Imran-ul-Haq

 

Department of Cardiology, Southern Railway Headquarters Hospital, CHENNAI-600 023, INDIA.

Email: drimranulhaqmd@yahoo.com

 

 

 

 

 

 

 

RESULTS
During the study period of six months i.e. from January 2017 to June 2017, those who met the inclusion and exclusion criteria were included in the study. A total of 50 patients were analyzed in the study.

Table 1: Age & Sex Distribution

        *Significant at 5% Level, NS: Non-Significant,χ2 (0.05, 1df) = 3.841

As is evident from the above table No. 1; that the incidence of stroke is more common in the age group of 5^th to the 7^th decade with male being 40.0% and female being 66.7%, which was statistically insignificant.

 

Table 2: Cardiac Symptoms In Stroke Patients

*Paroxysmal Nocturnal Dynpnea NS: Non-Significant, χ2 (0.05, 1df) = 3.841

The common cardiac symptoms in stroke patients were chest pain in 12% of patients (male were 14.3% and female were 6.7%). The next common cardiac symptom is orthopnea in 6% (male were 2.9% and female were 6%). Palpitation was seen in 2% of the patients (male were 2.9% and female were 2%). However, the cardiac symptoms were not statistically significant when compared to male and female patients. (Table No. 2)

 

Table 3: Risk factors in stroke patients

*Significant at 5% Level, NS: Non-Significant, χ2 (0.05, 1df) = 3.841

Most of the patients presented with co-morbid risk factors hence, from the above table it is evident that, hypertension was the most common risk factor 70% (male were 71.4% and female were 66.7%). Diabetes mellitus was the next common risk factor in this study 38% (male were 37.1% and female 19%). Smoking as a risk factor was seen in 34% (male were 17% and female were 0%). Alcohol in 20% (male were 28.6% and female were 0%). As is evident from the above table, smoking and alcohol were statistically significant when compared to male and female patients. (Table No. 3)

 

Table 4: ECG changes in stroke patients

*Significant at 5% Level, NS: Non-Significant, χ2 (0.05, 1df) = 3.841

The present study shows that, T wave inversions was present in 38%, (male were 28.6% and female were 60%), this was followed by ST segment depression/elevation in 20%, (male were 17.1% and female were 26.7%). QTc prolongation was seen in 8% and AF in 6%. However, QTc prolongation and T-wave inversion were statistically significant when compared to males and females. (Table No. 4)

 

Table 5:  2d echo changes in stroke patients

*Significant at 5% Level, NS: Non-Significant, χ2 (0.05, 1df) = 3.841

The above table No.5; shows that Diastolic dysfunction was seen in 76%, which was statistically not significant when compared to males and females. Left Ventricular Hypertrophy (LVH) was seen in 68% of patients (males were 57.1% and females 93.3%, which was statistically significant. The other echo abnormalities were calcified aortic valve 30.4%, Atrial Fibrillation (AF) in 4%, Mitral Regurgitation (MR) in 2%, Left Atrial (LA) clot in 2% and Mitral Stenosis (MS) in 2%, which were statistically not significant.

Table 6: Cardiac Markers In Stroke

*Significant at 5% Level, NS: Non-Significant, χ2 (0.05, 1df) = 3.841

In this study, CPK-MB was abnormal in 56% (males were 45.7% and females were 80%), which was statistically significant. Troponin-T was abnormal in 14% (males were 11.4% and females were 20.0%), which was statistically not significant as shown in Table No. 6.

 

Table 7: Cranial Imaging

*Significant at 5% Level, NS: Non-Significant, χ2 (0.05, 1df) = 3.841

The above table No.7 shows that, Middle Cerebral Artery (MCA) was the most common territory of infarct in ischemic stroke patients in this study i.e. 64% (males were 51.4% and females 32%), which was statistically significant. This was followed by vertebrobasilar insufficiency (VBI) in 26%, Anterior Cerebral Artery (ACA) infarct in 6% and watershed infarct in 4%, which was statistically not significant.

 

Table 8: Comparison of Incidence of Stroke Patients above age group of 51years

 

Table 9: Comparison of risk factors

 

Table 10: Comparison of ECG findings

 

Table 11: COMPARISON OF 2D ECHO FINDINGS

 

Table 12:  Comparison Of Cardiac Biomarkers

 

DISCUSSION
Cardiac abnormalities are one of the important causative factors in stroke. The present study helps to evaluate cardiac abnormalities by means of ECG, 2D ECHO, cardiac biomarkers in evaluating acute ischemic stroke. A total of 50 subjects were studied, of which males constituted 35 and females 15. The majority of subjects were male 70%. The cases of stroke were common in the age of 5^th -7^th decades, making 48% of it, which is comparable to a study done by Venkataramana et al⁸ in which the percentage of stroke cases above the age of 51 years was 41% and in the study by Carlo et al⁹ it was 71.8% as shown in table No. 8. Stroke is one of the leading causes of death in many countries. Several factors have been reported to increase the risk of stroke. Although there was a lack of unanimity, several factors have been reported to increase the risk of stroke. Reports from different countries have implicated different factors associated with high risk of stroke. To evaluate the risk factors, a prospective survey of a given population of the years as done in the Framingham Heart Study¹⁰ was essential. The epidemiological study of Abraham et al (1970) who found hypertension, diabetes mellitus, hypercholesteremia and syphilis to be the risk factors associated in hemiplegia patients.¹¹ Sharper et al in 1991 concluded that, hypertension; cigarette smoking and pre-existing IHD were found to be major risk factors.¹² In this present study, the risk factors- hypertension was present in majority of the cases i.e., 70%, which is comparable with that found in the studies of Smith et al¹³ i.e. 87%, and the next common risk factor was diabetes mellitus in 38% and smoking 34%, which are comparable with that found in Smith (2005) i.e., diabetes mellitus 50% and smoking in 35% as shown in table No. 9. Increased QTc was seen in 32% of cases in Goldstein et al,¹⁴ while in our study it is 8%. T wave inversion was seen in 15% by Goldstein et al while in our study it is 38%. ST segment depression was seen in 13% in Goldstein while in the present study it was 20%. U wave was seen in 28% in Goldstein et al, while in our study there was no presence of U wave. Atrial fibrillation (AF) was seen in 9% in Goldstein et al, ¹⁴ while in the present study only 6% of the cases had AF as shown in table No.10. In the present study, IHD was present in 4%, which was comparable to study done by S. Pujadas (2004),¹⁵ in which IHD was present in 20.1%. RHD was present in 1% in the present study, 12% was present in study done by R.Pujadas. Atrial fibrillation was present in 79.1% in study done by S.Pujadas, in the present study AF was seen in 2%. Mitral regurgitation was seen in 2% in the study done by S.Pujadas, in the present study also it was 2%. Left Ventricular Hypertrophy was seen in 30% in the study done by S.Pujadas,¹⁵ and in the present study LVH was seen in 68% cases as shown in table No.11.In this present study, CPKMB was positive in 56% and this was made in comparison to study done by Ismail apak et al,¹⁶ where CPKMB was positive in 45% of patients. Troponin-T was seen 32% of patients in a study done by Ismail Epak et al,¹⁶ where as in the present study Troponin-T was seen in 14% as shown in table No.12.

 

CONCLUSION
The present study helped to understand the cardiac abnormalities in patients of acute ischemic stroke. A total of 50 subjects were studied for cardiac abnormalities by means of history, risk factors, ECG, 2D Echo and cardiac biomarkers. Hypertension, DM and smoking were the most common risk factors with varied findings in ECG and 2D Echo from T-wave inversion to ST segment elevation and diastolic dysfunction to global hypokinesia, suggesting the presence of underlying cardiac complications in patients of acute ischemic stroke, who do not have known cardiac disease/symptoms. Thus this study underlies the importance of studying the cardiac abnormalities in patients of acute ischemic stroke which would help early recognition of the same and in-turn better treatment of patients which helps in decreasing mortality and morbidity of these patients.

 

REFERENCES

1. Kamath S. API Textbook of Medicine, 11th Ed. Mumbai: Jaypee Brothers Medical Publishers: 2017.
2. Byer E, Ashman R, Toth LA. Electrocardiograms with large upright T- waves and
   long QT intervals. American Heart Journal; 1947; 33: 796-806.
3. Baruch GE, Meyers R, Abildskov JA. A new electrocardiographic pattern observed in cerebrovascular accidents. Circulation. 1954; 9:719- 723.
4. Dimant J, Grob D. Electrocardiographic changes and myocardial damage in patients with acute CVA. Stroke. 1977; 8(4):448-55.
5. Davies KR, Geld AW, Mannien PH, Boughner DR, Bisnaire D. Cardiac function in aneurysmal SAH- A study of electrocardiographic and echocardiographic abnormalities. British Journal of Anaesthesia 1991; 67(1):58-63.
6. Sakka SG, Haettemann E, Renhart K. Acute left ventricular dysfunction and Subarachnoid hemorrhage. J. Neurosurg Anesthesiol 1999; 11(3):209-13.
7. I. Apak, K. Iltumur, Y. Tamam. Serum Cardiac Troponin-T Levels as an Indicator of Myocardial Injury in Ischemic and Hemorrhagic Stroke patients. Tohoku J Exp Med. 2005; 205(2):93-101.
8. Venkataraman S et al. Cerebrovascular accidents-Clinical and radiological features. JAPI 1977; 25(8):523.
9. Carlo AD et al. Sex difference in the clinical presentation, resource use and 3 month outcome of acute stroke in Europe. Stroke. 2003; 34: 1114-9.
10. Framingham Heart Study [Internet]. Framinghamheartstudy.org. 2018 [cited 25 May 2018]. Available from: https://www.framinghamheartstudy.org/
11. Abraham et al. Risk factors in stroke. Lancet 1970; 32:464-966.
12. Sharper AG, Philips AN, Pocock SJ et al. Risk factors of stroke in middle aged British men. BMJ 1991; 302:1111-5.
13. Melinda A. Smith, Lynda D. Lisabeth, Devin L. Brown, Lewis B.Morgenstern. Gender comparisons of diagnostic evaluation for ischemic stroke patients. Neurology. 2005; 65(6):855-8.
14. Goldstein DS. The electrocardiogram in stroke: relationship to pathophysiological type and comparison with prior tracings. Stroke. 1979; 10(3):253–9.
15. S. Pujadas, Gautham P. Reddy, Oliver Weber, Jennifer J. Lee, Charles B. Higgins. MR imaging assessment of cardiac function. Journal of Magnetic Resonance Imaging 2004; 19:789-99.
16. Ismail Apak, Kenan Iltumur, Yusuf Tamam, Nurettin Kaya. Serum Cardiac Troponin T Levels as an Indicator of Myocardial Injury in Ischemic and Hemorrhagic Stroke Patients. The Tohoku Journal of Experimental Medicine. 2005; 205(2):93-101.