Evaluation of Tp-e interval, Tp-e/QT, and Tp-e/QTc ratio in primary hyperparathyroidism before and after parathyroidectomy

Abstract

Aims: This study aimed to evaluate Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratios, which are new ventricular repolarization (VR) parameters in primary hyperparathyroidism (PHPT) patients, and also investigate the potential effect of parathyroidectomy (PTx) on these parameters. Methods: In total, 27 patients with PHPT who underwent PTx and 25 control subjects were selected for our study. Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratios of patients planned for PTx were compared to healthy matched controls. Electrocardiographic parameters measured 6 months after the surgery were also compared with preoperative values for each patient. Results: Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were significantly higher in PHPT patients compared to the control group (p<0.001, for all).It was observed that the parameters mentioned after surgery decreased significantly, and there was no statistical difference when compared to the control group.The correlation analysis revealed a significant and positive correlation between corrected calcium (CCa) and PTH levels with Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio (for Ca; r=0.515, p=0.006; r=0.398, p=0.040; r=0.797, p<0.001 respectively vs. for PTH; r=538, p=0.04; r=0.422, p=0.028; r=0.812, p<0.001 respectively). Conclusions: This study showed that Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were prolonged in PHPT.These values, which are accepted as an indicator of sudden cardiac death after PTx, decreased significantly. In addition, both high PTH and high calcium(Ca) levels appear to have the potential to cause arrhythmogenic effects separately.

Keywords

• Primary hyperparathyroidism
• ventricular repolarization
• parathyroidectomy
• ventricular arrhythmia

References

1. Pallan S, Rahman MO, Khan AA. Diagnosis and management of primary hyperparathyroidism. BMJ. 2012;344:e1013.
2. Walker MD, Silverberg SJ. Cardiovascular aspects of primary hyperparathyroidism. J Endocrinol Invest. 2008;31(10):925-931.
3. Insogna KL. Primary hyperparathyroidism. N Engl J Med. 2018; 379(11):1050-1059.
4. Elming H, Holm E, Jun L, et al. The prognostic value of the QT interval and QT interval dispersion in all-cause and cardiac mortality and morbidity in a population of Danish citizens. Eur Heart J. 1998;19(9):1391-1400.
5. Tse G, Yan BP. Traditional and novel electrocardiographic conduction and repolarization markers of sudden cardiac death. Europace. 2017;19(5):712-721.
6. Kors JA, Ritsema van Eck HJ, van Herpen G. The meaning of the Tp-Te interval and its diagnostic value. J Electrocardiol. 2008;41(6):575-580.
7. Castro Hevia J, Antzelevitch C, TornésBárzaga F, 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(9):1828-1834.
8. Li W, Liu W, Li H. Electrocardiography is useful to predict postoperative ventricular arrhythmia in patients undergoing cardiac surgery: a retrospective study. Front Physiol. 2022;13:873821.

9. Piepoli MF, Hoes AW, Agewall S, et al; ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-2381.
10. Gupta P, Patel C, Patel H, et al. T(p-e)/QT ratio as an index of arrhythmogenesis. J Electrocardiol. 2008;41(6):567-574.
11. Kors JA, van Herpen G, van Bemmel JH. QT dispersion as an attribute of T-loop morphology. Circulation. 1999;99(11):1458-1463.
12. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16(3):233-271. doi.org/10.1093/ehjci/jev014
13. Ozdemir D, Kalkan GY, Bayram NA, et al. Evaluation of left ventricle functions by tissue Doppler, strain, and strain rate echocardiography in patients with primary hyperparathyroidism. Endocrine. 2014;47(2):609-617.
14. Soares AA, Freitas WM, Japiassú AV, et al. Enhanced parathyroid hormone levels are associated with left ventricle hypertrophy in very elderly men and women. J Am SocHypertens. 2015;9(9):697-704.
15. Walker MD, Rundek T, Homma S, et al. Effect of parathyroidectomy on subclinical cardiovascular disease in mild primary hyperparathyroidism. Eur J Endocrinol. 2012;167(2):277-285.
16. Bosworth C, Sachs MC, Duprez D, et al. Parathyroid hormone and arterial dysfunction in the multi-ethnic study of atherosclerosis. Clin Endocrinol. 2013;79(3):429-436.
17. Ekmekci A, Abaci N, Colak Ozbey N, et al. Endothelial function and endothelial nitric oxide synthase intron 4a/b polymorphism in primary hyperparathyroidism. J Endocrinol Invest. 2009; 32(7):611-616.
18. Lind L, Ljunghall S. Serum calcium and the ECG in patients with primary hyperparathyroidism. J Electrocardiol. 1994;27(2):99-103.
19. Surawicz B. Role of electrolytes in etiology and management of cardiac arrhythmias. Prog Cardiovasc Dis. 1966;8(4):364-386.
20. Rosenqvist M, Nordenström J, Andersson M, Edhag OK. Cardiac conduction in patients with hypercalcaemia due to primary hyperparathyroidism. Clin Endocrinol. 1992;37(1):29-33.
21. Celik M, Emiroglu MY, Bayram Z, et al. Electrophysiologic changes and their effects on ventricular arrhythmias in patients with continuous-flow left ventricular assist devices. ASAIO J. 2022;68(3):341-348.
22. Barr CS, Naas A, Freeman M, et al. QT dispersion and sudden unexpected death in chronic heart failure. Lancet. 1994;343(8893):327-329.
23. Yamaguchi M, Shimizu M, Ino H, et al. T wave peak-to-end interval and QT dispersion in acquired long QT syndrome: a new index for arrhythmogenicity. Clin Sci. 2003;05(6):671-676.
24. Yan GX, Antzelevitch C. Cellular basis for the normal T wave and the electrocardiographic manifestations of the long-QT syndrome. Circulation. 1998;98(18):1928-1936.
25. Antzelevitch C, Shimizu W, Yan GX, et al. The M cell: its contribution to the ECG and to normal and abnormal electrical function of the heart. J Cardiovasc Electrophysiol. 1999;10(8):1124-1152.
26. Emori T, Antzelevitch C. Cellular basis for complex T waves and arrhythmic activity following combined I(Kr) and I(Ks) block. J Cardiovasc Electrophysiol. 2001;12(12):1369-1378.
27. Watanabe N, Kobayashi Y, Tanno K, et al. Transmural dispersion of repolarization and ventricular tachyarrhythmias. J Electrocardiol. 2004;37(3):191-200.
28. Milberg P, Reinsch N, Wasmer K, et al. Transmural dispersion of repolarization as a key factor of arrhythmogenicity in a novel intact heart model of LQT3. Cardiovasc Res. 2005;65(2):397-404.
29. Pepe J, Cipriani C, Curione M, et al. Reduction of arrhythmias in primary hyperparathyroidism, by parathyroidectomy, evaluated with 24-h ECG monitoring. Eur J Endocrinol. 2018;179(2):117-124.
30. Curione M, Letizia C, Amato S, et al. Increased risk of cardiac death in primary hyperparathyroidism: what is a role of electrical instability? Int J Cardiol. 2007;121(2):200-202.
31. Curione M, Amato S, Di Bona S, et al. Parathyroidectomy erase increased myocardial electrical vulnerability in patients with primary hyperparathyroidism. Int J Cardiol. 2010;141(2):201-202.
32. Yılmaz Y, Keleşoğlu Ş, Gökay F. Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios in patients with primary hyperparathyroidism and their relationship with cardiac arrhythmic events. Turk J Med Sci. 2022;52(2):397-404.
33. Yan H, Liu H, Wang G, et al. The Tp-e/QT ratio as a predictor of nocturnal premature ventricular contraction events in patients with obstructive sleep apnea. Sleep Breath. 2023;27(2):469-476.
34. Tashiro N, Muneuchi J, Ezaki H, et al. Ventricular repolarization dispersion is a potential risk for the development of life-threatening arrhythmia in children with hypertrophic cardiomyopathy. Pediatr Cardiol. 2022;43(7):1455-1461.
35. Shimizu M, Ino H, Okeie K, et al. T-peak to T-end interval may be a better predictor of high-risk patients with hypertrophic cardiomyopathy associated with a cardiac troponin I mutation than QT dispersion. Clin Cardiol. 2002;25(7):335-339.
36. Nilsson IL, Aberg J, Rastad J, Lind L. Maintained normalization of cardiovascular dysfunction 5 years after parathyroidectomy in primary hyperparathyroidism. Surg. 2005;137(6):632-638.
37. DiPette DJ, Christenson W, Nickols MA, Nickols GA. Cardiovascular responsiveness to parathyroid hormone (PTH) and PTH-related protein in genetic hypertension. Endocrinol. 1992;130(4):2045-2051.
38. Schlüter KD, Piper HM. Cardiovascular actions of parathyroid hormone and parathyroid hormone-related peptide. Cardiovasc Res. 1998;37(1):34-41.
39. Zhang YB, Smogorzewski M, Ni Z, Massry SG. Altered cytosolic calcium homeostasis in rat cardiac myocytes in CRF. Kidney Int. 1994;45(4):1113-1119.
40. Wald DA. ECG manifestations of selected metabolic and endocrine disorders. Emerg Med Clin North Am. 2006;24(1):145-157.