Cardiovascular Journal of Africa: Vol 28 No 6 (November/December 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 6, November/December 2017 370 AFRICA
Prevalence and predictive value of electrocardiographic
abnormalities in pulmonary hypertension: evidence
from the Pan-African Pulmonary Hypertension Cohort
(PAPUCO) study
Irina Balieva, Anastase Dzudie, Friedrich Thienemann, Ana O Mocumbi, Kamilu Karaye, Mahmoud U
Sani, Okechukwu S Ogah, Adriaan A Voors, Andre Pascal Kengne, Karen Sliwa
Abstract
Background: Pulmonary hypertension (PH) is prevalent in
Africa and is still often diagnosed only at an advanced stage,
therefore it is associated with poor quality of life and survival
rates. In resource-limited settings, we assessed the diagnostic
utility of standard 12-lead electrocardiograms (ECG) to
detect abnormalities indicating PH.
Methods: Sixty-five patients diagnosed with PH were
compared with 285 heart disease-free subjects. The prevalence
and diagnostic performance of ECG features indicative of
PH and right heart strain were calculated.
Results: Compared to the control group, all abnormalities
were more frequent in the PH cohort where no patient had
a completely normal ECG. The most prevalent (cases vs
control) ECG abnormalities were: pathological Q wave in
at least two contiguous peripheral leads (47.7 vs 6.7%), left
ventricular hypertrophy (38.5 vs 9.8%) and p-pulmonale
(36.9 vs 20.7%) (all p < 0.05). The sensitivity of ECG criteria
for right heart strain ranged between 6.2 and 47.7%, while
specificity ranged between 79.3 and 100%. Negative predictive
value ranged between 81.5 and 88.9% and positive predictive
value between 25 and 100%. Positive predictive value was
lowest (25%) for right bundle branch block and QRS right-
axis deviation (≥ 100°), and highest (100%) for QRS axis ≥
+100° combined with R/S ratio in V1 ≥ 1 or R in V1 > 7 mm.
Conclusion: When present, signs of PH on ECG strongly
indicated disease, but a normal ECG cannot rule out disease.
ECG patterns focusing on the R and S amplitude in V1 and
right-axis deviation had good specificity and negative predic-
tive values for PH, and warrant further investigation with
echocardiography.
Keywords: pulmonary hypertension, electrocardiogram, sub-
Saharan Africa, screening
Submitted 27/5/16, accepted 4/4/17
Published online 11/10/17
Cardiovasc J Afr 2017; 28: 370–376
DOI: 10.5830/CVJA-2017-020
Pulmonary hypertension (PH) is a worldwide public health
challenge with an estimated population of affected people in
resource-limited countries of 20 to 25 million in 2008.1,2 Based
on shared pathophysiology and disease mechanisms, the World
Health Organisation (WHO) and the 5th World Symposium on
Pulmonary Hypertension distinguish five groups of PH: arterial
Hatter Institute for Cardiovascular Research in Africa, SAMRC
Cape Heart Centre, IDM, Department of Medicine, Faculty of
Health Sciences, University of Cape Town, South Africa
Irina Balieva, BSc (med),
Anastase Dzudie, MD, PhD, FESC
Friedrich Thienemann, MD, PhD
Mahmoud U Sani, MB BS, PhD, FWACP, FACC
Andre Pascal Kengne, MD, PhD
Karen Sliwa, MD, PhD, FESC, FACC
University of Groningen, Groningen, the Netherlands
Irina Balieva, BSc (med),
Adriaan A Voors, MD, PhD
Department of Internal Medicine, Douala General Hospital,
Douala, Cameroon; NIH Millennium Fogarty Chronic
Disease Leadership Programme
Anastase Dzudie, MD, PhD, FESC
Soweto Cardiovascular Research Heart Unit (SOCRU),
Department of Medicine, University of the Witwatersrand,
Johannesburg, South Africa
Anastase Dzudie, MD, PhD, FESC
Karen Sliwa, MD, PhD, FESC, FACC
Clinical Infectious Diseases Research Initiative, IDM,
University of Cape Town; Integerafrica Research and
Development, Cape Town; Wellcome Centre Infectious
Diseases Research in Africa, Institue of Infectious
Diseases and Molecular Medicine, Cape Town; and
Department of Medicine, Groote Schuur Hospital, Faculty
of Health Sciences, University of Cape Town, South Africa
Friedrich Thienemann, MD, PhD
Instituto Nacional de Saúde; Faculty of Medicine, Eduardo
Mondlane University, Maputo, Mozambique
Ana O Mocumbi, MD, PhD, FESC
Department of Medicine, Bayero University, Kano, Nigeria
Kamilu Karaye, BM BCh, PhD, FACC, FESC
Mahmoud U Sani, MB BS, PhD, FWACP, FACC
Department of Medicine, University College Hospital,
Ibadan; Ministry of Health, Umuahia, Nigeria
Okechukwu S Ogah, MB BS, PhD, FWACP, FESC, FACC
Non-Communicable Diseases Unit, South African Medical
Research Council, Cape Town, South Africa
Andre Pascal Kengne, MD, PhD