Talasemi Major Hastalarında Tp-E Intervali Ve Tp-E/Qt, Tp-E/Qtc Oranlarının Değerlendirilmesi

Yıl 2022, Cilt: 6 Sayı: 1, 42 - 48, 27.03.2022

Zehra Erkal

https://doi.org/10.30565/medalanya.955688

Öz

Amaç: Talasemi majör (TM), kronik hemolitik anemiye sebep olan genetik bir hemoglobinopatidir. Tedavisinde tekrarlayan kan transfüzyonları gereklidir. Transfüzyonlara bağlı miyokardda biriken demir, kardiyomiyopati ve ventriküler aritmi gelişimine neden olur. Özellikle hayatı tehdit edebilecek ventriküler aritmi gelişme riskini öngörmek klinik açıdan çok önemlidir ve bu amaçla birçok parametre kullanılmıştır. Biz ventriküler repolarizasyonu gösteren, yeni ve güvenilir prediktörler olan Tp-e intervali, Tp-e/QT ve Tp-e/QTc oranını TM hastalarında ve sağlıklı kontrol grubunda karşılaştırmak amacıyla bu çalışmayı planladık.

Yöntem: Çalışmamıza Mart 2019- Haziran 2020 yılları arasında polikliniğimize rutin kardiyak kontrol amacıyla gelen 97 TM hastası ve 90 tane sağlıklı gönüllü kontrol grubu dahil edildi. Demografik ve ekokardiyografik bulgularına ek olarak retrospektif olarak hastaların elektrokardiyografileri (EKG) incelendi. Serum ferritin, C reaktif protein (CRP)düzeyleri ve nötrofil lenfosit oranları kaydedildi ve karşılaştırıldı. Yine hastalar aldıkları şelasyon tedavilerine göre sınıflandırılarak EKG parametreleri arasındaki fark açısından karşılaştırıldı.

Bulgular: Talasemi majör hasta grubunda Tp-e intervali 80 msn (60.0-80.0) iken kontrol grubunda 60 msn (50.0-70.0) (p<0.001), Tp-e/QT oranı TM grubunda 0.200 (0.160-0.225) iken kontrol grubunda 0.175(0.150-0.210) (p:0.014), Tp-e/QTc oranı TM grubunda 0.180 (0.130-0.190) iken kontrol grubunda 0.150 (0.130-0.180) (p:0.035) tespit edildi. Serum ferritin düzeyi ile EKG parametreleri arasında korelasyon izlenmedi.

Sonuç: Talasemi majör hastalarında EKG de artmış Tp-e intervali, Tp-e/QT ve Tp-e/QTc oranları, artmış kardiyak demir depolanmasına bağlı oluşan ventriküler repolarizasyon bozuklukları ve ventriküler aritmiler ile ilişkilidir. Aritmi gelişme riskini öngörmede bu basit ama güvenilir parametreler kullanılabilir.

Anahtar Kelimeler

Aritmi, elektrokardiyografi, talesemi

Assessment Of Tp-E Interval, Tp-E/Qt, Tp-E/Qtc Ratıos In Thalassemıa Major Patıents

Öz

Aim: Thalassemia major (TM) is a genetic hemoglobinopathy that causes chronic hemolytic anemia. Repeated blood transfusions are needed for treatment. Iron accumulation is used to predict the risk of ventricular arrhythmia. We designed this study to compare the Tp-e interval, Tp-e/QT ratio and Tp-e/QTc ratio, which are the novel and reliable predictors that show ventricular repolarization, between the TM patients and healthy control group.

Method: We included 97 TM patients who presented to our outpatient clinic for routine cardiac check-up from March 2019 to June 2020 and 90 healthy volunteers. In addition to the demographic and echocardiographic findings, patients’ electrocardiograms (ECG) were retrospectively analyzed. Their serum ferritin, C reactive protein (CRP) levels and neutrophil to lymphocyte ratios were recorded and compared.

Result: The Tp-e interval was 80 msn (60.0-80.0) in the group of thalassemia major patients whereas it was 60 msn (50.0-70.0) (p<0.001) in the control group. The Tp-e/QT ratio was 0.200 (0.160-0.225) in the TM group while it was 0.175(0.150-0.210) in the control group (p=0.014). The Tp-e/QTc ratio was 0.180 (0.130-0.190) in the TM group while it was 0.150 (0.130-0.180) in the control group (p=0.035). No correlation was found between their serum ferritin levels and ECG parameters.

Conclusion: Prolonged Tp-e interval, Tp-e/QT ve Tp-e/QTc ratios on the ECG in TM patients are associated with impaired ventricular repolarization due to excessive cardiac iron deposition and ventricular arrhythmias. These simple but reliable parameters can be used to predict the risk of arrhythmia.

Anahtar Kelimeler

arrhythmia, electrocardiography, thalassemia

Kaynakça

• 1. Pistoia L, Meloni A, Salvadori S, Renne S, Giuliano P, Caccamo P et al. “P6213 Role of different phenotypic groups of thalassemia major patients studied by CMR’’ European Heart Journal. 2018;39(1):1287-. DOI: 10.1093/eurheartj/ehy566.P6213.
• 2. Hershko C, Link G, Cabantchik I. Pathophysiology of iron overload. Ann N Y Acad Sci. 1998;850:191-201. doi: 10.1111/j.1749-6632.1998.tb10475.x.
• 3. Russo V, Rago A, Papa AA, Nigro G. Electrocardiographic Presentation, Cardiac Arrhythmias, and Their Management in β-Thalassemia Major Patients. Ann Noninvasive Electrocardiol. 2016;21(4):335-42. doi: 10.1111/anec.12389.
• 4. Dural M, Mert KU, İskenderov K. Evaluation of Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio in patients with mitral valve stenosis before and after balloon valvuloplasty. Anatol J Cardiol. 2017;18(5):353-60. DOI: 10.14744/anatoljcardiol.2017.7876.
• 5. Goldenberg I, Moss AJ, Zareba W. QT interval: how to measure it and what is normal. J Cardiovasc Electrophysiol. 2006;17(3):333-6. DOI: 10.1111/j.1540-8167. 2006.00408. x
• 6. Castro Hevia J, Antzelevitch C, Tornes Barzaga F, Dorantes Sanchez M, Dorticos Balea F, Molina RZ et al. Tpeak-Tend and Tpeak-Tend dispersion as risk factors for ventricular tachcardia/ventricular fibrillation in patients with the Brugada syndrome. J Am Coll Cardiol. 2006;47(9):1828-34. DOI: 10.1016/j.jacc.2005.12.049.
• 7. Hershko C, Link G, Cabantchik I. Pathophysiology of iron overload. Ann N Y Acad Sci. 1998;850:191-201. DOI: 10.1111/j.1749-6632.1998.tb10475.x
• 8. Jensen PD. Evaluation of iron overload. Br J Haematol. 2004;124(6):697-711. DOI: 10.1111/j.1365-2141.2004.04838.x.
• 9. Kim E, Giri SN, Pessah IN. Iron (II) is a modulator of ryanodine-sensitive calcium channels of cardiac muscle sarcoplasmic reticulum. Toxicol Appl Pharmacol. 1995;130(1):57-66. DOI: 10.1006/taap.1995.1008.
• 10. Rose RA, Sellan M, Simpson JA, Izaddoustor F, Cifelli C, Panama BK et al. Iron overload decreases CaV1.3- dependent L-type Ca2+ currents leading to bradycardia, altered electrical conduction, and atrial fibrillation. Circ Arrhythm Electrophysiol. 2011;4(5):733-42. DOI: 10.1161/CIRCEP.110.960401
• 11. Zurlo MG, De Stefano P, Borgna-Pignatti C, Di Palma A, Piga A, Melevendi C et al. Survival and causes of death in thalassemia major. Lancet. 1989;2(8653):27-30. DOI: 10.1016/s0140-6736(89)90264-x
• 12. Borgna-Pignatti C, Rugolotto S, De Stefano P, Piga A, Di Gregorio F, Sabato V et al. Survival and disease complications in thalassemia major. Ann NY Acad Sci. 1998;850:227-31. DOI: 10.1111/j.1749-6632.1998.tb10479.x.
• 13. Veglio F, Melchio R, Rabbia F, Molino P, Genova GC, Martini G et al. Blood pressure and heart rate in young thalassemia major patients. Am J Hypertens. 1998;11(5):539-47. DOI: 10.1016/s0895-7061(97)00263-x.
• 14. Schellhammer PF, Engle MA, Hagstrom JW. Histochemical studies of the myocardium and conduction system in acquired iron storage disease. Circulation. 1967;35(4):631-7. DOI: 10.1161/01.cir.35.4.631.
• 15. Russo V, Papa AA, Rago A, D'Ambrosio P, Cimmino G, Palladino A, Politano L, Nigro G. Increased heterogeneity of ventricular repolarization in myotonic dystrophy type 1 population. Acta Myol. 2016;35(2):100-106. PMID: 28344440
• 16. Russo V, Rago A, Politano L, Papa AA, Di Meo F, Russo MG, Golino P, Calabrò R, Nigro G. Increased dispersion of ventricular repolarization in Emery Dreifuss muscular dystrophy patients. Med Sci Monit. 2012;18(11):CR643-7. doi: 10.12659/msm.883541.
• 17. Nigro G, Russo V, Rago A, Papa AA, Carbone N, Marchel M, Palladino A, Hausmanowa-Petrusewicz I, Russo MG, Politano L. Regional and transmural dispersion of repolarisation in patients with Emery-Dreifuss muscular dystrophy. Kardiol Pol. 2012;70(11):1154-9. PMID: 23180524.
• 18. Nigro G, Russo V, de Chiara A, Rago A, Cioppa ND, Chianese R, Manfredi D, Calabrò R. Autonomic nervous system modulation before the onset of sustained atrioventricular nodal reentry tachycardia. Ann Noninvasive Electrocardiol. 2010;15(1):49-55. doi: 10.1111/j.1542-474X.2009.00339.x.
• 19. Narayanan K, Zhang L, Kim C, Uy-Evanado A, Teodorescu C, Reinier K, Zheng ZJ, Gunson K, Jui J, Chugh SS. QRS fragmentation and sudden cardiac death in the obese and overweight. J Am Heart Assoc. 2015;4(3):e001654. doi: 10.1161/JAHA.114.001654.
• 20. Yan GX, Antzelevitch C. Cellular basis for the normal T wave and the electrocardiographic manifestations of the long QT syndrome. Circulation. 1998,98(18),1928-36. DOI: 10.1161/01.CIR.98.18.1928.
• 21. Gupta P, Patel C, Patel H, Narayanaswamy S. Malhotra B, Green JT et al. T(p-e)/QT ratio as an index of arrhythmogenesis. J Electrocardiol. 2008;41(6):567-74. DOI: 10.1016/j.jelectrocard.2008.07.016
• 22. Yayla C, Bilgin M, Akboğa MK, Yayla K, Canpolat U, Asarcıklı LD et al. Evaluation of Tp-E interval and Tp-E/QT ratio in patients with aortic stenosis. Ann Noninvasive Electrocardiol. 2016;21(3): 287-93. DOI: 10.1111/anec.12298.
• 23. Demirol M, Karadeniz C, Ozdemir R, Çoban Ş, Katipoğlu N, Yozgat Y, Meşe T, Unal N. Prolonged Tp-e Interval and Tp-e/QT Ratio in Children with Mitral Valve Prolapse. Pediatr Cardiol. 2016;37(6):1169-74. doi: 10.1007/s00246-016-1414-7.
• 24. Akboğa MK, Balcı KG, Yılmaz S, Aydın S, Yayla Ç, Ertem AG et al. Tp-e interval and Tp-e/QTc ratio as novel surrogate markers for prediction of ventricular arrhythmic events in hypertrophic cardiomyopathy. Anatol J Cardiol. 2017;18:48-53. DOI: 10.14744/AnatolJCardiol.2017.7581. DOI:10.14744/AnatolJCardiol.2017.7865
• 25. Karaman K, Altunkaş F, Çetin M, Karayakali M, Arısoy A, Akar İ et al. New markers for ventricular repolarization in coronary slow flow: Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio. Ann Noninvasive Electrocardiol. 2015;20(4):338-44. DOI: 10.1111/anec.12203.
• 26. Ajibare AO, Olabode OP, Fagbemiro EY, Akinlade OM, Akintunde AA, Akinpelu OO, Olatunji LA, Soladoye AO, Opadijo OG. Assessment of Ventricular Repolarization in Sickle Cell Anemia Patients: The Role of QTc Interval, Tp-e Interval and Tp-e/QTc Ratio and Its Gender Implication. Vasc Health Risk Manag. 2020;16:525-533. doi: 10.2147/VHRM.S259766.