European Journal of Cardiovascular Medicine

COPD, as defined by GOLD 2023, is a lung condition that is characterised by chronic respiratory symptoms such as dyspnoea, cough, expectoration, and exacerbations. These symptoms are caused by abnormalities in the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema), which result in persistent and often progressive airflow obstruction (1). Airflow blockage is characterised by a forced expiratory volume in one second to forced vital capacity ratio (FEV1/FVC) of less than 0.70. FEV1 is classified as Mild when it is greater than 80% of the predicted value, Moderate when it is between 50% and 80% of the predicted value, Severe when it is between 30% and 50% of the projected value, and Very Severe when it is less than 30% of the predicted value. In 2019, Chronic obstructive pulmonary disease (COPD) resulted in 3 million fatalities globally, making it the third most common cause of death (2). Cardiovascular diseases (CVDs) are a major health issue that often occurs alongside chronic obstructive pulmonary disease (COPD) and greatly increases the chance of death (3). Ischaemic heart disease (IHD), heart failure, and arrhythmias are often observed as cardiovascular diseases (CVDs) in patients with chronic obstructive pulmonary disease (COPD). The incidence rates of ischaemic heart disease (IHD), heart failure, and arrhythmias in individuals with chronic obstructive pulmonary disease (COPD) range from 19% to 61%, 11% to 31%, and 9% to 16%, respectively, depending on the specific characteristics of the research population (4,5,6). The prevalence of cardiovascular disease (CVD) was much greater in patients with chronic obstructive pulmonary disease (COPD) compared to those without COPD. Specifically, 59.7% of COPD patients had CVD, while only 28.5% of non-COPD patients had CVD (7). COPD can cause a range of abnormalities in the structure and blood flow of the heart, which can in turn affect several aspects of the electrocardiogram (ECG). The main causes of ECG changes in patients with COPD are increased airway obstruction, higher pressure on the right side of the heart, displacement of the diaphragm due to excessive inflation of the lungs, rotation of the right side of the heart in a clockwise direction, and changes in body mass index that are associated with clockwise rotation of the QRS-vector in the front of the heart (8,9). The objective of our study was to examine the alterations in electrocardiography among patients with chronic obstructive pulmonary disease (COPD) and to establish a correlation between ECG findings and the severity of COPD based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Criteria.

This is a cross sectional, observational study done in patients who attended OPD and admitted in wards in department of General Medicine and department of Pulmonary Medicine in Maharajah Institute of Medical Sciences, Vizianagaram.

Study Design:  Cross sectional, Observational study.

Study Setting: Maharajah Institute of Medical Sciences, Vizianagaram, Andhra Pradesh

Study Population: Patients who attended OPD and admittedin wards in the department of General Medicine and department of Pulmonary Medicine in Maharajah Institute of Medical Sciences,a tertiary care hospital, Vizianagaram during january 2021 to March 2022

Sample size – 75

Inclusion Criteria: patients aged >40 years, diagnosed with COPD based on symptoms and confirmed by pulmonary function test.

Exclusion criteria- Bronchial asthma, OSA, Bronchiectasis,ILD and tuberculous obstructive airway disease (TOPD),previous lung surgery, Known cardiac diseases and Hypertension.

Study Duration: 15months, From January 2021 to march2022.

Data Collection -After getting approval from Institutional Ethical committee and taking prior consent, data of all patients who were diagnosed to have COPD fulfilling inclusion criteria duringJanuary 2021 to March 2022 who attended OPD and admitted in wards in department of General medicine and department of Pulmonary medicine inMaharajah Institute of Medical Sciences, Vizianagaram was collected. Data related to History, ECG, Pulmonary function tests, Chest x-ray, and routine blood investigation were collected. 

Statistical Analysis:  The collected data was analysed using SPSS version 21 statistical software. Results were expressed as proportions using appropriate tables and figures.

In our study most of the patients belong to age group of 51-70 years (73.2%), most common in 61- 70 years (38.6%) with male preponderance (85.3%). 59 of 64 males were smokers and 4 of 11 females has history of smoking. (Table -1)

In our study Mild, Moderate, Severe, and Very severe disease of COPD cases were observed in 6%, 30.6%, 40%, and 22.6% respectively (Table -2) 

Out of 75 patients, 44 patients (58.5%) have ECG abnormalities. ECG changes were observed in 20%, 43.4%, 60%, and 88.2 % in Mild, moderate, severe, and very severe COPD cases respectively(Table -3) 

The most common ECG abnormality was RAD (Right Axis Deviation) (41.3 %), followed by RVH and low voltage complexes in 36% each, P pulmonale in 33.3%, RBBB in 16%and Multifocal atrial tachycardia was observed in 5.3 % of patients. (Table -4)

In patients with mild COPD, only one patient out of 5 had ECG changes (RAD and RVH), in moderateCOPD, RAD is the most common ECG abnormality seenin 6 of 23 (26.08%),  in severe cases RAD, RVH, and Low voltage complexes are seen in10 of 30(33.3%) each. In very severe cases 88.2% had ECG changes (Table -5) 

Overall the most common ECG abnormality is RAD in  31 patients of a total 75(41.3%). MAT is seen in 4 patients of 75 (5.3%), increasing prevalence with disease severityie, 3.3% in severe and 17.6% in very severe cases. NO patient has MAT in mild-moderate cases.

This is a cross-sectional observational study in COPD patients, to studythe ECG changes.In our study most of the patients belong to the age group of 51-70 years (73.2%), which is in concordance with studies done by Srinivasulu M et al (10), Krishna Appaji CS et al (11), Verma L et al (12). most common age group is 61- 70 years (38.6%). Malepreponderance (85.3%) is seen with a male:female ratio of 5.84:1 which is similar to Srinivasulu M et al (10), Krishna Appaji CS et al (11) and discordant with Pal A et al (13)where males were male at 61.5%.84% of the total study population were smokers, 59 of 64 males were smokers (92.18%),and 4 of 11 (36.36%) females hada history of smoking of which 3 of them were reverse smokers.Another study has 71% of smokers (12).

Based on the severity according to GOLD criteria, our study has the highest number in severe criteria accounting for 40% which is in concordance with studies (10,12,13)and is discordant with a study by Musku MR et al (14) where moderate severity was the most common accounting to 44%. Our study has a moderate severity of 30.6%.

In our study, ECG changes are more common as the severity increases. out of 75 patients, 44 patients (58.5%) have ECG changes. ECG changes were observed in 20%, 43.4%, 60%, and 88.2 % of Mild, moderate, severe, and very severe COPD cases respectivelysimilar to other studies by Verma L et al (12), Jatav VS et al(15).  The most common ECG abnormality was RAD (Right Axis Deviation) (41.3 %), followed by RVH and low voltage complexes in 36%in the present study which is similar to the study done by Singhal S et al(16) (28%) where RAD was the most common, but other studies (13,14,16)P pulmonale was the most common ECG finding and in afew studies(10,12) RVH was the most common ECG abnormality.Multifocal atrial tachycardiawas seen in 4 patients out of 75 (5.3%) in the present study which is comparable to the results in another study by Nalabothu SK et al (17) MAT seen in 2%.

Correlating COPD severity with ECG changes,in patients with mild COPD only one patient out of 5 had ECG changes ( RAD and RVH), in moderate COPD, RAD is the most common ECG abnormality seen in 6 of 23 (26.08%),  in severe cases RAD, RVH and Low voltage complexes are seen in10 of 30(33.3%) each. In very severe cases 88.2% had ECG changes.MAT is seen in 4 patients out of 75 (5.3%), increasing prevalence with disease severity ie. 3.3% in severe and 17.6% in very severe cases. None of the patients had MAT in mild-moderate cases. As the COPD severity progresses, the ECG changes also increasedwhich is concordant with other studies(12,15).

COPD is a common condition in patients with smoking and is associated with ECG abnormalities. RAD (Right Axis Deviation) is the most common ECG change observed in the study.  As the severity of the disease increases, ECG abnormalities become more common. All patients should undergo ECG to prevent cardiovascular morbidity and mortality.

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