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Original research
Role of the electrocardiogram in the risk stratification of pulmonary hypertension
  1. Paul M Hendriks1,2,
  2. Robert M Kauling1,
  3. Laurie W Geenen1,
  4. Jannet A Eindhoven1,
  5. Jolien W Roos-Hesselink1,
  6. Karin A Boomars2,
  7. Annemien E van den Bosch1
  1. 1 Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
  2. 2 Department of Respiratory Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
  1. Correspondence to Dr. Annemien E van den Bosch, Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands; a.e.vandenbosch{at}


Introduction The prognosis of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) remains dismal. Better risk prediction is needed. This study investigated the prognostic value of ECG characteristics.

Methods In this single-centre prospective study, consecutive treatment-naïve patients with PAH or CTEPH were included at time of diagnosis. From the 12-lead ECG, obtained at baseline, the following parameters were collected: heart rate (HR), rhythm, QRS axis, conduction times, P-top amplitudes in II, R-top and S-wave amplitudes in V1 and V5 and repolarisation disorders. Associations between the ECG and transplant-free survival was assessed by Kaplan-Meier curves and Cox-proportional hazard regressions.

Results In total, 140 patients were included (median age: 60.7 years, 63.6% female). The ECG was abnormal in 86.2%: sinus rhythm was not present in 9.3%, right QRS axis was observed in 47.8%, mean QRS duration was 101±17 ms. Only 42.5% of the patients had normal repolarisation, 34.5% had right ventricular strain and 14.4% non-specific repolarisation disorders. Over a median follow-up time of 3.49 (IQR: 1.37–6.42) years, 45 patients (32.5%) died or underwent lung transplantation. Transplant-free survival was worse in patients presenting with an abnormal ECG (64.0% vs 86.0%; p=0.037). The following ECG characteristics were associated with all-cause mortality or lung transplantation: heart rate (HR 1.02, 95% CI: 1.00 to 1.05), QRS duration >120 ms (HR 2.61, 95% CI: 1.01 to 6.71) and S-wave amplitude in V5 (HR 1.10, 95% CI: 1.04 to 1.17).

Conclusion Only 13.8% of patients with PAH and CTEPH presented with a normal ECG, which is associated with favourable outcome. The ECG provides additional prognostic value to current clinical parameters and should be considered in risk prediction.

  • hypertension, pulmonary
  • electrocardiography
  • pulmonary arterial hypertension

Data availability statement

Data are available on reasonable request. Data are available on reasonable request from the corresponding author.

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Data availability statement

Data are available on reasonable request. Data are available on reasonable request from the corresponding author.

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  • Contributors Conceptualisation: PMH, RMK, LWG, JAE, JWR-H, KAB, AEvdB. Patient inclusion: PMH, RMK, LWG, JAE, KAB, AEvdB. Data curation: PMH, LWG. Formal analysis: PMH. Supervision: JWR, KAB, AEvdB. Writing, review and editing: PMH, RMK, LWG, JAE, JRH, KAB, AEvdB. All authors read and approved the manuscript. PMH and AEvdB had full access to all the data in the study and take responsibility for the its integrity and the data analysis.

  • Funding This research project was supported by an unrestricting research grant by Johnson & Johnson—Actelion Pharmaceuticals.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.