.13 ± 9.88. The incidence of CVA in the present study was more common in the age group 65-74 years (33%) followed by 74-84 years (28%). Patient in the study group had one or more risk factors. 75% were hypertensive, 45 had the positive history of smoking, 10% reported to be diabetic, 25% had elevated cholesterol level and 7% had the history of alcohol consumption.
Total 100 stroke patients in the study group were divided into two major categories-ischemic group and haemorrhagic group. Out of 100 patients 74 had ischemic CVA (74%) and 26 had haemorrhagic CVA (26%). In case of 74 patients in the ischemic group 44 were male and 30 were female and in case of 26 patients in the haemorrhagic group 20 were male and 6 were female. Most of the ischemic CVA patients presented with hemiplegia, hemi paresis, weakness of upper and lower limb (70-80%), hypertension and few were presented with headache, insomnia, dementia, constipation. In case of haemorrhagic group majority were presented with headache, hemiplegia, hemi paresis, hypertension, and around 5-10% were presented with vomiting, bradycardia, disorientation. In both group of patient around 85% showed planter extensor on the side of affected limb (positive Babinski sign).
The mean heart rate in case of CVA group was 69.74 with standard deviation (standard deviation [SD] = 12.03), and in case of control group mean heart rate was 76.58 and SD = 6.31 and the difference was significant (P value <0.01 **).
Electrocardiogram changes were seen in total 80 patients among the ischemic and haemorrhagic group. Out of 100 patients 74 had ischemic CVA (74%) and 26 had haemorrhagic CVA (26%). Among haemorrhagic cases 21 had intracranial haemorrhage and 5 had sub arachnoid haemorrhage. In ischemic group of 74 patients 60 patients had ECG changes (81.08%) and in the haemorrhagic group of 26 patients 20 showed ECG changes (76.92%). The abnormalities were more common in the ischemic group (81.08%) than seen in the haemorrhagic group (76.92%), but the difference was not significant.
Comparison of electrocardiogram changes of stroke patients and normal controls
Average heart rate of controls was 76.58 ± 6.31 per min and in stroke it was 69.74 ± 12.03 per min. The P value was significant (<0.01). In case of other ECG parameters (p wave amplitude, Q wave amplitude, QRS complex duration, voltage criteria analysis for ventricular enlargement, T wave amplitude) the observed difference was not significant. Axis, P-R interval, ST segment, Q-Tc intervals were significantly worse in patients suffering from stroke as compared to normal [Table 1].
Comparison of electrocardiogram changes of ischemic and haemorrhagic stroke
Average heart rate of ischemic stroke was 71.36 ± 12.17 per min and in the haemorrhagic stroke it was 65.12 ± 10.52 per min. The P value was significant (0.02* < 0.05). In case of other ECG parameters (axis, P wave amplitude, P-R interval, Q wave amplitude, QRS complex duration, voltage criteria analysis for ventricular enlargement, T wave amplitude) the observed P value was not significant [Table 2]. The obtained ST segment value in the ischemic CVA was −0.51 ± 0.93 mm, and in the haemorrhagic stroke it was −0.50 ± 0.45. The observed P value was not significant (0.92). The corrected Q-T interval in the ischemic group was 0.43 ± 0.04 s and in the haemorrhagic stroke it was 0.42 ± 0.03 s. The P value was not significant (0.58).
| Discussion | | |
The mean age in the study group was 68.13 ± 9.88. The incidence of CVA in the present study was more common in the age group 65-74 years (33%) followed by 74-84 years (28%). It is comparable to the other three studies done by Truelsen et al. [3] (64.2 years), Sridharan et al. [4] (67 years), and Kim et al. [5] (65.2 years). Lack of early screening of hypertensives, dyslipaedaemics, and diabetics in the Indian population may contribute to the higher rate of prevalence of CVA in relatively younger age group. [4] A recent hospital based multicenteric prospective stroke registry in India was carried with an objective to determine risk factors. Results showed that patients with stroke had high rates of risk factors including high alcohol consumption, tobacco consumption, diabetes, hypertension and dyslipidemia. [9]
In the present study 75% patients were hypertensive, 45% patients had the positive history of smoking, 10% patients had diabetes mellitus, 7% patients were alcoholic and 25% patients had elevated blood cholesterol level which are comparable with Pandiyan et al. [13] study where hypertension (71.9%) was the major risk factor for stroke, followed by diabetes mellitus (49.8%), hyperlipidaemia (26.1%), and smoking (23.6%). Recently INTER-STROKE (international case-control study in 22 high, middle and low-income countries including India, has been developed since 2008 to determine the importance of established and emerging risk factors for stroke on a global population.) [8] and INSPIRE (The Indian Stroke Prospective Registry is a large, multi-centre prospective pilot registry whose objective is to determine etiologies, clinical practice patterns and outcomes of stroke in India began in 2009.) [9] studies are being conducted for association of emerging risk factors with CVA.
In the present study ischemic CVA is much more common than haemorrhagic CVA. 74% patients had ischemic CVA and 26% patients had haemorrhagic (ischemic, haemorrhagic ratio 2.85:1) CVA which is comparable to the Das et al. [14] prospective community-based study of stroke in Kolkata with ischemic and haemorrhagic ratio 1.86:1. In the study of Kumar et al. [10] the incidence of ischemic stroke was 56%.
Haemorrhagic CVA is less common than ischemic CVA. Among haemorrhagic cases 21 had intracranial haemorrhage and 5 had sub arachnoid haemorrhage. Haemorrhagic CVA showed more bradycardia, headache, vomiting and more serious brain damage. Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure and potentially fatal herniation syndromes. A recent multicentric Indian Collaborative Acute Stroke Study conducted among 2162 admitted stroke patients across Southern, Northern, and Western India, observed ischemic stroke in 77%, hemorrhagic stroke in 22%, and unspecified stroke in 1% of cases based on cerebral CT scans. [11]
In the present study ECG changes were seen in 80% of total CVA patients among the ischemic and haemorrhagic group. In ischemic group of 74 patients 60 patients had ECG changes (81.08%) which are a bit higher than haemorrhagic group (out of 26 patients 20 showed ECG changes that is 76.92%). These findings are identical with the previous studies by Bozluolcay et al. [15] in 2003 and Purushothaman et al. [16] in 2014. Normal function of the heart is regulated by CNS (central nervous system). [17],[18] Catecholamine causes increase intracellular calcium that leads to continuous stimulation of actin-myosin filament and cell death. Coronary vasospasm causes cardiac dysfunction. [18] Arrhythmias are common due to increased sympathetic tone and decrease vagal activity. [18]
In the present study 14.86% patients in the ischemic group showed P-R interval prolongation and 11.54% patients of haemorrhagic stroke showed prolonged P-R interval. ST segment elevation was present 05.41% in ischemic CVA. ST segment depression was present 62.16% in ischemic and 65.38% in haemorrhagic CVA. Tall T wave was positive in the 08.11% ischemic group. T wave inversion was present 06.76% in the ischemic group. Among the ischemic group 59.46% showed Q-Tc prolongation and 34.62% haemorrhagic group showed prolonged corrected Q-T interval. The ischemic group 09.46% and the haemorrhagic group 23.08% showed arrhythmia. Tachycardia was present 5.41% in ischemic CVA and 3.85% in haemorrhagic CVA but bradycardia was present in 24.32% and 30.77% respectively.
In studies by Purushothaman et al. [16] Study in 2014, ECG changes were noted in 78% patients. Among the ischemic group, T wave inversion (34.48%), ST segment depression (32.75%), Q-Tc prolongation (29.31%), and presence of U waves (27.58%). In cases of hemorrhagic stroke, it was: T wave inversion (33.33%), arrhythmias (33.33%), U waves (30.95%), and ST segment depression (23.80%). In studies by Togha et al. [6] in 2013 T-wave abnormalities, prolonged Q-Tc interval and arrhythmias, which were respectively found in 39.9%, 32.4%, and 27.1% of the stroke patients. Aro AL:et al. [7] in 2014 revealed that stroke was associated with prolonged PR interval but that not caused increased mortality.
A similar study was done by Familoni et al. [19] in 2006 where QTc prolongation was seen in 43.8% of the cases, T wave inversion in 21.8%, ST segment depression in 29.7%, U wave in 9.3% and arrhythmia in 34.4% of the cases in study group who had no preexisting heart disease.
EGG abnormalities in association with CVA in the vicinity of area 13 (posterior orbitofrontal cortex) on the orbital surface of the frontal lobe or around the circle of Willis, resulted from alteration in sympathetic and parasympathetic tone mediated> by fibres from the orbito frontal area to the heart via the stellate ganglion. Prolonged and intense sympathetic activity on the heart, catecholamine induced injuries, changes in the autonomic functions as a consequence of CVA may result ECG abnormalities, and however acute myocardial damage is unusual. [15],[16],[17],[18]
In the present study bradycardia, arrhythmia, S-T segment depression were more common to haemorrhagic CVA but tachycardia, P-R interval prolongation, S-T segment elevation, T wave abnormality and Q-Tc prolongation were more common in the ischemic group. During statistical comparison of ECG changes of ischemic and haemorrhagic CVA P value was not found to be significant except in case of heart rate similar to the previous study conducted by Dogan et al. [18] in 2004.
| Conclusion | | |
Cerebrovascular accident patients often have abnormal ECG in absence of preexisting known organic heart disease or electrolyte imbalance. ECG changes are identical in ischemic and haemorrhagic CVAs, independent of the nature of accident. The major ECG abnormalities are S-T segment depression, prolonged corrected Q-T interval and abnormalities in heart rate and rhythm. The minor abnormalities are abnormal T wave, P-R interval prolongation, widening of QRS complexes. The patients of acute CVAs in developing countries need to be treated with proper follow-up considering the neurological as well as cardiological complications.
| References | | |
| 1. | Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990-2010: Findings from the Global Burden of Disease Study 2010. Lancet 2014;383:245-54.  |
| 2. | Hamel E. Perivascular nerves and the regulation of cerebrovascular tone. J Appl Physiol 2006;100:1059. |
| 3. | Truelsen T, Heuschmann PU, Bonita R, Arjundas G, Dalal P, Damasceno A, et al. Standard method for developing stroke registers in low-income and middle-income countries: Experiences from a feasibility study of a stepwise approach to stroke surveillance (STEPS Stroke). Lancet Neurol 2007;6:134-9. |
| 4. | Sridharan SE, Unnikrishnan JP, Sukumaran S, Sylaja PN, Nayak SD, Sarma PS, et al. Incidence, types, risk factors, and outcome of stroke in a developing country: The Trivandrum Stroke Registry. Stroke 2009;40:1212-8. |
| 5. | Kim BS, Lee HJ, Kim JH, Jang HS, Bae BS, Kang HJ, et al. Relationship between left atrial size and stroke in patients with sinus rhythm and preserved systolic function. Korean J Intern Med 2009;24:24-32. |
| 6. | Togha M, Sharifpour A, Ashraf H, Moghadam M, Sahraian MA. Electrocardiographic abnormalities in acute cerebrovascular events in patients with/without cardiovascular disease. Ann Indian Acad Neurol 2013;16:66-71. [ PUBMED]  |
| 7. | Aro AL, Anttonen O, Kerola T, Junttila MJ, Tikkanen JT, Rissanen HA, et al. Prognostic significance of prolonged PR interval in the general population. Eur Heart J 2014;35:123-9. |
| 8. | O'Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study. Lancet 2010;376:112-23. [ PUBMED] |
| 9. | Xavier D, O Donnell M, Pais P, Sigamani R, Joshi R, Gupta R, et al. Interstroke Study. Method and Preliminary Results of a Large Stroke Registry from India; 2012. |
| 10. | Kumar HH, Kalra B, Goyal N. A study on stroke and its outcome in young adults (15-45 Years) from coastal South India. Indian J Community Med 2011;36:62-5. |
| 11. | Dalal PM. For the ICASS investigators. Burden of stroke: Indian perspective. Int J Stroke 2006;3:164-6. |
| 12. | Goldberger AL. ECG differential diagnosis. In: Clinical Electrocardiography a Simplified Approach. 7 th ed. Noida: Elsevier; 2007. p. 283-8. |
| 13. | Pandiyan U, Arjundas G, Arjundas D. Risk factors and stroke outcome- An Indian study. Int J Pharm Med Res 2005;16:29-33. |
| 14. | Das SK, Banerjee TK, Biswas A, Roy T, Raut DK, Mukherjee CS, et al. A prospective community-based study of stroke in Kolkata, India. Stroke 2007;38:906-10. |
| 15. | Bozluolcay M, Ince B, Celik Y, Harmanci H, Ilerigelen B, Pelin Z. Electrocardiographic findings and prognosis in ischemic stroke. Neurol India 2003;51:500-2. |
| 16. | Purushothaman S, Salmani D, Prarthana KG, Bandelkar SM, 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. |
| 17. | Khechinashvili G, Asplund K. Electrocardiographic changes in patients with acute stroke: A systematic review. Cerebrovasc Dis 2002;14:67-76. |
| 18. | Dogan A, Tunç E, Oztürk M, Erdemoglu AK. Comparison of electrocardiographic abnormalities in patients with ischemic and hemorrhagic stroke. Anadolu Kardiyol Derg 2004;4:135-40. |
| 19. | Familoni OB, Odusan O, Ogun SA. The pattern and prognostic features of QT intervals and dispersion in patients with acute ischemic stroke. J Natl Med Assoc 2006;98:1758-62. |
[Table 1], [Table 2]
|
Search Pubmed for