Electrocardiographic markers of abnormal left ventricular wall motion in acute subarachnoid hemorrhage

Abstract

A reversible and presumably neurogenic form of myocardial dysfunction may occur following subarachnoid hemorrhage (SAH), but the relationship of this finding to electrocardiographic abnormalities remains unclear. To clarify this issue, serial electrocardiograms (ECGs, mean 6.2 per patient) and echocardiograms (mean 3.4 days after SAH) were obtained in 57 SAH patients without preexisting cardiac disease. The goal was to determine which specific electrocardiographic changes, if any, reflect abnormal left ventricular wall motion in acute SAH. Wall motion abnormalities were identified in five (8%) of 57 patients. Four of these affected patients experienced hypotension (systolic blood pressure < 100 mm Hg) and three exhibited pulmonary edema within 6 hours of SAH, compared to none of the 52 patients with normal wall motion (p < 0.0001). Patients with abnormal wall motion were more likely than patients with normal echocardiograms to have symmetrical T wave inversion (five of five vs. seven of 52, p < 0.001) and severe (> or = 500 msec) QTc segment prolongation (five of five vs. three of 52, p < 0.001) on serial ECGs. These associations maintained their significance with analysis limited to single ECGs performed on or near the day of echocardiography. Abnormal wall motion was also associated with borderline (2% to 5%) creatine kinase MB elevation (five of five vs. three of 52, p < 0.001) and poor neurological grade (p < 0.0001). Although no combination of findings on a single ECG resulted in 100% sensitivity for abnormal wall motion, the presence of either inverted T waves or severe QTc segment prolongation on serial ECGs was associated with 100% sensitivity and 81% specificity. These results demonstrate an association between reduced left ventricular systolic function, mild creatine kinase MB elevation, and electrocardiographic repolarization abnormalities in acute SAH. Symmetrical T wave inversion and severe QTc segment prolongation best identified patients at risk for myocardial dysfunction and may serve as useful criteria for echocardiographic screening following SAH.

Electrocardiographic Changes in Patients with Acute Stroke: A Systematic Review

“…From the reports, it was not possible to determine if echocardiography and ECG findings indicated the same localization of myocardial lesions. In total, cardiac wall motion abnormalities by echocardiography were detected in 13% (95 CI 7–23) of SAH patients without previous cardiac disorders [4, 13]. Data on the coexistence of specific ECG changes and cardiac wall motion abnormalities detected by echocardiography were not available for other subtypes of stroke.…”

“…Comparison of ECG changes with other cardiac investigations and symptoms were presented in 11 studies, including cardiac wall motion abnormality detected by echocardiography in 2 studies [4, 13], biochemical markers of myocardial damage in 6 studies (CK in 4 [8, 9, 26, 32], CK-MB in 1 [20]and cardiac troponin-I in 1 [11]), autopsy findings in 2 [10, 35]and chest pain in 1 study [28]. One article reported data on the coexistence of ECG abnormalities with cardiac abnormalities, detected by thallium-201 scintigraphy in SAH patients [41].…”

“…The vast majority of articles fulfilling the inclusion criteria described ECG changes in patients with SAH only [4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26]. Two articles were restricted to patients with CI only [27, 28], 1 article to patients with ICH only [29]and 1 article to patients with TIA only [30].…”

“…Ischemic-like ECG changes suspicious of cardiac damage may cause undue delay of mobilization and rehabilitation after a stroke or a delay of surgical interventions in patients with SAH. Correct diagnosis of myocardial infarction or angina pectoris is complicated by the fact that clinical symptoms or patient complaints like chest pain do not usually accompany myocardial damage in acute stroke [4, 5]. …”

Cardiac Arrhythmias after Subarachnoid Hemorrhage: Risk Factors and Impact on Outcome

“…Electrocardiogram (ECG) changes, including P wave abnormalities, prolonged QTc interval, ST segment and T-wave changes, occur in over 50% of patients [1,2,3], often in the first few days after SAH onset, and are associated with poor neurologic grade on admission [4]. …”