Electrocardiographic QRS Axis Shift ,Rotation and COVİD-19

Retrospective Evaluation of Electrocardiographic Findings of Right Ventricular Overload in Covid 19 Patients With Respiratory Distress

In patients with coronavirus disease (COVID-19), severe dyspnea is the most dramatic complication.Severe respiratory difficulties may include electrocardiographic frontal QRS axis rightward shift (Rws) and clockwise rotation (Cwr).

This study investigated the predictability of advanced lung tomography findings with QRS axis shift and rotation.

This was a retrospective analysis of 160 patients.The patients were divided into two groups: normal oxygen saturation(SpO2) (NS; n = 80) and low SpO2(LS;n = 80).They were then divided into NS Rws (n = 37), NS leftward shift (Lws; n = 43), LS Rws (n = 40), and LS Lws (n = 40) according to electrocardiographic follow-up findings. These groups were compared in terms of electrocardiographic rotation (Cwr, counterclockwise rotation, or normal transition), tomographic stage (CO-RADS5(advanced)/CO-RADS1-4), electrocardiographic intervals, and laboratory findings

Study Overview

• Status: Completed
• Conditions: Covid19
• Intervention / Treatment: Diagnostic test: Electrocardiography ,Tomographic imaging

Detailed Description

The lung is the most seriously damaged organ in patients with coronavirus disease (COVID-19). In patients with advanced lung involvement, the alveoli are filled with fluid, white blood cells, mucus, and damaged lung cell debris [1].

The electrical position of the heart in the frontal plane is defined as normal, right, left, or northwest quadrant axis deviation, while its position in the horizontal plane is defined as clockwise rotation (Cwr), normal transition, or counterclockwise rotation (Ccwr)[2].

As respiratory disease progresses,rightward shift(Rws) of the frontal QRS axis can result from Cwr of the heart around its longitudinal axis as viewed from the apex, sudden increase in pulmonary vascular resistance causing right ventricle dilatation, or both [3].

Electrocardiographic changes should be monitored intermittently, as this disease progresses rapidly to near 50% mortality within 7-28 days [4].The aim of this study was to investigate whether easily detectable electrocardiographic axis and rotation changes could predict advanced lung involvement[4].

Methods Study design Records of 250 hospitalized patients with dyspnea and COVID-19 were analyzed retrospectively.Patients were excluded if they received positive pressurized oxygen therapy(n:25),underwent mechanical ventilation,(n:15)exhibited atrial fibrillation(n:10), conditions precluding the assessment of QRS transitional rotation ;complete bundle branch block(n:10), significant arrhythmias(n:5,complete atrioventricular block(n:2), polymorphic ventricular tachycardia(n:2), and ventricular fibrillation), Wolff-Parkinson-White syndrome(n:1), supraventricular tachycardia(n:4), or had unclear QRS axis orientation(n:20). The remaining160 patients who had electronic medical records, nursing records,at least three electrocardiographic recordings taken a few days apart, and laboratory and tomographic findings were included in the study.Patients with normal oxygen saturation (SpO2; ≥ 90%) who did not receive oxygen therapy and patients with low SpO2(<90%) who received nasal oxygen therapy were included in this study. Patients were divided into two groups: normal SpO2(NS,n = 80) and low SpO2(LS, n = 80).

Electrocardiographic measurements were performed as previously described.The Tpe (T peak to T end) interval was measured from precordial leads [5].The delta corrected QT interval(QTc) calculated as last electrocardiographic QTc minus first electrocardiographic QTc. Discrepancies between computerized electrocardiographic analysis and the mean of three computer-aided measurements(Adobe Photoshop program-300dpi resolution) by a researcher were resolved by consultation with a second researcher.

Using follow-up electrocardiography,according to the direction of QRS axis shift between the first and last electrocardiograms, both groups were divided into two main subgroups:patients with rightward shift (Rws) and patients with leftward shift(Lws) of the QRS axis.The patient numbers were as follows: NS Rws (n=37),NS Lws(n=43),LS Rws (n=40),andLS Lws (n=40). Based on electrocardiographic follow-up analyses,the two main groups were compared in terms of rotation condition (i.e., Cwr, normal transition, or CCwr), electrocardiographic intervals, and laboratory findings

Tomographic findings were evaluated in accordance with COVID-19 Reporting and Data System (CO-RADS)classification.CO-RADS scores are as follows: 1 (very low level of suspicion), 2 (low level of suspicion), 3 (equivocal), 4 (high level of suspicion),and 5 (very high level of suspicion)[6].

• Study Type: Observational
• Enrollment (Actual): 160

Contacts and Locations

Study Locations

• Turkey
  • Ankara, Turkey, 06530
    • Şahbender Koç

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: ADULT; OLDER_ADULT; CHILD
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Hospitalized patients with dyspnea and COVID-19

Description

Inclusion Criteria:

Hospitalized patients with dyspnea and COVID-19

Exclusion Criteria:

Patients who received positive pressurized oxygen therapy Patients who underwent mechanical ventilation, Atrial fibrillation Complete bundle branch block Significant arrhythmias(complete atrioventricular block, polymorphic ventricular tachycardia, and ventricular fibrillation), Wolff-Parkinson-White syndrome, supraventricular tachycardia Unclear QRS axis orientation.

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Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Group1:normal SpO2(NS,n = 80) and low SpO2(LS, n = 80).; Patients with normal oxygen saturation (SpO2; ≥ 90%) who did not receive oxygen therapy and patients with low SpO2(<90%) who received nasal oxygen therapy were included in this study	Diagnostic test: Electrocardiography ,Tomographic imaging; Based on electrocardiographic follow-up analyses,the two main groups were compared in terms of rotation condition (i.e., Cwr, normal transition, or CCwr), electrocardiographic intervals, and laboratory findings In our study,CO-RADS5 was considered an advanced tomographic finding(e.g., multifocal ground glass opacities with consolidation, vascular thickening,crazy paving pattern,mixed pattern),while CO-RADS1,2,3, and 4 were considered non-advanced tomographic findings.
Group2:Rightward axis shift(Rws) and Leftward axis shift (Lws); Both groups were divided into two main subgroups:patients with Rws and patients with leftward shift(Lws) of the QRS axis.The patient numbers were as follows: NS Rws (n=37),NS Lws(n=43),LS Rws (n=40),andLS Lws (n=40)	Diagnostic test: Electrocardiography ,Tomographic imaging; Based on electrocardiographic follow-up analyses,the two main groups were compared in terms of rotation condition (i.e., Cwr, normal transition, or CCwr), electrocardiographic intervals, and laboratory findings In our study,CO-RADS5 was considered an advanced tomographic finding(e.g., multifocal ground glass opacities with consolidation, vascular thickening,crazy paving pattern,mixed pattern),while CO-RADS1,2,3, and 4 were considered non-advanced tomographic findings.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Differences in the electrocardiographic QRS axis shift(°),	Differences in the axis shift between the Rws and Lws groups in patients with NS /LS groups.	10-15 days
Differences in the electrocardiographic rotation	Differences in clockwise,counterclockwise,normal transition between the groups.	10-15 days
Differences in the CO-RADS5/CO-RADS1-4 ratio	Differences in the CO-RADS5/CO-RADS1-4 ratio between the groups.	10-15 days

Collaborators and Investigators

• Sponsor: Ankara Education and Research Hospital
• Investigators: Principal Investigator: Şahbender Koç, University of Health Sciences Ankara Keçiören Education Hospital

Publications and helpful links

General Publications

• Koc S, Bozkaya VO, Yikilgan AB. Electrocardiographic QRS axis shift, rotation and COVID-19. Niger J Clin Pract. 2022 Apr;25(4):415-424. doi: 10.4103/njcp.njcp_9_21.

Study record dates

Study Major Dates

• Study Start (ACTUAL): July 22, 2020
• Primary Completion (ACTUAL): October 15, 2020
• Study Completion (ACTUAL): November 5, 2020

Study Registration Dates

• First Submitted: January 4, 2021
• First Submitted That Met QC Criteria: January 5, 2021
• First Posted (ACTUAL): January 6, 2021

Study Record Updates

• Last Update Posted (ACTUAL): January 6, 2021
• Last Update Submitted That Met QC Criteria: January 5, 2021
• Last Verified: January 1, 2021

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Coronavirus Infections; Coronaviridae Infections; Nidovirales Infections; RNA Virus Infections; Virus Diseases; Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Pneumonia, Viral; Pneumonia; Lung Diseases; COVID-19
• Other Study ID Numbers: 22/7/2020-2152

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No