Electrocardiographic Profile of Cirrhosis Patients and Its relation to Cardiac Dysautonomia

Balan, N (2006) Electrocardiographic Profile of Cirrhosis Patients and Its relation to Cardiac Dysautonomia. Masters thesis, Stanley Medical College, Chennai.


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INTRODUCTION: Cirrhosis is a chronic disease of the liver that leads to a number of complications, some of which may eventually prove fatal. There are reports of association of chronic liver disease with autonomic neuropathy. Patients with chronic liver disease who have associated autonomic neuropathy respond inappropriately or defectively to major events such as septicaemia and variceal haemorrhage. Autonomic Neuropathy (AN) is associated with hemodynamic impairment and with increased vasoactive drug requirements during liver transplantation, probably associated with impaired reflex vasoconstrictor responses to surgical manipulations and changes of blood volume. AN may be associated with a greater surgical risk during liver transplantation. Preoperative evaluation of AN may select a high-risk population of liver transplant recipients. The present study was undertaken primarily to investigate autonomic functions in hepatic cirrhosis (in both alcoholics and non-alcoholics), analyse characteristics of patients who develop autonomic neuropathy, and to determine the relationship between severity of liver damage and extent of autonomic function impairment. Electrocardiogram is a very simple and noninvasive investigation in diagnosing asymptomatic autonomic dysfunction. It helps in early recognition of cardiac dysautonomia, which is asymptomatic autonomic dysfunction and precursor of symptomatic autonomic dysfunction. This also helps in taking sufficient precaution to delay or arrest its progression by various measures. In this study the prevalence of various ECG abnormalities and cardiac dysautonomia in cirrhotic patients are assessed by various ECG markers. AIMS OF THE STUDY: 1. To study the prevalence of various ECG abnormalities in cirrhotic patients as compared to controls. 2. To study the prevalence of cardiac dysautonomia in cirrhotic patients by various ECG markers. MATERIALS AND METHODS: Study Population: Study group - 50 patients with cirrhosis with portal hypertension Control group - 50 age and sex matched controls. Place of Study: Department of Medicine, Department of Gastroenterology, Stanley Medical College Chennai-1. Period of Study: June 2005 to December 2005. Methods: All the study group patients and controls were subjected for thorough physical examination. Blood samples were drawn and subjected to estimation of estimation of liver function, renal function and glucose levels. Exclusion Criteria: 1. Age above 60 years. 2. Documented ischemic heart disease. 3. Documented valvular/congenital heart disease. 4. Hypertension and Diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Drugs-β blockers, digoxin, calcium channel blockers. 7. Features of hypothyroidism. 8. Uraemia. 9. Features of parkinsonism and rheumatoid arthritis Cardiovascular autonomic dysfunction was assessed by the following maneuvers. RESULTS: 1. The Resting Heart rate in Cirrhotics (90 ± 16.98 bpm) was significantly (p<0.05) higher than that of Controls (76.78 ± 11.23 bpm). 2. The R-R Interval of Study group (690.54 ± 133.38 msec) is significantly lower than Control group (797.98 ± 119.17 msec) (p<0.005) correlating with increased resting heart rate signifying parasympathetic damage. 3. Both Study (139.36 ± 19.09 msec) and Control Group (143.76 ± 18.62 msec) show no statistically significant difference in P-R Interval (p>0.05). 4. The QRS Duration in Study Group( 77.68 ± 10.87 msec) and Control Group( 65.28 ± 12.77 msec) showed no statistically significant difference (p>0.05). 5. The QRS Axis in Study Group (42.12 ± 31.64 degrees) and Control Group (48.92 ± 23.38 degrees) show no statistically significant difference (p>0.05). 6. The QTC Interval of Study group (430.14 +/- 41.43 msec) is significantly prolonged than Control group (376.36 +/- 36.54 msec) (p<0.005). 7. 46% of Study Group have abnormal E:I ratio which is suggestive of an early parasympathetic dysfunction. 8. 12% of the Study Group show significant Postural Drop of SBP (>20mmHg) on standing which probably indicates sympathetic nervous system dysfunction. 9. This study shows that QTc prolongation is common (20% ) in patients when compared to Control Group (4%). 10. QTc prolongation was seen in none of the patients in Child ‘A’, 19% in Child ‘B’ and 50% in Child ‘C’. So there is a positive correlation between QTc Prolongation and increasing severity of Cirrhosis. 11. Parasympathetic Dysfunction (E: I Ratio <1.1) was seen in none of the patients in Child ‘A’, 45% in Child ‘B’ and 100% in Child ‘C’. So there is a positive correlation between Disease Severity & Parasympathetic Dysfunction. 12. Sympathetic Dysfunction (Postural Drop of SBP >20mmHg) was seen in none of the patients in Child ‘A’ , 9.5% in Child ‘B’ & 50% in Child ‘C’. There is a positive correlation between Disease Severity & Sympathetic Dysfunction. 13. None of the patients had Sympathetic Dysfunction alone. All the patients with Sympathetic Dysfunction had Parasympathetic Dysfunction as well. 14. There is no statistically significant difference in QTc Interval (p>0.05) between Alcoholics (426.30 ±37.11 msec) & Non-Alcoholics (433.4 ±45.22 msec). 15. There is no statistically significant difference in QTc Interval (p>0.05) between Bleeders (428.176 ± 41.82 msec) & Non-Bleeders (434.31 ± 41.62 msec). 16. There is no statistically significant difference in QTc Interval (p>0.05) between male (435.61 ± 39.026 msec) and female patients (416.72 ± 45.734msec). 17. Parasympathetic Dysfunction is seen in 61.7% of Bleeders & 12.5% of Non-Bleeders while both Parasympathetic & Sympathetic Dysfunction is seen in 14.7% of Bleeders & 6.2% of Non-Bleeders. So this study shows that Cardiac dysautonomia is commoner in Bleeders when compared to Non-Bleeders. CONCLUSION: This study has shown that autonomic dysfunction is very common in cirrhotic patients. The incidence of autonomic dysfunction also increases with increasing severity of liver disease. This study also highlights the importance of simple bedside investigations like ECG and clinical evaluation in early diagnosis of autonomic dysfunction. The mortality of cirrhosis patients is partly related to poor autonomic responses to stressful events like sepsis or bleeding. On the basis of this evidence, it is suggested that consideration should be given for early liver transplantation in patients with autonomic neuropathy. These patients should also be given intensive care in the per-operative and post-operative period to decrease the mortality rate.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Electrocardiographic Profile ; Cirrhosis Patients ; Cardiac Dysautonomia.
Subjects: MEDICAL > General Medicine
Depositing User: Subramani R
Date Deposited: 23 Mar 2018 02:43
Last Modified: 23 Mar 2018 02:43
URI: http://repository-tnmgrmu.ac.in/id/eprint/6435

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