Left atrial involvement in acute pulmonary edema

left

atrial

involvement

in acute

pulmonary

edema

Donald W. Romhilt, M.D. Ralph C. Scott, M.D. Cincinnati, Ohio

L

eft atria1 involvement frequently was noted to be a transient finding on the electrocardiogram (ECG) in a previous study correlation with postmortem left atria1 and ventricular hypertrophy.’ ECG evidence of left atria1 involvement has been correlated with left-sided heart disease by Morris and associates2 and with increased left atria1 volume and pressure by Kasser and Kennedy,3 but neither group suggested that the ECG changes could be transient. Prior to this, in 1962, Sutnick and Soloff described temporary posterior rotation of the atria1 vector in left ventricular failure in a. retrospective study. Both Grossman and Delman5 and Heikkila and Luomanmaki6 recognized that left atria1 involvement was sometimes transient in patients with myocardial infarction and was associated with signs of left ventricular dysfunction. Neither study5z6 established the frequency with which left atria1 involvement occurred and disappeared in acute left ventricular failure. To evaluate further the transient nature of left atria1 involvement, serial ECG’s were obtained in patients admitted in acute pulmonary edema. In this setting we evaluated the presence of left atria1 involvement at a time of increased left atria1 volume and pressure.

The serial ECG’s determined if left atria1 involvement disappeared with the resolution of pulmonary edema when left atria1 volume and pressure often would have decreased to some extent.

Methods Fifty consecutive patients with acute pulmonary edema with normal sinus rhythm admitted in one year to the University of Cincinnati n’ledical Center were studied. All patients had a technically satisfactory 12 lead ECG taken in the emergency room during the acute event. Patients with atria1 fibrillation or atria1 flutter and patients without a technically satisfactory 12 lead ECG taken during the acute event were excluded. The diagnosis of acute pulmonary edema was based on the presence of all the following: sudden onset of severe dyspnea and wheezing, diffuse bilateral pulmonary r$les, and evidence of cardiomegaly with diffuse bilateral infiltrates on the chest x-ray. ECG evidence of left atria1 involvement was defined as terminal negativity of the P wave in Lead V1 of 1 mm. or more in depth with a duration of 0.04 second or more. ECG’s were obtained on days 4 and 7 following admission. There were 31 men and 19 women. The

From

the Division of Cardiology. Departmrnt oi Internal Medicine. T:niversity of Cincinnati cinnati, Ohio. Suwmrted in lnar: bv United States Public IIealth S+rvicr wants IIL6.307 and HE-5445. Keckved for bublickon May 28, 1971. Keprint requests Donald W. Komhilt, M.D., Department of Internal Medicine, TTniversity of Medicine, Cincinnati, Ohio 45229.

to:

328

American

Heart

Journal

March,

1972

Vol.

Medical

Crntct-.

of Cincinnati

Cin-

College

83, No. 3, pp. 328-331

l’olume Number

83 3

Left utrial involvement in acute fiulmonary

Table I. Etiologies of underlying disease in 50 patients

Etiology Coronary artery

disease (one with an acute myocardial infarction) Hypertensive cardiovascular disease Coronary artery disease and hypertensive cardiovascular disease Myocardiopathy Rheumatic heart disease 1,uetic aortic insufficiency

edema

329

heart

No. of patients 18 20 7 3 1 1

mean age was 61.1 years. The etiologies of the underlying heart disease are presented in Table I. Results

Of the 50 patients, 38 (76 per cent) had left atria1 involvement on the tracing taken during acute pulmonary edema (positive group) while 12 (24 per cent) did not have left atria1 involvement (negative group) on the initial ECG. Day 4 results. Of the 38 patients in the positive group, 30 had follow-up ECG’s on day 4. Prior to day 4, six patients in this group died and two patients were discharged; however, six of these eight patients had ECG’s taken prior to death or discharge. Thirteen (43.3 per cent) of the 30 patients still had left atria1 involvement on the ECG obtained on day 4 and one of the six patients who died still had left atria1 involvement on day 2 (Table II). Seventeen (56.7 per cent) of the 30 patients in this positive group with ECG’s taken on day 4 did not have left atria1 involvement of this follow-up ECG (Figs. 1 and 2). Also, five of the six patients who died or were discharged prior to day 4 demonstrated the disappearance of ECG evidence of left atria1 involvement on ECG’s taken on day 1 or 2 following admission (Table II). Of the 12 patients in the negative group, 3 (25 per cent) now had left atria1 involvement on day 4, and nine patients continued to be without left atria1 involvement (Table III). Thus 16 (38.1 per cent) of 42 patients with ECG’s taken on day 4 had left atria1 involvement. There is a significant dif-

Fig. 1. A 27-year-old man with primary myocardiopathy admitted in acute pulmonary edema with left atria1 involvement on the admission ECG (upper panels) which has disappeared on the ECG taken 4 days after admission (lower panels).

II

Fig. 2. A 54-year-old man with coronary artery disease and an old anterior wall myocardial infarction admitted in acute pulmonary edema with left atria1 involvement on the admission ECG (upper panels) which has disappeared on the ECG taken 4 days later (lower panels).

ference between the incidence of left atria1 involvement on admission and day 4 (p < 0.001, chi square test). Day 7 results. Of the 13 patients in the positive group who still had left atria1 involvement on the fourth day, eight were still positive, two were now negative, and three had been discharged prior to day

330

Romhilt

Table II. Follow-up

Still

Now

Am. Heart I. March. 1972

and Scott

of positives on admission

positive: Still positive day 7 Now negative day 7 No ECG day 7

13

negative: Still negative day No ECG day 7

17

No ECG

on day

1

14

5

22

8 2 3

7

14 3

4

-

Total

30

-

6

2

2 38 -

Table III. admission

Follow-up

of negatives on

there is no difference on days 4 and 7.

between

the incidence

Discussion ECG on day 4 Still negative: Still negative day No ECG day 7

9 7

Now positive: Still positive day 7 Negative again day 7 Total

8 1 3 1 2 12

7 (Table II). Fourteen of the 17 patients in the positive group who had the disappearance of left atria1 involvement on day 4 still were negative on day 7 and three patients were discharged prior to day 7 (Table II). Eight of the nine patients in the negative group who were without left atria1 involvement on admission and day 4 were still negative and one was discharged prior to day 7 (Table III). Of the three patients in the negative group who developed left atria1 involvement on day 4, one was still positive and two had the disappearance of left atria1 involvement (Table III). Over all, nine (25.7 per cent) of the 3.5 patients who had ECG’s on day 7 had left atria1 involvement. There is also a significant difference between the incidence of left atria1 involvement on admission and day 7 (p < 0.001, chi square test); however,

Left atria1 involvement was found in a high percentage of patients with left-sided heart diseasewith acute pulmonary edema. Left atria1 involvement was often transient and 22 (61 per cent) of 36 patients who initially had left atria1 involvement on the admission ECG during the acute episode of pulmonary edema no longer had left atria1 involvement on ECG’s taken on or before the fourth day after admission at a time when pulmonary edema had resolved. In a few instances the left atria1 involvement disappeared in several hours following treatment. There is a significant correlation between ECG evidence of left atria1 involvement at a time when left atria1 volume and pressure are increased in patients with acute pulmonary edema and the disappearance of left atria1 involvement at a time when the pulmonary edema has resolved and left atria1 volume and pressure have decreased to some extent. There was no difference in the incidence of left atria1 involvement among the different etiologies of underlying left-sided heart disease. Any disease process that causes leftsided heart disease, particularly with associated cardiac decompensation, can cause the posterior rotation of the terminal P wave vector, resulting in the ECG finding of left atria1 involvement. The 76 per cent incidence of left atria1 involvement in patients with acute pulmonary edema ap-

Left atria1 involvement in acute pulmonary

proaches the 86 per cent incidence that Morris and colleagues2 found in patients with left-sided valvular disease. Therefore, temporary increases in left atria1 volume and pressure in acute pulmonary edema will cause left atria1 involvement on the ECG nearly as often as the sustained increases that are produced by left-sided valvular heart disease. This is contrary to the suggestion of Heikkila and Luomanmaki6 that left atria1 involvement is not a sensitive indicator of left ventricular failure; however the ECG must be obtained during the acute episode. The frequency of left atria1 involvement in pulmonary edema and left-sided valvular heart disease is considerably higher than the 44 per cent incidence of left atria1 involvement that we found in patients with postmortem left atria1 hypertrophy.’ The high incidence and transience of left atrial involvement in acute pulmonary edema suggests that the production of left atria1 involvement is more dependent on increases in left atria1 pressure and volume or left atria1 dilatation than actual increases in left atria1 mass.

331

cent) of 42 patients who were available for follow-up ECG’s still had left atria1 involvement (p < 0.001). By day 7 the incidence of left atria1 involvement had decreased further to nine (25.7 per cent) positives in 35 patients. There was a high incidence of left atria1 involvement on the ECG during acute pulmonary edema, but with resolution of the pulmonary edema left atria1 involvement frequently disappeared. This suggests that the posterior rotation of the terminal P wave vector producing left atria1 involvement is dependent more on increased left atria1 pressure and volume than on increased left atria1 mass.

REFERENCES 1.

2.

Romhilt, D. W., Bove, K. E., Conradi, S., and Scott. R. C.: Moroholoeic sisnificance of left atrial’ involvement, AM. !&AR; J. 83:322, 1972. Morris, J. J., Estes, E. H., Whalen, R. E., Thompson, H. K., and McIntosh, H. D.: P-wave analysis in valvular heart disease, Circulation

29:242, 1964. 3. Kasser, I., and Kennedy,

Summary

The incidence of the ECG finding of left atria1 involvement was evaluated during the acute episode and on days 4 and 7 in 50 patients admitted with acute pulmonary edema. During the acute episode of pulmonary edema 38 (76 per cent) of the patients had left atria1 involvement on the initial ECG. On day 4 only 16 (38.1 per

edema

4. 5.

J. W.: The relationship of increasedleft atria1 volume and pressureto abnormal P waves on the electrocardiogram, Circulation 39:339, 1969. Sutnick, A. I., and Soloff, L. A.: Posterior rotation of the atria1 vector, Circulation 26:913, 1962. Grossman, J. I., and Delman, A. J.: Serial P wave changes in acute myocardial infarction,

AM. HEART 1. 77:336. 1969. 6. Heikkila, J.: and Luomanmaki,

K.: serial P wave changes in indicating failure in myocardial infarction, Brit. 32510, 1970.

Value of left heart Heart J.