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Rudrajit et al., Int J Med Res Health Sci. 2014;3(3):639-644

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com Volume 3 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886
Received: 3
rd
May 2014 Revised: 24
th
May 2014 Accepted: 12
th
Jun 2014
Research Article
EPIDEMIOLOGICAL STUDY OF DILATED CARDIOMYOPATHY FROM EASTERN INDIA WITH
SPECIAL REFERENCE TO LEFT ATRIAL SIZE
*
Rudrajit Paul
1
, Saumen Nandi
2
, Pradip K Sinha
3
1
Assistant Professor, Department of Medicine, Medical College, Kolkata88, College Street, Kolkata
2
RMO, Department of Chest Medicine, Malda Medical College, Malda, West Bengal
3
Professor and HOD, Department of Medicine, Malda Medical College, Malda, West Bengal
*Corresponding author email:[email protected]
ABSTRACT
Background: Dilated cardiomyopathy (DCM) is a common cause of emergency visit in our country. The disease
is often misdiagnosed and mistreated. There are very few studies on DCM from India. We undertook a small
study on DCM patients from Eastern India to find the demographic and echocardiographic characteristics.
Patients and methods: We undertook this study in a tertiary care Medical College of Eastern India. All patients
coming to the emergency with dyspnea were evaluated for cardiac dysfunction. Emergency echocardiography was
done to diagnose dilated cardiomyopathy. Patients with DCM were then evaluated as per protocol. After
stabilization, echocardiography was repeated to note the study parameters like left atrial diameter. Standard
statistical tests were used. Results: we had a total of 70 patients in our study with a male: female ratio of 43:27.
Most patients were aged over 40 years. Patients with COPD, history of radiation, malignancy or drug abuse were
excluded. Most patients (47%) were on NYHA stage 3 at the time of presentation. In our patient cohort, 24%
were alcoholic and 46% were smokers. Atrial fibrillation was present in 15.7% of the patients and right and left
bundle branch block had been present in 8 and 15 patients respectively. In echocardiography, increased left atrial
(LA) size (>40 mm) was found in 45 patients. Many patients had valvular regurgitation, mitral, aortic or tricuspid.
LA size was positively correlated with left ventricular systolic diameter (r=0.403) and negatively correlated with
ejection fraction (r= -0.23). Analysis and conclusion: different ECG abnormalities like bundle branch block and
arrhythmias like atrial fibrillation are quite common in DCM. In echocardiography, left atrial size is an important
prognostic marker and correlates with left ventricular function.
Keywords: Dilated cardiomyopathy, left atrial size, LVIDS, male preponderance, NYHA staging
INTRODUCTION
Dilated cardiomyopathy (DCM) is an important cause
for emergency room visits in our country. This
disease is often misdiagnosed as COPD or asthma
and patients often receive wrong treatment for a long
time. Exact prevalence of DCM in India is not
known. In a study from Europe, the incidence of
DCM was found to be 6.95/100 000/year.
1
Diabetes,
alcoholism, neurological disorders and congenital
cardiac diseases were the main associated
comorbidities in DCM patients in this study.
1
But in
many cases, the cause remained unknown. The
patients were also found to have different types of
arrhythmia.
DOI: 10.5958/2319-5886.2014.00410.X
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Rudrajit et al., Int J Med Res Health Sci. 2014;3(3):639-644
Studies regarding DCM are very rare from India. A
study on paediatric patients with DCM found a very
high incidence of different viral infections like CMV
and Coxsackie.
2
However, similar risk factors for
Indian adults are largely unknown. One study
evaluated the role of inheritance in Indian DCM
patients.
3
However, there were no definite
conclusions and DCM in India was found to be a
heterogeneous disease. Diet, especially pure
vegetarian diet with no animal protein, was found to
be an important factor in causation of DCMin India.
3
DCM is a very common problem in daily practice,
but we hardly know the epidemiological features in
Indian setting. We, therefore, undertook this small
pilot study from Eastern India to characterise the
different demographic variables in DCM patients.
The Electrocardiographic (ECG) and
echocardiographic characteristics of these patients
were also studied for any association.
PATIENTS AND METHODS
This was a hospital based cross sectional
observational study. Adult patients coming to the
emergency of a tertiary care medical college with
dyspnea and/or chest pain were evaluated.
Emergency chest X ray, Electrocardiography (ECG)
and echocardiography were done and a trained
cardiologist examined the patients clinically. Those
who were found to have dilated cardiomyopathy
(DCM) were then evaluated after stabilization.
Informed written consent was taken from each study
subject or next of kin, also obtained permission of an
institutional ethical committee of the medical
collegeDemographic data like alcoholism history and
smoking history were taken from the patient or next
of kin. Exclusion criteria: Patients with coexisting
COPD (chronic obstructive pulmonary disease), any
malignancy, rheumatological disorder, drug abuse,
history of radiation to the thorax or those with
congenital cardiac diseases were excluded from the
study.
ECG (electrocardiography) was done using a standard
BPL machine (model number: CMECG-04) at paper
speed of 25 mm/second. All ECGs were interpreted
by the same person.
Echocardiography was done using a Philips Envisor
machine version C.1.3 model number M2540A. All
the echocardiographic observations were made by the
same observer to avoid inter-observer variations.
Echocardiography was done in emergency to
diagnose DCM. But for the chamber dimensions and
other study parameters, the test was repeated after the
patient was stabilized. Left atrial size was measured
as the anterio-posterior diameter in parasternal long
axis view (PLAX). In the same view, ejection fraction
and fractional shortening were also measured.
Valvular regurgitation was measured by continuous
wave Doppler (CWD) in apical four chamber view as
per the European Association of Echocardiography
recommendations, 2010.
There were a total of 70 patients in our study. Initially
88 patients were chosen, but some did not consent to
the study and some others were found to have one or
more of exclusion criteria. The data was entered into
Microsoft excel worksheet before analysis.
Continuous data is here expressed as mean S.D. and
discrete data is expressed as number/percentage. Chi-
square test with Yates correction has been used to
calculate p-value (2-tailed) of 22 contingency tables.
For continuous data, Pearsons correlation coefficient
was calculated. For discrete data like NYHA class,
Spearmans Rho coefficient was used. To compare
means of continuous data, students T test has been
used. P value of less than 0.05 was considered
significant.
RESULTS
We had a total of 70 patients in our study. The male:
female ratio was 43:27 (table 1). Most of the patients
(n=60) were aged over 40 years. 50% of the patients
were 60 years or older. As table 1 show, 24% of the
patients had a history of regular intake of alcoholic
drinks and 46% of the patients were smokers. Of the
smoker subset, 15 patients (46.9%) had a smoking
history of more than 20 pack-years. The chief
presenting complaint of DCM was dyspnea. Majority
of the patients were in New York heart association
(NYHA) class 3 (figure 1). Palpitation and chest pain
were found in minority of study population (n=4 and
n=6 respectively).
Table 2 shows the different electrocardiographic
(ECG) characteristics of our patients. Tachycardia
(heart rate>100/minute)
waspresentin48patients.However, rate>120/minute
was present in only 8 patients. Atrial fibrillation
(figure 2) was found in 11 patients and ectopic beats
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Rudrajit et al., Int J Med Res Health Sci. 2014;3(3):639-644
were found in 15 patients. Of these 15 patients, 11
had ventricular ectopics. Right bundle branch block
(figure 3) was found in 8 (11.4%) patients.
Table 1: Table showing the demographic
characteristics of the study subjects (N=70)
Parameter Number
[percentage]
Age in
years
<20 2 [2.8]
20<40 8 [11.4]
41<60 25 [35.7]
61 35 [50]
Sex Male 43 [61.4]
Female 27 [38.6]
Alcohol
intake
No 39 [55.7]
Occasional (1-2
times/week)
4 [5.7]
Frequent (>2
times/week)
17 [24.3]
Smoking None 38 [54.3]
20 pack year 17 [24.3]
>20 pack year 15 [21.4]
Table 2: Table showing the ECG findings in our
study (n=70)
Parameter Number/
%
Rate
(/minute)
100 22/31.4%
101-110 27/38.6%
111-120 13/18.6%
121-130 7/10%
131 1/1.4%
Rhythm Regular 44/62.9%
Irregular Ectopics 15/21.4%
Atrial
fibrillation
11/15.7%
Bundle
branch block
(BBB)
Rt-BBB 8/11.4%
Lt BBB
15/21.4%
Ectopics Atrial 4/5.7%
Ventricular 11/15.7%
Table 3: Table showing the echocardiographic
findings of our study subjects
Parameter Number (%)
Ejection
Fraction
<20% 3 (4.3)
20-30% 27 (38.6)
>3040% 30 (42.9)
>4050% 10 (14.3)
>50% 0
Left atrial
size
3 cm 0
3.1-4 cm 25 (35.7)
4.1-5 cm 39 (55.7)
>5 cm 6 (8.6)
LVIDd 6 cm 0
6.17 cm 29 (41.4)
7.18 cm 35 (50)
>8 cm 6 (8.6)
LVIDs 4 cm 6 (8.6)
4.15 cm 32 (45.7)
5.16 cm 29 (41.4)
>6 cm 3 (4.3)
Regurgitatio
n
Mitral 11 (15.7)
Aortic 1 (1.4)
Combined
mitral and aortic
12 (17.1)
Tricuspid 20 (28.6)
Table 4: showing the age group wise parameters
Parameter 50 years >50 years p-
value
Gender ratio M:F 17:11 26:16 0.92
Ejection fraction (%) 32 9.2 33.1 6.2 0.54
Heart rate 108.1 16.8 102.7 12.6 0.12
Atrial fibrillation 3 (10.7%) 8 (19%) 0.50
Left atrial size
(mm)
43.4 4.6 42.6 4.7 0.46
LVIDs (mm) 50 7.4 49.5 5.6 0.76
The p-values show that there was no significant
statistical difference between the two age groups.
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Rudrajit et al., Int J Med Res Health Sci. 2014;3(3):639-644
Fig 1: Pie diagram showing the presentation
according to NYHA classification.
13
:
NYHA 1:angina, dyspnea, syncope or palpitation
(ADSP) at more than usual physical activity
NYHA2:ADSP at usual/ordinary physical activity
NYHA3:ADSP at less than usual physical activity
NYHA 4:ADSP at rest or with minimal activity.
Bedbound Patients
Fig 2: ECG showing atrial fibrillation
Fig3: ECG showing right bundle branch block (RBBB)
Table 3 shows the echocardiographic characters of
the study subjects. It is seen that 57 of the patients
had an ejection fraction between 20 and 40%. None
of the patients in our study had an ejection fraction
above 50%. Left atrial diameter above 4 cm was
found in 45 (64.3%) of the patients. Left ventricular
systolic and diastolic internal diameters were also
elevated in most of the patients. Systolic internal
diameter was more than 4 cm in 64 out of the 70
subjects and diastolic diameter was more than 6 cm in
all the subjects. Due to the left ventricular
enlargement, Valvular regurgitation was quite
common. It is seen that combined mitral and aortic
regurgitation was present in 17% of the patients.
Tricuspid regurgitation was present in 20 patients.
As seen in table 4, there was no significant difference
in the parameters based on age. In those aged over 50
years, atrial fibrillation was present in 19% cases.
It was seen that left ventricular systolic diameter
(LVIDs) was positively correlated with left atrial
(LA) size (r=0.403; p=0.0005). Thus, more the left
ventricular systolic dimensions (LVIDs), more the
left atrial size.No such positive correlation was found
with diastolic dimensions of left ventricle (LVIDD).
The ejection fraction was negatively correlated with
the left atrial size (r= -0.2306; p=0.055). Similar
relations were found with fractional shortening (FS)
of left ventricle (r=-0.279; p=0.019). The LA size
showed a negative correlation with heart rates of the
patient (r= -0.2342) although this was not statistically
significant. LVIDs showed a weak correlation with
the presenting NYHA stage of the patient (r=0.253,
p<0.05 by Spearmans rho coefficient).
DISCUSSION
In our study, we found a male preponderance (1.59:1)
in our DCM patient cohort. Also, most of the patients
were elderly. Similar finding has been reported from
U.P., India, where the male: female ratio was 1.5:1
and 48% of the patients were above 60 years of
age.
4
In our study, 50% of the patients were 60 years
or older. In the aforementioned study, DCM in less
than 40 years, females was mainly due to peripartum
cardiomyopathy
4
. However, in our study, there were
11 females in the under-40 age group. But only 3 of
them (27.3%) had postpartum cardiomyopathy. For
the rest, no specific cause was identified. Similar
male preponderance in DCM has also been reported
from other European studies.
1, 5
The exact cause for
this is not known. But some authors think that the
male hormones and lifestyle related changes may
predispose to cardiac muscle dysfunction and
alteration of cardiomyocyte membrane
functions.
3
However, there are also a few studies
where this male predominance has not been found. In
one study comparing DCM in blacks and whites in
USA, they have found that in the black subset, the
male: female ratio was almost equal.
6
With age, comorbidities like hypertension, diabetes,
malignancy or renal failure increase. These may
cause DCM and heart failure. In the European study,
0, 0%
24, 34%
33, 47%
13, 19%
CLINICAL FEATURES OF PATIENTS
NYHA 1
NYHA 2
NYHA 3
NYHA 4
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in autopsy proven DCM cases, the mean age of
patients was 63 13.3 years.
1
In our study, the mean
age was 54.416.2 years.
Alcohol and smoking are two risk factors for different
types of heart disease, including DCM. In an Indian
study from Hyderabad, smokers and alcoholics
comprised almost 18 and 16% of DCM cases
respectively.
3
In our study, 1 in 4 patients were
alcoholic. However, it is said that only alcohol is not
enough to cause DCM in most cases; alcoholic
cardiomyopathy is more common in those with
genetic predisposition to heart diseases, in contrast to
those without.
7
But we did not do genetic testing in
alcoholic DCM cases due to financial reasons. Once
DCM develops in alcoholics or smokers, the
prognosis is uniformly poor.
7
Different ECG and echocardiographicfindings are
found in DCM patients. In one Indian study, they
found ST-T changes in 90% cases, Left bundle
branch block (LBBB) in 30% and atrial fibrillation in
5% of the cases.
4
In our study, LBBB was found in
21% cases and atrial fibrillation (AF) in 15.7% (table
2). ST-T changes were found in 51% of the cases.
Atrial fibrillation and other arrhythmias are potential
risk factors for sudden cardiac death in DCM
patients. AF may occur spontaneously or may be
related to changes in geometry of the heart. In a study
from Romania, they found presence of increased
LVIDD and mitral regurgitation as risk factors for
occurrence of AF.
8
Also, they found that higher the
NYHA class, the more the chance of having
permanent AF.
8
In our study, 45.5% of patients with
AF had mitral regurgitation (MR). Overall prevalence
of AF was 15.7%, but among patients with MR, AF
was present in 21.7%. Also, as figure 1 shows,
overall 46 patients in our study had NYHA class 3 or
4 symptoms (65.7%). But among patients with AF in
our study, 72.7% had NYHA 3 or 4 symptoms.
Prominent echocardiographic findings in our study
included valvular regurgitation and increased
dimensions of left sided chambers (table 3).
Especially we found left atrial (LA) diameter >4 cm
in 45 patients. Left atrial diameter has important
prognostic implications.
9
It is a good indicator of left
ventricular end diastolic pressure.
9
In a study from
Kosovo, the authors have found a significant
correlation between LVIDD and different left atrial
dimensions like diameter, volume and LA area
withdifferent views in heart failure patients.
10
Large
LA size is also a risk factor for thrombotic episodes,
which may lead to sudden death. Not only cardiac
events, but cerebrovascular stroke is also increased in
patients with large LA.
10
In another study from
Turkey, the authors have found significantly
increased LA size in those with large LV systolic
dimensions in DCM.
11
This was also linked to
increased chance of AF and LA thrombus. Thus,
systolic dysfunction in DCM, as evidenced by
increased LVIDS, is a risk factor for these
comorbidities. LA size may act as a surrogate marker
for severity of systolic dysfunction. Appropriate
prophylactic therapy may be needed in some cases to
prevent potential catastrophe.
In our study, the LV ejection fraction was negatively
correlated with LA size of the patients. This
correlation between left atrial size and left ventricular
function has been found in some other studies too. In
one study, the sensitivity of left atrial dimensions in
predicting abnormal ejection fraction was found to be
71%
12
. LA size>40 mm was a marker of reduced
ejection fraction in that study.
12,13
Limitation of the study; our study is limited by the
small number of patients. Also, further
echocardiographic studies are needed with newer
parameters like LA volume, LV mass and tissue
Doppler imaging to characterise the cardiomyopathic
changes in DCM. We also could not do trans-
esophageal echocardiography in our patients due to
logistic reasons. This is a better technique in
assessing left atrial abnormalities.
CONCLUSION
This small observational study depicts the high
prevalence of DCM in elderly population, especially
males. These patients are more likely to have
arrhythmia and embolic episodes. Certain
echocardiographic parameters like left atrial size were
found to correlate with left ventricular parameters and
thus may be useful in predicting prognosis in DCM.
However, further multicentric studies are needed in
order to find the associated features in DCM patients
in India and to better elucidate the significance of
different chamber dimensions.
Conflict of interest: None
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Rudrajit et al., Int J Med Res Health Sci. 2014;3(3):639-644
ACKNOWLEDGMENT
Principal and M.S.V.P of the institution for allowing
us to conduct the study in the institution and guiding
us throughout.
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