European Journal of Cardiovascular Medicine

Hypertension is a leading risk factor for cardiovascular morbidity and mortality, often leading to structural and functional cardiac changes, particularly affecting the left ventricle. Diastolic dysfunction—characterized by impaired relaxation and increased chamber stiffness—can be asymptomatic yet significantly increase the risk of heart failure with preserved ejection fraction (HFpEF), atrial fibrillation, and stroke.

Prevalence of Systemic Hypertension (HTN) in general population is very high in India.  About 33% urban and 25% rural Indians are hypertensive. Of these, 25% rural and 42% urban Indians are aware of their hypertensive status, only 25% rural and 38% of urban Indians are being treated for hypertension [1]. Sizeable numbers of these patients of HTN do get left ventricular diastolic dysfunction (LVDD). Now, out of these patients of left ventricular diastolic dysfunction, many patients may get diastolic heart failure and exercise limitations [2].

Hypertension can lead to various cardiovascular complications like Left ventricular hypertrophy, Congestive heart failure (CHF), Coronary heart disease, Cardiac arrhythmias, Stroke, Peripheral arterial disease, etc. Out of these, one important complication is congestive heart failure (CHF). In many cases, CHF may be related to diastolic dysfunction[3].

Chronic hypertension leads to increased afterload, resulting in left ventricular hypertrophy (LVH), interstitial fibrosis, and impaired myocardial relaxation. These changes elevate left ventricular filling pressures and impair diastolic filling. Clinically, this results in symptoms like exertional dyspnea despite normal systolic function.

Doppler echocardiography is the established method for assessing LVDD, it may not always be available, especially in resource-limited settings. This has stimulated interest in identifying reliable ECG-based markers that correlate with diastolic dysfunction. This review investigates the value of ECG parameters—Tpeak-Tend interval, VAT, PTFV1, and PWD—as non-invasive alternatives or adjuncts to echocardiography in hypertensive patients. [4,5]

So present study was undertaken to asses the efficacy of ECG criteria (Tpeak-Tend interval, VAT, PWD and PTFV1) to screen for left ventricular diastolic dysfunction among hypertensive patients in comparison to echocardiography.

The present Prospective case control study was conducted among 200 patients who were having diastolic dysfunction on 2D Echo at tertiary care centre, Maharasthra. Study period was 24 months from 1st September 2022 to 31st august 2024.

200 Patients with Diastolic Dysfunction On 2D ECHO, out of which 100 were hypertensives and 100 non-hypertensives included in this study. 100 known hypertensive patients were taken in group 1. 100 patients, who underwent 2D Echo for reasons other than hypertension, were included in the group 2.

Patients who were below 18 years and had Congenital heart disease, Valvular heart disease

Ischemic heart disease, Pericardial disease, LVH / RVH (by ECG / Echo), Arrhythmias or conduction abnormalities were excluded.

ECG markers (Tpeak-Tend, VAT, PTFV1 and PWD of all 200 patients calculated. Tp-Te Interval, VAT, PWD and PTFV1, as the ECG markers were studied and compared with diastolic dysfunction assessed by Echocardiography.

Blood Pressure (BP) measurements were performed during the morning session (from 8 am to 12 noon). Sequential BP measurements were performed in a quiet room, after 10 minutes of rest; then after 2hrs, 4hrs and 12 hrs on the same arm and with the participant in the sitting position, by using mercury sphygmo- manometer. The average of three consecutive BP measurements was considered as the systolic/diastolic BP levels.

Echocardiography was done by the standard USFDA approved ACUSON X300 machine and the degree of diastolic dysfunction was noted. Details such as age, gender, treatment for hypertension, symptoms and blood pressure were recorded in the data sheet.

Permission to conduct the study and ethical clearance was obtained from the institutional ethics committee. Written informed consent was taken from patients participating in the study. All patients were explained the concept of assessment of ECG markers and their correlation with 2D-ECHO. Participants were fully informed about the purpose, procedures, benefits and risks of participation in the study.

Statistical Analysis.  Statistical analysis was done using Statistical Package of Social Science (SPSS Version 26; Chicago Inc., USA). Data comparison was done by applying specific statistical tests to find out the statistical significance of the comparisons. Quantitative variables were compared using mean values and qualitative variables using proportions. Significance level was fixed at P < 0.05.

Table 1: Age wise distribution of study subjects in group 1 and group 2.

Table1 reveals age wise distribution of study subjects in group 1 and group 2. 200 Patients with Diastolic Dysfunction On 2D ECHO, out of which 100 were hypertensives and 100 non hypertensives included in this study. 100 known hypertensive patients were taken in group 1. 100 patients, who underwent 2D Echo for reasons other than hypertension, were included in the group 2. All patient were 21- to 68-year-old. There was statistically not significant difference found in age wise distribution of study subjects in group 1 and group 2. (P=0.515)

Table 2: Gender wise distribution of study subjects in group 1 and group 2.

Table2/figure2 reveals Gender wise distribution of study subjects in group 1 and group 2. Out of 200 patients, 116 were male and 84 were female. There was statistically not significant difference found in age wise distribution of study subjects in group 1 and group 2. (P=0.999)

Table 3: Clinical Features among group I & 2 Patients.

*- Significant

Table3 reveals clinical Features among group I & 2 Patients. Persistent headache, Shortness of breath, Fatigue, blurring of vision, Giddiness, Nasal bleeding Diaphoresis were common clinical features found among patients. Shortness of breath, Fatigue, blurring of vision, Giddiness were found more among group 2 as compare to group 1 while Persistent headache & nasal bleeding were more common among group 1 patients.

Table 4: Grade of Diastolic dysfunction'

Table 5: Comparative evaluation of ECG Markers in group 1 and group 2.

Table 6 reveals Sensitivity and Specificity of all four ECG markers. Tpeak - Tend Interval & PTFV1 had highest sensitivity i.e.71.0% as compare to other markers which is followed by VAT (68.0%) and then by PWD (62.0%). PWD had highest specificity (76.0%) which is followed by Tpeak - Tend Interval (74.0%). PTFV1 had least 70.0% specificity.

Table 6 reveals Sensitivity and Specificity of all four ECG markers. Tpeak - Tend Interval & PTFV1 had highest sensitivity i.e.71.0% as compare to other markers which is followed by VAT (68.0%) and then by PWD (62.0%). PWD had highest specificity (76.0%) which is followed by Tpeak - Tend Interval (74.0%). PTFV1 had least 70.0% specificity.

After doing extensive web search, it appears that this is the first prospective cross sectional case control study, in which all four electrocardiography (ECG) markers, i.e., Tpeak-Tend interval, VAT , PTFV1 and PWD are used for evaluation of diastolic dysfunction. As we know from invention of 2D- Echocardiography, we depend on 2D Echocardiography for diagnosis of diastolic dysfunction. However, due to unavailability of 2D-Echocardiography machine in rural setup and cost issues these ECG markers can be used for diagnosis of diastolic dysfunction.

Since hypertension, in early stage, is an asymptomatic and insidious disease, early ECG signs for cardiac electrical remodeling provide a wealth of information for disease stratification and therapeutic considerations. Furthermore, this diastolic dysfunction is mostly an asymptomatic variant that gets estimated whenever patient undergoes 2D-Echocardiography. Hence, these four ECG markers will be helpful for early detection of diastolic dysfunction in hypertensive patient and add on benefit being far cheaper and noninvasive investigation as compared to 2D-Echocardiography. Also, it will be helpful as a screening tool at the rural level for diagnosis of diastolic dysfunction in hypertensive patients.

At present, in India, ECG markers are not routinely used for diagnosing diastolic heart dysfunction. In our study we found that all four ECG markers have better sensitivity and specificity for diagnosing diastolic dysfunction in hypertensive patients. In this discussion part, we will compare results of this study of all four ECG markers with previous studies done by other workers.

Andrew J Sauer, Jane E Wilcox, et al.[6] hypothesized that the ECG T-peak to T-end (TpTe) interval, represents trans-mural dispersion of repolarization, and was associated with echocardiographic markers of diastolic dysfunction (DD). They performed a prospective, cross-sectional study of the association between Tpeak-Tend (TpTe) interval and markers of diastolic dysfunction in 84 consecutive, unselected patients referred for exercise echocardiography. They found that Increased TpTe is associated with both resting and exercise-induced DD. They found that, electromechanical coupling may represent a pathophysiologic link between electrical transmural dispersion of repolarization and abnormal myocardial relaxation, and may be a novel therapeutic target.

In the present study, we studied 100 hypertensive patients (Group 1) and 100 non hypertensive patients (Group 2) having diastolic dysfunction. We found that Tpeak-Tend interval had sensitivity of 71 % and specificity of 70 % for mean Tpeak-Tend interval of 96.94ms and p values < 0.001. Also the results of our study are comparable with study done by Andrea Ferrucci, et al. [7]. So, this marker is found useful in detecting diastolic dysfunction in hypertensive patients.

Venkatesh G and Krishnamurthy U et al.[8] studied R and S wave voltages of electrocardiogram in smokers and alcoholics. Their study stated that Ventricular activation time (VAT) is the time taken for the impulse to traverse the myocardium from the endocardial to the epicardial surface. Hence, prolonged VAT denotes the diastolic dysfunction. In this study, VAT was found to be increased in the study groups, indicating the presence of diastolic dysfunction in asymptomatic alcoholics and smokers.

Choong CY, Herrmann HC, Weyman et al. [9] hypothesized that trans- mitral velocities in trans-mitral doppler (TMD) studies are influenced by pressure preload whereas tissue Doppler image (TDI) values are far less affected by it. If so, the strong negative relationship between ventricular activation time (VAT) and the TDI parameters such as e′ and e′/a′ support their hypothesis that a prolongation of VAT is an independent marker of diastolic dysfunction (DD) in patients with hypertension. Moreover, VAT increased with E/e′, a ratio that estimates left ventricular (LV) filling pressure, an indicator of diastolic filling abnormalities, thus providing further evidence of a relationship between VAT and diastolic dysfunction (DD).

In the present study, we found that Ventricular Activation Time had sensitivity of 68 % and specificity of 72% and mean VAT of 42.10ms and p values < 0.001. Also the results of our study are comparable with the studies done by Choong CY et al.[9] and by Boles U, et al.[10]. Therefore, this marker is also useful in detecting diastolic dysfunction in hypertensive patients.

Lee E, Michaels AD, Schindler D et al.[11] proposed that a P wave terminal force in lead V1 (PTFV1) of more than minus 40 mm/ms would theoretically reflect left atrial (LA) geometric changes in diastolic dysfunction due to delayed electrical propagation in the atrial tissue. P-wave amplitude and duration together (in PTFV1) have superior diagnostic value in assessing left ventricular (LV) end-diastolic pressure and hence diastolic dysfunction than P- wave duration only.

Brown et al. [12] studied PTFV1, as an ECG marker, and compared with diastolic parameters assessed by echocardiography. The patient cohort included previously undiagnosed hypertensives who were screened by echocardiography for diastolic dysfunction. Those who had diastolic dysfunction were investigated further using PTFV1 on the surface ECG. Echo parameters for diastolic dysfunction were statistically significant with PTFV1 ≥40 mm/ms with a sensitivity of 62% and specificity of 75%. Their study highlights the potential role of PTFV1 in diagnosing DD in hypertensive subjects, in the early phases.

In the present study, we found that hypertensive group had sensitivity of 71% and specificity of 70 % and mean PTFV1 of 46.40ms and p values < 0.001. These results of our study are comparable with the study done by Liu G, et al. [13] and by Brown et al. [12]. Hence, this marker too is useful in detecting diastolic dysfunction in hypertensive patients.

Asif Zaman Tushar, AAS Majumder, STM Abu Azam, Mohammad Ullah et al.[14] studied 100 patients: 50 with diastolic dysfunction and 50 without diastolic dysfunction. P wave dispersions were calculated by measuring difference between minimum and maximum P wave duration values on the surface electrocardiogram. The relationships between P wave dispersion and echocardiographic measurements of diastolic dysfunction were assessed. Maximum P wave duration was observed significantly (p=0.001) in patients with left ventricular diastolic dysfunction (119.60±8.2 ms vs 114.0±6.4 ms). Minimum P wave duration was observed significantly (p=0.001) higher in patients without diastolic dysfunction (72.6±7.5 ms vs 62.70±7.4 ms). P wave dispersion was observed significantly (p=0.001) higher in patients with left ventricular diastolic dysfunction (56.6±6.3 ms vs 41.5±5.2 ms). When patients were grouped according to grades of diastolic dysfunction, P wave dispersion was observed sequentially increased among 3 grades of left ventricular diastolic dysfunction (55.8±5.2 ms vs 55.9±7.0 ms vs 61.4±4.7); but the differences were not statistically significant (p=0.09). From their study they concluded that, left ventricular diastolic dysfunction is associated with increased P wave dispersion in patients with ischemic heart disease. There is a positive correlation between P wave dispersion and left ventricular diastolic dysfunction (LVDD). So, keen observation of P wave dispersion in surface ECG is needed which is a cheap, easily available tool, can help us in predicting left ventricular diastolic dysfunction in patients with ischemic heart disease.

Dilaveris PE, Gialafos EJ, Andrikopoulos GK et al [15] 2000, proposed that P - Wave Dispersion (PWD) has been extensively studied in various cardiovascular and non-cardiac conditions. At present, PWD is an established non-invasive marker for risk of developing atrial fibrillation.

In the present study, we found that P Wave Dispersion had sensitivity of 62% and specificity of 72% and mean P Wave Dispersion of 46.54ms and p values < 0.001. Also, these results of our study are comparable with study done by Asif Zaman Tushar, et al.[14] and those done by Dogan et al.[16] Thus, this marker was found useful in detecting diastolic dysfunction in hypertensive patients.

Although echocardiography remains the definitive modality for evaluating left ventricular diastolic dysfunction, certain ECG markers—Tpeak-Tend, VAT, PTFV1, and PWD—hold significant promise as accessible, cost-effective tools in the early identification and monitoring of diastolic dysfunction in hypertensive patients. Used judiciously and in combination, these parameters can serve as valuable adjuncts to echocardiographic assessment, especially in resource-constrained settings.

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