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A new marker for myocardial injury in carbon monoxide poisoning: T peak–T end

Published:October 02, 2013DOI:https://doi.org/10.1016/j.ajem.2013.08.049

      Abstract

      Objectives

      Carbon monoxide (CO) poisoning frequently affects repolarization, resulting in abnormal electrocardiography findings. The goal of this study was to examine the effect of CO poisoning on the novel transmyocardial repolarization parameters T peak–T end (Tp-e), Tp-e dispersion, and Tp-e/QT and the relationship of these parameters to myocardial injury (MI).

      Methods

      This prospective study included 94 patients with CO poisoning and 40 healthy controls. Participants received an electrocardiography and had their blood drawn at admission and 6 and 24 hours after admission. The QT, Tp-e, Tp-e dispersion, and the Tp-e/QT ratio were calculated. Myocardial injury was determined based on an elevation in troponin any time during the first 24 hours. The patients were divided into 2 subgroups: those with and without MI.

      Results

      T peak–T end, Tp-e dispersion, and the Tp-e/QT ratio were higher at admission than after 6 and 24 hours of hospitalization and were higher than the control group (P < .001). There was a correlation between the carboxyhemoglobin level at admission and Tp-e and Tp-e dispersion (P < .001). The MI subgroup (n = 14) had a higher Tp-e at admission than did the non-MI subgroup (n = 80) (96 [11] milliseconds vs 87 [12] milliseconds, P = .03). There were no any significant differences in the Tp-e dispersion or the Tp-e/QT ratio between the 2 MI subgroups. Receiver operating characteristic analysis showed that a Tp-e cutoff value for MI of 91.5 milliseconds had a sensitivity of 72.7% and a specificity of 67.2%.

      Conclusion

      Transmyocardial repolarization parameters indicative of arrhythmia were prolonged in patients with CO poisoning. T peak–T end was associated with MI.
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      References

        • Gandini C.
        • Castoldi A.F.
        • Candura S.M.
        • Locatelli C.
        • Butera R.
        • Priori S.
        • et al.
        Carbon monoxide cardiotoxicity.
        J Toxicol Clin Toxicol. 2001; 39: 35-44
        • Fiorista F.
        • Casazza F.
        • Comolatti G.
        Silent myocardial infarction caused by acute carbon monoxide poisoning.
        G Ital Cardiol. 1993; 23: 583-587
        • Adir Y.
        • Merdler A.
        • Ben Haim S.
        • Front A.
        • Harduf R.
        • Bitterman H.
        Effects of exposure to low concentrations of carbon monoxide on exercise performance and myocardial perfusion in young healthy men.
        Occup Environ Med. 1999; 56: 535-538
        • Aslan S.
        • Uzkeser M.
        • Seven B.
        • Gundogdu F.
        • Acemoglu H.
        • Aksakal E.
        • et al.
        The evaluation of myocardial damage in 83 young adults with carbon monoxide poisoning in the East Anatolia region in Turkey.
        Hum Exp Toxicol. 2006; 25: 439-446
        • Thiels H.
        • Van Durme J.P.
        • Vermeire P.
        • Pannier R.
        Immediate and late electrocardiographic changes in the course of acute carbon monoxide poisoning.
        Lille Med. 1972; 17: 191-195
        • Cosby R.S.
        • Bergeron M.
        Electrocardiographic changes in carbon monoxide poisoning.
        Am J Cardiol. 1963; 11: 93-96
        • Carnevali R.
        • Omboni E.
        • Rossati M.
        • Villa A.
        • Checchini M.
        Electrocardiographic changes in acute carbon monoxide poisoning.
        Minerva Med. 1987; 78: 175-178
        • Castro Hevia J.
        • Antzelevitch C.
        • Tornes Barzaga F.
        • Dorantes Sanchez M.
        • Dorticos Balea F.
        • Zayas Molina R.
        • et al.
        Tpeak-Tend and Tpeak-Tend dispersion as risk factors for ventricular tachycardia/ventricular fibrillation in patients with the Brugada syndrome.
        J Am Coll Cardiol. 2006; 47: 1828-1834
        • Savelieva I.
        • Yap Y.G.
        • Yi G.
        • Guo X.
        • Camm A.J.
        • Malik M.
        Comparative reproducibility of QT, QT peak, and T peak–T end intervals and dispersion in normal subjects, patients with myocardial infarction, and patients with hypertrophic cardiomyopathy.
        Pacing Clin electrophysiol. 1998; 21: 2376-2381
        • Hlaing T.
        • Guo D.
        • Zhao X.
        • DiMino T.
        • Greenspon L.
        • Kowey P.R.
        • et al.
        The QT and Tp-e intervals in left and right chest leads: comparison between patients with systemic and pulmonary hypertension.
        J Electrocardiol. 2005; 38: 154-158
        • Satran D.
        • Henry C.R.
        • Adkinson C.
        • Nicholson C.I.
        • Bracha Y.
        • Henry T.D.
        Cardiovascular manifestations of moderate to severe carbon monoxide poisoning.
        J Am Coll Cardiol. 2005; 45: 1513-1516
        • Gupta P.
        • Patel C.
        • Patel H.
        • Narayanaswamy S.
        • Malhotra B.
        • Green J.T.
        • et al.
        T(p-e)/QT ratio as an index of arrhythmogenesis.
        J Electrocardiol. 2008; 41: 567-574
        • Cevik Y.
        • Tanriverdi F.
        • Delice O.
        • Kavalci C.
        • Sezigen S.
        Reversible increases in QT dispersion and P wave dispersion during carbon monoxide intoxication.
        Hong Kong J Emerg Med. 2010; 17: 441-450
        • Lippi G.
        • Rastelli G.
        • Meschi T.
        • Borghi L.
        • Cervellin G.
        Pathophysiology, clinics, diagnosis and treatment of heart involvement in carbon monoxide poisoning.
        Clin Biochem. 2012; 45: 1278-1285
        • Douglas C.G.
        • Haldane J.S.
        • Haldane J.B.
        The laws of combination of haemoglobin with carbon monoxide and oxygen.
        J Physiol. 1912; 44: 275-304
        • Prockop L.D.
        • Chichkova R.I.
        Carbon monoxide intoxication: an updated review.
        J Neurol Sci. 2007; 262: 122-130
        • Tibbles P.M.
        • Edelsberg J.S.
        Hyperbaric-oxygen therapy.
        N Engl J Med. 1996; 334: 1642-1648
        • Tritapepe L.
        • Macchiarelli G.
        • Rocco M.
        • Scopinaro F.
        • Schillaci O.
        • Martuscelli E.
        • et al.
        Functional and ultrastructural evidence of myocardial stunning after acute carbon monoxide poisoning.
        Crit Care Med. 1998; 26: 797-801
        • Hajsadeghi S.
        • Tavakkoli N.
        • Jafarian Kerman S.R.
        • Shahabadi A.
        • Khojandi M.
        Electrocardiographic findings and serum troponin I in carbon monoxide poisoned patients.
        Acta Med Iran. 2012; 50: 185-191
        • Dallas M.L.
        • Yang Z.
        • Boyle J.P.
        • Boycott H.E.
        • Scragg J.L.
        • Milligan C.J.
        • et al.
        Carbon monoxide induces cardiac arrhythmia via induction of the late Na+ current.
        Am J Respir Crit Care Med. 2012; 186: 648-656
        • Andre L.
        • Boissiere J.
        • Reboul C.
        • Perrier R.
        • Zalvidea S.
        • Meyer G.
        • et al.
        Carbon monoxide pollution promotes cardiac remodeling and ventricular arrhythmia in healthy rats.
        Am J Respir Crit Care Med. 2010; 181: 587-595
        • Yelken B.
        • Tanriverdi B.
        • Cetinbas F.
        • Memis D.
        • Sut N.
        The assessment of QT intervals in acute carbon monoxide poisoning.
        Anadolu Kardiyol Derg. 2009; 9: 397-400
        • Hanci V.
        • Ayoglu H.
        • Yurtlu S.
        • Yildirim N.
        • Okyay D.
        • Erdogan G.
        • et al.
        Effects of acute carbon monoxide poisoning on the P-wave and QT interval dispersions.
        Anadolu Kardiyol Derg. 2011; 11: 48-52
        • Mozos I.
        • Serban C.
        The relation between QT interval and T-wave variables in hypertensive patients.
        J Pharm Bioallied Sci. 2011; 3: 339-344
        • Kayrak M.
        • Acar K.
        • Gul E.E.
        • Ozbek O.
        • Abdulhalikov T.
        • Sonmez O.
        • et al.
        The association between myocardial iron load and ventricular repolarization parameters in asymptomatic beta-thalassemia patients.
        Adv Hematol. 2012; 2012: 170510
        • Yan G.X.
        • Wu Y.
        • Liu T.
        • Wang J.
        • Marinchak R.A.
        • Kowey P.R.
        Phase 2 early afterdepolarization as a trigger of polymorphic ventricular tachycardia in acquired long-QT syndrome: direct evidence from intracellular recordings in the intact left ventricular wall.
        Circulation. 2001; 103: 2851-2856
        • Yan G.X.
        • Martin J.
        Electrocardiographic T wave: a symbol of transmural dispersion of repolarization in the ventricles.
        J Cardiovasc Electrophysiol. 2003; 14: 639-640
        • Yan G.X.
        • Antzelevitch C.
        Cellular basis for the normal T wave and the electrocardiographic manifestations of the long-QT syndrome.
        Circulation. 1998; 98: 1928-1936
        • Antzelevitch C.
        • Shimizu W.
        • Yan G.X.
        • Sicouri S.
        Cellular basis for QT dispersion.
        J Electrocardiol. 1998; 30: 168-175
        • Letsas K.P.
        • Weber R.
        • Astheimer K.
        • Kalusche D.
        • Arentz T.
        Tpeak-Tend interval and Tpeak-Tend/QT ratio as markers of ventricular tachycardia inducibility in subjects with Brugada ECG phenotype.
        Europace. 2010; 12: 271-274
        • Zhao Z.
        • Yuan Z.
        • Ji Y.
        • Wu Y.
        • Qi Y.
        Left ventricular hypertrophy amplifies the QT, and Tp-e intervals and the Tp-e/QT ratio of left chest ECG.
        J Biomed Res. 2010; 24: 69-72
        • Panikkath R.
        • Reinier K.
        • Uy-Evanado A.
        • Teodorescu C.
        • Hattenhauer J.
        • Mariani R.
        • et al.
        Prolonged Tpeak-to-tend interval on the resting ECG is associated with increased risk of sudden cardiac death.
        Circ Arrhythm Electrophysiol. 2011; 4: 441-447
        • Lubinski A.
        • Kornacewicz-Jach Z.
        • Wnuk-Wojnar A.M.
        • Adamus J.
        • Kempa M.
        • Krolak T.
        • et al.
        The terminal portion of the T wave: a new electrocardiographic marker of risk of ventricular arrhythmias.
        Pacing Clin Electrophysiol. 2000; 23: 1957-1959
        • Tintinalli J.D.
        • Stapczynski J.S.
        • Ma O.J.
        Tintinalli's emergency medicine: a comprehensive study guide. 7th ed. Mc Graw-Hill Professional, New York, NY2010