REVISITING THE ROLE OF ELECTROCARDIOGRAPHY FOR SCREENING OF CONGENITAL HEART DISEASE IN YOUNG ADULTS PERAN ELEKTROKARDIOGRAFI DALAM PENAPISAN PENYAKIT JANTUNG BAWAAN PADA DEWASA MUDA

Introduction: Congenital heart disease (CHD) is the most prevalent congenital disability found in newborns. Many cases remain unknown until complications occur, usually in young adults. Transthoracic and Doppler echocardiography are modalities of choice for CHD detection, but these are limited in Indonesia. Electrocardiography (ECG) is a widely available and low-cost test. This study investigated the role of ECG as a screening modality for CHD. Methods: A cross-sectional study was held at Atma Jaya School of Medicine and Health Science from August to November 2019. Participants were students aged 18 years old or more. Exclusion criteria was previously detected for CHD. Data were collected through history taking, anthropometrics, blood pressure measurement, and 12 leads ECG. ECG results were interpreted independently by two cardiologists to minimize observer bias. Results: A total of 193 students, 78 male and 115 female, participated. The mean age was 19.22±1.85 years. ECG abnormalities were discovered in 57 (29.5%) participants:15 with crochetage sign, 13 right axis deviation, three left axis deviation, nine right ventricle hypertrophy, and nine left ventricle hypertrophy, six left bundle branch block, and two defective T wave. Further evaluation was done with echocardiography in 20 participants, which resulted in one participant having mitral valve prolapsed (MVP).


INTRODUCTION
Congenital heart disease (CHD) is the most common congenital disease found in newborns.Congenital heart disease affects approximately 6-8 per 1000 live births worldwide and becomes the leading cause of mortality from birth defects. 1,2The incidence of CHD is increasing over time, especially in mild types. 3In Asian and Black ethnic groups, the incidence of CHD is significantly higher. 2 About 40.000 children per year are born with CHD in the United States. 3We found there is no national report on CHD in Indonesia.
Hospital-based study in Sardjito hospital, a tertiary referral hospital in Yogyakarta and Central Java, the incidence of CHD in 2014 was 134/10.000person-years newly diagnosed by echocardiography.These consisted of 22% adults with mean age of 32.7 ± 13.5 years old. 4 Although all newborns underwent congenital defect screening, delayed diagnosis still occurs in over 10% of critical congenital heart disease cases.The leading causes are associated with delivery outside a tertiary hospital and isolated CHD. 5 In mild cases, it is not uncommon to remain undiagnosed until a complication occurs.
One in 150 adults is expected to have some form of CHD.The severity of lesions varies from mild lesions without dysfunction to severe lesions such as hypoplastic left heart syndrome.Atrial septal defect (ASD) and Tetralogy of Fallot (TOF) are the most common CHD in adults. 6From 2015 to 2016, the death rate from congenital cardiovascular defects increased from 0.30 to 0.60 per 100.000people in adults 25 years and above.
For ages 15 to 24 years old, there were 0.40 deaths per 100.000people. 6rly recognition of CHD in adults is essential to prevent further decrement of cardiac function.Transthoracic and Doppler echocardiography is the most widely used imaging tool in diagnosing CHD.Other options include cardiac magnetic resonance (CMR), cardiac computed tomography, and nuclear scintigraphy. 7Echocardiography is still a limited resource in Indonesia.It is unavailable in primary health care and only performed in higher health care facilities when there is a suspicion of cardiac abnormalities.On the other side, electrocardiography (ECG) is a well-known modality with low cost and is widely used in health care for cardiac assessment.Some reports state that patients with ECG abnormalities have CHD using further evaluation. 8,9normalities in ECG may refer to lesions found in CHD. 10 First-degree heart block, third-degree heart block, right bundle branch block, and right or/and left ventricular hypertrophy may be found in ventricular septal defect (VSD). 11Previous studies reported incomplete right bundle branch block and crochetage R wave presence in inferior derivations in patients with ASD. 12 Other than that, defective T wave (DTW) has recently been described as a sensitive marker for ASD. 13 In the patient with patent ductus arteriosus (PDA), the ECG may demonstrate sinus tachycardia, atrial fibrillation, left ventricular hypertrophy, right ventricular hypertrophy, right bundle branch block, and left atrial enlargement in moderate to large ductus shunts. 14,15Electrocardiogram in a most patients with ToF shows right bundle branch block (RBBB) with or without QRS fragmentation. 16 is now recognized that CHD is associated with lifelong comorbidities such as arrhythmias, pulmonary hypertension, and a repeated need for surgery. 17After reaching 25 years old, the heart will undergo permanent remodeling.Early recognition and repair prevent morbidity and mortality caused by CHD. 182][13][14][15][16] We, therefore, examine ECG as an alternative early screening modality to assess cardiac abnormalities in CHD.

METHODS
A descriptive cross-sectional study was done at the Faculty of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia.Participants were all students above 18 years old and willing to be assessed.
Participants with a history of CHD will be excluded from this study.One participant with incomplete RBBB was found to have mild mitral valve prolapsed (MVP).Data are shown in Table 5.        21 Other findings, a defective T wave (DTW), has also been described as a sensitive finding for ASD.DTW is defined as an inverted proximal limb of the T wave in the right precordial leads. 12 our study, 29.5% of participants had interpreting ECG in young people. 10Moreover, specific abnormalities on ECG, suggesting signs of congenital heart disease.Crochetage sign and DTW were found in 15 and 2 participants, respectively.This result should raise our concern about finding the culprit and preventing early complications.Although ECG findings can indicate the existence of CHD, a normal variation or a false positive result is possible, which are common findings in

Table 1 .
Criteria for ECG Findings

Table 3 .
Reported Symptoms and Signs

Table 6 .
Electrocardiography findings in Congenital Heart Disease