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An electrocardiographic score to predict pulmonary hypertension in children with atrial septal defect
Indah K Murni1,2, Taichi Kato3, Muhammad Taufik Wirawan4
1Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia. indah.kartika.m@ugm.ac.id.
Insights
A new electrocardiogram (ECG) score can predict pulmonary hypertension (PH) in children with atrial septal defect (ASD). This simple tool aids in identifying high-risk patients in resource-limited settings.
Area of Science:
- Cardiology
- Pediatrics
- Medical Diagnostics
Background:
- Pulmonary hypertension (PH) in children with atrial septal defect (ASD) requires timely intervention, especially in resource-limited settings where advanced diagnostics are scarce.
- Predicting PH is crucial for prioritizing ASD closure and preventing complications.
- Currently, no scoring system exists to predict PH in pediatric ASD patients using readily available methods like ECG.
Purpose of the Study:
- To develop and validate a prediction score for pulmonary hypertension (PH) in children with atrial septal defect (ASD) using electrocardiography (ECG) parameters.
- To provide a simple, accessible tool for PH risk assessment in resource-limited environments.
Main Methods:
- A cross-sectional study was conducted on 144 children with newly diagnosed isolated ASD in Indonesia (2016-2018).
- Medical records, including ECGs, were reviewed. ASD and PH diagnoses were confirmed via echocardiography and/or cardiac catheterization.
- A PH prediction score was developed using the Spiegelhalter Knill-Jones approach and validated with ROC curve analysis.
Main Results:
- Out of 144 children, 50 (34.7%) had PH.
- Key ECG predictors identified included QRS axis ≥120°, P wave ≥3mm (Lead II), R without S (V1), Q wave (V1), right bundle branch block (RBBB), and specific R/S wave criteria in V1, V2, aVR, V6, and Lead I.
- The prediction score achieved an Area Under the Curve (AUC) of 0.908, demonstrating high accuracy (sensitivity 76%, specificity 96.8%) with a cut-off of 3.5.
Conclusions:
- A simple electrocardiographic score, incorporating specific ECG parameters, can effectively predict the presence of PH in children with ASD.
- The developed score demonstrates moderate sensitivity and high specificity for PH prediction.
- This ECG-based score offers a valuable, accessible tool for risk stratification in pediatric ASD patients, particularly in settings with limited diagnostic capabilities.
Background:
In limited resource settings, identification of factors that predict the occurrence of pulmonary hypertension(PH) in children with atrial septal defect(ASD) is important to decide which patients should be prioritized for defect closure to prevent complication. Echocardiography and cardiac catheterization are not widely available in such settings. No scoring system has been proposed to predict PH among children with ASD. We aimed to develop a PH prediction score using electrocardiography parameters for children with ASD in Indonesia.
Methods:
A cross-sectional study reviewing medical record including ECG record was conducted among all children with newly diagnosed isolated ASD admitted to Dr Sardjito Hospital in Yogyakarta, Indonesia during 2016-2018. Diagnosis of ASD and PH was confirmed through echocardiography and/or cardiac catheterization. Spiegelhalter Knill-Jones approach was used to develop PH prediction score. Accuracy of prediction score was performed using a receiver operating characteristic (ROC) curve.
Results:
Of 144 children, 50(34.7%) had PH. Predictors of pulmonary hypertension were QRS axis ≥120°, P wave ≥ 3 mm at lead II, R without S at V1, Q wave at V1, right bundle branch block (RBBB), R wave at V1, V2 or aVR > normal limit and S wave at V6 or lead I > normal limit. ROC curve from prediction scores yielded an area under the curve (AUC) 0.908(95% CI 0.85-0.96). Using the cut-off value 3.5, this PH prediction score had sensitivity of 76%(61.8-86.9), specificity 96.8%(91.0-99.3), positive predictive value 92.7%(80.5-97.5), negative predictive value 88.4%(82.2-92.6), and positive likelihood ratio 23.8(7.7-73.3).
Conclusions:
A presence of PH in children with ASD can be predicted by the simple electrocardiographic score including QRS axis ≥120°, P wave ≥3 mm at lead II, R without S at V1, Q wave at V1, RBBB, R wave at V1, V2 or aVR > normal limit and S wave at V6 or lead I > normal limit. A total score ≥ 3.5 shows a moderate sensitivity and high specificity to predict PH among children with ASD.
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