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Rahola JT, Mattila SM, Kiviniemi AM, Ukkola OH, Tulppo MP, Junttila MJ, Huikuri HV, Kenttä TV, Perkiömäki JS. Prognostic significance of beat-to-beat variability of spatial heterogeneity of repolarization analyzed from a 5-minute resting electrocardiogram in coronary artery disease. Heart Rhythm 2024; 21:1093-1099. [PMID: 38597856 DOI: 10.1016/j.hrthm.2024.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Data on the prognostic significance of temporal variability of spatial heterogeneity of electrocardiographic repolarization in coronary artery disease (CAD) are limited. OBJECTIVE The purpose of this study was to evaluate the prognostic value of temporal variability of T-wave morphology analyzed from a 5-minute resting electrocardiogram in CAD. METHODS The standard deviation (SD) of T-wave morphology dispersion (TMD-SD) and the SD of total cosine R-to-T were analyzed on a beat-to-beat basis from a 5-minute period of the standard resting 12-lead electrocardiogram obtained before the clinical stress test in 1702 patients with angiographically verified CAD and well-preserved left ventricular function. RESULTS During an average of 8.7 ± 2.2 years of follow-up, 60 patients experienced sudden cardiac death/arrest (SCD/SCA) (3.5%), 69 patients nonsudden cardiac death (NSCD) (4.1%), and 161 patients noncardiac death (9.5%). TMD-SD was significantly higher in patients who experienced SCD/SCA than in other patients (1.72 ± 2.00 vs 1.12 ± 1.75; P = .01) and higher in patients who succumbed to NSCD than in other patients (1.57 ± 1.74 vs 1.12 ± 1.76; P = .04), but it did not differ significantly between patients who experienced noncardiac death and those without such an event (1.16 ± 1.42 vs 1.14 ± 1.79; P = .86). In the Cox multivariable hazards model, TMD-SD retained its significant association with the risk of SCD/SCA (hazard ratio 1.119; 95% confidence interval 1.015-1.233; P = .024) but not with the risk of NSCD (hazard ratio 1.089; 95% confidence interval 0.983-1.206; P = .103). CONCLUSION TMD-SD is independently associated with the long-term risk of SCD/SCA in patients with CAD.
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Affiliation(s)
- Janne T Rahola
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Severi M Mattila
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mikko P Tulppo
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.
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Malik M. The value of invisible electrocardiography. Heart Rhythm 2024; 21:1100-1101. [PMID: 38639683 DOI: 10.1016/j.hrthm.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Marek Malik
- National Heart and Lung Institute, Imperial College, London, United Kingdom; Faculty of Medicine, Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic.
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Din S, Qaraqe M, Mourad O, Qaraqe K, Serpedin E. ECG-based cardiac arrhythmias detection through ensemble learning and fusion of deep spatial-temporal and long-range dependency features. Artif Intell Med 2024; 150:102818. [PMID: 38553158 DOI: 10.1016/j.artmed.2024.102818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 04/02/2024]
Abstract
Cardiac arrhythmia is one of the prime reasons for death globally. Early diagnosis of heart arrhythmia is crucial to provide timely medical treatment. Heart arrhythmias are diagnosed by analyzing the electrocardiogram (ECG) of patients. Manual analysis of ECG is time-consuming and challenging. Hence, effective automated detection of heart arrhythmias is important to produce reliable results. Different deep-learning techniques to detect heart arrhythmias such as Convolutional Neural Network (CNN), Long Short-Term Memory (LSTM), Transformer, and Hybrid CNN-LSTM were proposed. However, these techniques, when used individually, are not sufficient to effectively learn multiple features from the ECG signal. The fusion of CNN and LSTM overcomes the limitations of CNN in the existing studies as CNN-LSTM hybrids can extract spatiotemporal features. However, LSTMs suffer from long-range dependency issues due to which certain features may be ignored. Hence, to compensate for the drawbacks of the existing models, this paper proposes a more comprehensive feature fusion technique by merging CNN, LSTM, and Transformer models. The fusion of these models facilitates learning spatial, temporal, and long-range dependency features, hence, helping to capture different attributes of the ECG signal. These features are subsequently passed to a majority voting classifier equipped with three traditional base learners. The traditional learners are enriched with deep features instead of handcrafted features. Experiments are performed on the MIT-BIH arrhythmias database and the model performance is compared with that of the state-of-art models. Results reveal that the proposed model performs better than the existing models yielding an accuracy of 99.56%.
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Affiliation(s)
- Sadia Din
- Texas A&M University, Electrical and Computer Engineering Program, Doha, Qatar.
| | - Marwa Qaraqe
- Hamad Bin Khalifa University, Qatar Foundation, Division of Information and Computing Technology, College of Science and Engineering, Doha, Qatar
| | | | - Khalid Qaraqe
- Texas A&M University, Electrical and Computer Engineering Program, Doha, Qatar
| | - Erchin Serpedin
- Texas A&M University, College Station, Electrical and Computer Engineering Department, TX, USA
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Hnatkova K, Andršová I, Novotný T, Vanderberk B, Sprenkeler D, Junttila J, Reichlin T, Schlögl S, Vos MA, Friede T, Bauer A, Huikuri HV, Willems R, Schmidt G, Sticherling C, Zabel M, Malik M. QRS complex and T wave planarity for the efficacy prediction of automatic implantable defibrillators. Heart 2024; 110:178-187. [PMID: 37714697 PMCID: PMC10850677 DOI: 10.1136/heartjnl-2023-322878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/19/2023] [Indexed: 09/17/2023] Open
Abstract
OBJECTIVE To test the hypothesis that in recipients of primary prophylactic implantable cardioverter-defibrillators (ICDs), the non-planarity of ECG vector loops predicts (a) deaths despite ICD protection and (b) appropriate ICD shocks. METHODS Digital pre-implant ECGs were collected in 1948 ICD recipients: 21.4% females, median age 65 years, 61.5% ischaemic heart disease (IHD). QRS and T wave three-dimensional loops were constructed using singular value decomposition that allowed to measure the vector loop planarity. The non-planarity, that is, the twist of the three-dimensional loops out of a single plane, was related to all-cause mortality (n=294; 15.3% females; 68.7% IHD) and appropriate ICD shocks (n=162; 10.5% females; 87.7% IHD) during 5-year follow-up after device implantation. Using multivariable Cox regression, the predictive power of QRS and T wave non-planarity was compared with that of age, heart rate, left ventricular ejection fraction, QRS duration, spatial QRS-T angle, QTc interval and T-peak to T-end interval. RESULTS QRS non-planarity was significantly (p<0.001) associated with follow-up deaths despite ICD protection with HR of 1.339 (95% CI 1.165 to 1.540) but was only univariably associated with appropriate ICD shocks. Non-planarity of the T wave loop was the only ECG-derived index significantly (p<0.001) associated with appropriate ICD shocks with multivariable Cox regression HR of 1.364 (1.180 to 1.576) but was not associated with follow-up mortality. CONCLUSIONS The analysed data suggest that QRS and T wave non-planarity might offer distinction between patients who are at greater risk of death despite ICD protection and those who are likely to use the defibrillator protection.
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Affiliation(s)
- Katerina Hnatkova
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Irena Andršová
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic
| | - Tomáš Novotný
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic
| | - Bert Vanderberk
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - David Sprenkeler
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Juhani Junttila
- MRC Oulu, University Central Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Simon Schlögl
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Gottingen, Germany
- German Center of Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Marc A Vos
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tim Friede
- German Center of Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Axel Bauer
- University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Heikki V Huikuri
- University Central Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Rik Willems
- Division of Experimental Cardiology, Department of Cardiovascular Diseases, University of Leuven, Leuven, Belgium
- Division of Clinical Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Georg Schmidt
- Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | | | - Markus Zabel
- German Center of Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
- Cardiology and Pneumology, Heart Center, University Hospital Göttingen, Göttingen, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic
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5
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Dural M, Ghossein MA, Gerrits W, Daniels F, Meine M, Maass AH, Rienstra M, Prinzen FW, Vernooy K, van Stipdonk AMW. Association of vectorcardiographic T-wave area with clinical and echocardiographic outcomes in cardiac resynchronization therapy. Europace 2023; 26:euad370. [PMID: 38146837 PMCID: PMC10766142 DOI: 10.1093/europace/euad370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023] Open
Abstract
AIMS Data on repolarization parameters in cardiac resynchronization therapy (CRT) are scarce. We investigated the association of baseline T-wave area, with both clinical and echocardiographic outcomes of CRT in a large, multi-centre cohort of CRT recipients. Also, we evaluated the association between the baseline T-wave area and QRS area. METHODS AND RESULTS In this retrospective study, 1355 consecutive CRT recipients were evaluated. Pre-implantation T-wave and QRS area were calculated from vectorcardiograms. Echocardiographic response was defined as a reduction of ≥15% in left ventricular end-systolic volume between 3 and 12 months after implantation. The clinical outcome was a combination of all-cause mortality, heart transplantation, and left ventricular assist device implantation. Left ventricular end-systolic volume reduction was largest in patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs compared with QRS area ≥ 109 μVs and T-wave area < 66 μVs (P = 0.004), QRS area < 109 μVs and T-wave area ≥ 66 μVs (P < 0.001) and QRS area < 109 μVs and T-wave area < 66 μVs (P < 0.001). Event-free survival rate was higher in the subgroup of patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs (n = 616, P < 0.001) and QRS area ≥ 109 μVs and T-wave area < 66 μVs (n = 100, P < 0.001) than the other subgroups. In the multivariate analysis, T-wave area remained associated with echocardiographic response (P = 0.008), but not with the clinical outcome (P = 0.143), when QRS area was included in the model. CONCLUSION Baseline T-wave area has a significant association with both clinical and echocardiographic outcomes after CRT. The association of T-wave area with echocardiographic response is independent from QRS area; the association with clinical outcome, however, is not.
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Affiliation(s)
- Muhammet Dural
- Department of Cardiology, Eskişehir Osmangazi University Faculty of Medicine, Odunpazarı, Eskişehir 26040, Turkey
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
| | - Mohammed A Ghossein
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Willem Gerrits
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Fenna Daniels
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alexander H Maass
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
| | - Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
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Stabenau HF, Waks JW. BRAVEHEART: Open-source software for automated electrocardiographic and vectorcardiographic analysis. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 242:107798. [PMID: 37734217 DOI: 10.1016/j.cmpb.2023.107798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/17/2023] [Accepted: 09/03/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Electrocardiographic (ECG) and vectorcardiographic (VCG) analyses are used to diagnose current cardiovascular disease and for risk stratification for future adverse cardiovascular events. With increasing use of digital ECGs, research into novel ECG/VCG parameters has increased, but widespread computer-based ECG/VCG analysis is limited because there are no currently available, open-source, and easily customizable software packages designed for automated and reproducible analysis. METHODS AND RESULTS We present BRAVEHEART, an open-source, modular, customizable, and easy to use software package implemented in the MATLAB programming language, for scientific analysis of standard 12-lead ECGs acquired in a digital format. BRAVEHEART accepts a wide variety of digital ECG formats and provides complete and automatic ECG/VCG processing with signal denoising to remove high- and low-frequency artifact, non-dominant beat identification and removal, accurate fiducial point annotation, VCG construction, median beat construction, customizable measurements on median beats, and output of measurements and results in numeric and graphical formats. CONCLUSIONS The BRAVEHEART software package provides easily customizable scientific analysis of ECGs and VCGs. We hope that making BRAVEHART available will allow other researchers to further the field of ECG/VCG analysis without having to spend significant time and resources developing their own ECG/VCG analysis software and will improve the reproducibility of future studies. Source code, compiled executables, and a detailed user guide can be found at http://github.com/BIVectors/BRAVEHEART. The source code is distributed under the GNU General Public License version 3.
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Affiliation(s)
- Hans Friedrich Stabenau
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Jonathan W Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America.
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Gomez N, Ramirez J, Martinez JP, Laguna P. Time-Warping Analysis of the T-Wave Peak-to-End Interval to Quantify Ventricular Repolarization Dispersion During Ischemia. IEEE J Biomed Health Inform 2023; 27:5314-5325. [PMID: 37651478 DOI: 10.1109/jbhi.2023.3310878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Variations in the dispersion of ventricular repolarization can be quantified by T-wave time-warping based index, dw. However, the early phase of the T-wave can be affected by ST-segment changes during ischemia. We hypothesized that restricting dw to the T-wave peak-to-end ( Tpe) would circumvent this limitation while still quantifying variations in repolarization dispersion. A total of 101 ECG recordings from patients undergoing coronary occlusion, together with their control recordings, were analyzed. A series of dw values was calculated by quantifying the Tpe morphological variations between the T-waves at different occlusion stages and a baseline T-wave. We introduced a normalized version of dw, Rd, reflecting variations of dw during occlusion relative to control recordings ( Rd = 1 corresponds to the same level of variation). The dw series followed a gradually increasing trend with occlusion time, reaching median [range] Rd values of 9.44 [1.01, 80.74] at the occlusion end. Rd at occlusion end was significantly higher than threshold values of 1, 2, 5, and 10 in 94.1%, 85.11%, 64.4% and 48.5% of patients, respectively. The spatial lead-wise analysis of dw showed distinct distributions depending on the occluded artery, suggesting a relation with the ischemia location. The relative variation R with ischemia of index dw (9.4) is greater than that of the T-wave amplitude (7.7), Tpe interval (2.7) and T-wave width (3.0). In conclusion, dw tracks ischemic-induced variations in repolarization dispersion in a more robust manner than classical indexes, avoiding the impact of ST segment elevation/depression or early T-wave distortions, thus warranting further clinical studies.
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Hekkanen JJ, Kenttä TV, Holmström L, Tulppo MP, Ukkola OH, Pakanen L, Junttila MJ, Huikuri HV, Perkiömäki JS. Association of electrocardiographic spatial heterogeneity of repolarization and spatial heterogeneity of atrial depolarization with left ventricular fibrosis. Europace 2023; 25:820-827. [PMID: 36635858 PMCID: PMC10062366 DOI: 10.1093/europace/euac273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/14/2022] [Indexed: 01/14/2023] Open
Abstract
AIMS To evaluate the relationship between spatial heterogeneity of electrocardiographic repolarization and spatial heterogeneity of atrial depolarization with arrhythmic substrate represented by left ventricular fibrosis. METHODS AND RESULTS We assessed the associations of T- and P-wave morphology parameters analysed from the standard 12-lead electrocardiograms with left ventricular fibrosis in 378 victims of unexpected sudden cardiac death (SCD) who underwent medico-legal autopsy. Based on autopsy findings, the SCD victims were categorized into four different groups according to different stages of severity of left ventricular fibrosis (substantial fibrosis, moderate patchy fibrosis, scattered mild fibrosis, no fibrosis). T-wave and P-wave area dispersion (TWAd: 0.0841 ± 0.496, 0.170 ± 0.492, 0.302 ± 404, 0.296 ± 0.476, P = 0.008; PWAd: 0.574 ± 0.384, 0.561 ± 0.367, 0.654 ± 0.281, 0.717 ± 0.257, P = 0.011, respectively; low values abnormal), non-dipolar components of T-wave and P-wave morphology (T_NonDipolarABS: 0.0496 ± 0.0377, 0.0571 ± 0.0487, 0.0432 ± 0.0476, 0.0380 ± 0.0377, P = 0.027; P_NonDipolarABS: 0.0132 ± 0.0164, 0.0130 ± 0.0135, 0.0092 ± 0.0117, 0.0069 ± 0.00472, P = 0.005, respectively, high values abnormal), T-wave morphology dispersion (TMD: 45.9 ± 28.3, 40.5 ± 25.8, 35.5 ± 24.9, 33.0 ± 24.6, P = 0.030, respectively, high values abnormal), and P-wave heterogeneity (PWH: 20.0 ± 9.44, 19.7 ± 8.87, 17.9 ± 9.78, 15.4 ± 4.60, P = 0.019, respectively, high values abnormal) differed significantly between the groups with different stages of left ventricular fibrosis. After adjustment with heart weight, T_NonDipolarABS [standardized β (sβ) = 0.131, P = 0.014], PWAd (sβ = -0.161, P = 0.003), P_NonDipolarABS (sβ = 0.174, P = 0.001), and PWH (sβ = 0.128, P = 0.015) retained independent association, and TWAd (sβ = -0.091, P = 0.074) and TMD (sβ = 0.097, P = 0.063) tended to retain their association with the degree of myocardial fibrosis. CONCLUSION Our findings suggest that abnormal values of T- and P-wave morphology are associated with arrhythmic substrate represented by ventricular fibrosis partly explaining the mechanism behind their prognostic significance.
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Affiliation(s)
- Jenni J Hekkanen
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Lauri Holmström
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Mikko P Tulppo
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Lasse Pakanen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Hoitajanrinne 1, P.O. Box 310, FI-90101 Oulu, Finland
- Department of Forensic Medicine, Medical Research Center Oulu, Research Unit of Internal Medicine, University of Oulu, Aapistie 5B, P.O. Box 5000, FI-90014 Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
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9
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Laitinen I, Kenttä TV, Passi J, Haukilahti MAE, Eranti A, Holkeri A, Aro AL, Kerola T, Noponen K, Seppänen T, Rissanen H, Knekt P, Heliövaara M, Ukkola OH, Junttila MJ, Huikuri HV, Perkiömäki JS. Prognostic value of P-wave morphology in general population. Europace 2023; 25:164-174. [PMID: 35852923 PMCID: PMC10112844 DOI: 10.1093/europace/euac121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/19/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS To evaluate the prognostic significance of novel P-wave morphology descriptors in general population. METHODS AND RESULTS Novel P-wave morphology variables were analyzed from orthogonal X-, Y-, Z-leads of the digitized electrocardiogram using a custom-made software in 6906 middle-aged subjects of the Mini-Finland Health Survey. A total of 3747 (54.3%) participants died during the follow-up period of 24.3 ± 10.4 years; 379 (5.5%) of the study population succumbed to sudden cardiac death (SCD), 928 (13.4%) to non-SCD (NSCD) and 2440 (35.3%) patients to non-cardiac death (NCD). In univariate comparisons, most of the studied P-wave morphology parameters had a significant association with all modes of death (P from <0.05 to <0.001). After relevant adjustments in the Cox multivariate hazards model, P-wave morphology dispersion (PMD) still tended to predict SCD [hazard ratio (HR): 1.006, 95% confidence interval (CI): 1.000-1.012, P = 0.05) but not NSCD (HR: 0.999, 95% CI: 0.995-1.003, P = 0.68) or NCD (HR: 0.999, 95% CI: 0.997-1.001, P = 0.44). The P-wave maximum amplitude in the lead Z (P-MaxAmp-Z) predicted SCD even after multivariate adjustments (HR: 1.010, 95% CI: 1.005-1.015, P = 0.0002) but also NSCD (HR: 1.005, 95% CI: 1.002-1.009, P = 0.0005) and NCD (HR: 1.002, 95% CI: 1.000-1.005, P = 0.03). CONCLUSION Abnormalities of P-wave morphology are associated with the risk of all modes of death in general population. After relevant adjustments, PMD was still closely associated with the risk of SCD but not with NSCD or NCD. P-MaxAmp-Z predicted SCD even after adjustments, however, it also retained its association with NSCD and NCD.
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Affiliation(s)
- Idamaria Laitinen
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jussi Passi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mira Anette E Haukilahti
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti Eranti
- Heart Center, Turku University Hospital, Turku, Finland
| | - Arttu Holkeri
- Division of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Aapo L Aro
- Division of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tuomas Kerola
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Kai Noponen
- Center for Machine Vision and Signal Analysis, University of Oulu, Oulu, Finland
| | - Tapio Seppänen
- Center for Machine Vision and Signal Analysis, University of Oulu, Oulu, Finland
| | - Harri Rissanen
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Paul Knekt
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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10
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The role of β-adrenergic stimulation in QT interval adaptation to heart rate during stress test. PLoS One 2023; 18:e0280901. [PMID: 36701349 PMCID: PMC9879473 DOI: 10.1371/journal.pone.0280901] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
The adaptation lag of the QT interval after heart rate (HR) has been proposed as an arrhythmic risk marker. Most studies have quantified the QT adaptation lag in response to abrupt, step-like changes in HR induced by atrial pacing, in response to tilt test or during ambulatory recordings. Recent studies have introduced novel methods to quantify the QT adaptation lag to gradual, ramp-like HR changes in stress tests by evaluating the differences between the measured QT series and an estimated, memoryless QT series obtained from the instantaneous HR. These studies have observed the QT adaptation lag to progressively reduce when approaching the stress peak, with the underlying mechanisms being still unclear. This study analyzes the contribution of β-adrenergic stimulation to QT interval rate adaptation in response to gradual, ramp-like HR changes. We first quantify the QT adaptation lag in Coronary Artery Disease (CAD) patients undergoing stress test. To uncover the involved mechanisms, we use biophysically detailed computational models coupling descriptions of human ventricular electrophysiology and β-adrenergic signaling, from which we simulate ventricular action potentials and ECG signals. We characterize the adaptation of the simulated QT interval in response to the HR time series measured from each of the analyzed CAD patients. We show that, when the simulated ventricular tissue is subjected to a time-varying β-adrenergic stimulation pattern, with higher stimulation levels close to the stress peak, the simulated QT interval presents adaptation lags during exercise that are more similar to those measured from the patients than when subjected to constant β-adrenergic stimulation. During stress test recovery, constant and time-varying β-adrenergic stimulation patterns render similar adaptation lags, which are generally shorter than during exercise, in agreement with results from the patients. In conclusion, our findings support the role of time-varying β-adrenergic stimulation in contributing to QT interval adaptation to gradually increasing HR changes as those seen during the exercise phase of a stress test.
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11
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Ramírez J, Kiviniemi A, van Duijvenboden S, Tinker A, Lambiase PD, Junttila J, Perkiömäki JS, Huikuri HV, Orini M, Munroe PB. ECG T-Wave Morphologic Variations Predict Ventricular Arrhythmic Risk in Low- and Moderate-Risk Populations. J Am Heart Assoc 2022; 11:e025897. [PMID: 36036209 PMCID: PMC9496440 DOI: 10.1161/jaha.121.025897] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Early identification of individuals at risk of sudden cardiac death (SCD) remains a major challenge. The ECG is a simple, common test, with potential for large-scale application. We developed and tested the predictive value of a novel index quantifying T-wave morphologic variations with respect to a normal reference (TMV), which only requires one beat and a single-lead ECG. Methods and Results We obtained reference T-wave morphologies from 23 962 participants in the UK Biobank study. With Cox models, we determined the association between TMV and life-threatening ventricular arrhythmia in an independent data set from UK Biobank study without a history of cardiovascular events (N=51 794; median follow-up of 122 months) and SCD in patients with coronary artery disease from ARTEMIS (N=1872; median follow-up of 60 months). In UK Biobank study, 220 (0.4%) individuals developed life-threatening ventricular arrhythmias. TMV was significantly associated with life-threatening ventricular arrhythmias (hazard ratio [HR] of 1.13 per SD increase [95% CI, 1.03-1.24]; P=0.009). In ARTEMIS, 34 (1.8%) individuals reached the primary end point. Patients with TMV ≥5 had an HR for SCD of 2.86 (95% CI, 1.40-5.84; P=0.004) with respect to those with TMV <5, independently from QRS duration, corrected QT interval, and left ventricular ejection fraction. TMV was not significantly associated with death from a cause other than SCD. Conclusions TMV identifies individuals at life-threatening ventricular arrhythmia and SCD risk using a single-beat single-lead ECG, enabling inexpensive, quick, and safe risk assessment in large populations.
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Affiliation(s)
- Julia Ramírez
- Clinical Pharmacology and Precision Medicine William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom.,Aragon Institute of Engineering Research University of Zaragoza Zaragoza Spain.,Centro de Investigación Biomédica en Red - Bioingeniería, Biomateriales y Nanomedicina Zaragoza Spain
| | - Antti Kiviniemi
- Research Unit of Internal Medicine Medical Research Center Oulu, University of Oulu and Oulu University Hospital Oulu Finland
| | - Stefan van Duijvenboden
- Clinical Pharmacology and Precision Medicine William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom.,Institute of Cardiovascular Science University College London London United Kingdom
| | - Andrew Tinker
- Clinical Pharmacology and Precision Medicine William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom.,National Institute for Health and Care Research Barts Cardiovascular Biomedical Research Centre Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom
| | - Pier D Lambiase
- Institute of Cardiovascular Science University College London London United Kingdom.,Barts Heart Centre St Bartholomew's Hospital London United Kingdom
| | - Juhani Junttila
- Research Unit of Internal Medicine Medical Research Center Oulu, University of Oulu and Oulu University Hospital Oulu Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine Medical Research Center Oulu, University of Oulu and Oulu University Hospital Oulu Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine Medical Research Center Oulu, University of Oulu and Oulu University Hospital Oulu Finland
| | - Michele Orini
- Institute of Cardiovascular Science University College London London United Kingdom.,Barts Heart Centre St Bartholomew's Hospital London United Kingdom
| | - Patricia B Munroe
- Clinical Pharmacology and Precision Medicine William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom.,National Institute for Health and Care Research Barts Cardiovascular Biomedical Research Centre Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom
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12
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Andršová I, Hnatkova K, Toman O, Šišáková M, Smetana P, Huster KM, Barthel P, Novotný T, Schmidt G, Malik M. Intra-subject stability of different expressions of spatial QRS-T angle and their relationship to heart rate. Front Physiol 2022; 13:939633. [DOI: 10.3389/fphys.2022.939633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Three-dimensional angle between the QRS complex and T wave vectors is a known powerful cardiovascular risk predictor. Nevertheless, several physiological properties of the angle are unknown or poorly understood. These include, among others, intra-subject profiles and stability of the angle relationship to heart rate, characteristics of angle/heart-rate hysteresis, and the changes of these characteristics with different modes of QRS-T angle calculation. These characteristics were investigated in long-term 12-lead Holter recordings of 523 healthy volunteers (259 females). Three different algorithmic methods for the angle computation were based on maximal vector magnitude of QRS and T wave loops, areas under the QRS complex and T wave curvatures in orthogonal leads, and weighted integration of all QRS and T wave vectors moving around the respective 3-dimensional loops. These methods were applied to orthogonal leads derived either by a uniform conversion matrix or by singular value decomposition (SVD) of the original 12-lead ECG, giving 6 possible ways of expressing the angle. Heart rate hysteresis was assessed using the exponential decay models. All these methods were used to measure the angle in 659,313 representative waveforms of individual 10-s ECG samples and in 7,350,733 individual beats contained in the same 10-s samples. With all measurement methods, the measured angles fitted second-degree polynomial regressions to the underlying heart rate. Independent of the measurement method, the angles were found significantly narrower in females (p < 0.00001) with the differences to males between 10o and 20o, suggesting that in future risk-assessment studies, different angle dichotomies are needed for both sexes. The integrative method combined with SVD leads showed the highest intra-subject reproducibility (p < 0.00001). No reproducible delay between heart rate changes and QRS-T angle changes was found. This was interpreted as a suggestion that the measurement of QRS-T angle might offer direct assessment of cardiac autonomic responsiveness at the ventricular level.
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13
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Stahi T, Kaminer K, Shavit I, Nussinovitch U. Diabetes without Overt Cardiac Disease Is Associated with Markers of Abnormal Repolarization: A Case-Control Study. Life (Basel) 2022; 12:life12081173. [PMID: 36013351 PMCID: PMC9410176 DOI: 10.3390/life12081173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 12/02/2022] Open
Abstract
Patients with diabetes mellitus (DM) are prone to advanced atherosclerosis, microvascular disease, and tissue fibrosis. Despite the increased risk for arrhythmias, little is known about cardiac repolarization abnormalities in DM. We aimed to determine whether abnormal T-wave morphology markers are common among patients with DM and no known cardiac disease. Patients were recruited and classified as having DM or impaired fasting glucose (IFG) according to accepted guidelines. Total cosine R to T (TCRT) and T-wave morphology dispersion (TMD) were computed with custom-designed software for randomly selected and averaged beats. Among 124 patients recruited; 47 were diagnosed with DM and 3 IFG. DM patients and the control group had similar clinical characteristics, other than statins and anti-diabetic drugs, which were more common among DM patients. Patients with DM/IFG had decreased TCRT values computed from a random beat (0.06 ± 0.10 vs. 0.43 ± 0.07, p < 0.01) and an average beat (0.08 ± 0.09 vs. 0.44 ± 0.06, p < 0.01), when compared with the control group. TMD parameters did not differ. In conclusion, TCRT is reduced in patients with DM and no known cardiac diseases. Further research is required to investigate whether repolarization-associated changes in DM are the consequence of subclinical atherosclerosis, diabetic cardiomyopathy, or a combination of the two.
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Affiliation(s)
- Tomer Stahi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6329302, Israel; (T.S.); (I.S.)
| | - Keren Kaminer
- Department of Endocrinology, Rabin Medical Center, Petach Tikva 4941492, Israel;
| | - Itay Shavit
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6329302, Israel; (T.S.); (I.S.)
| | - Udi Nussinovitch
- Alpha Helix Ventures, Petach Tikva 4921352, Israel
- Correspondence: ; Tel.: +972-53-526-8535
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14
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Santos Rodrigues A, Augustauskas R, Lukoševičius M, Laguna P, Marozas V. Deep-Learning-Based Estimation of the Spatial QRS-T Angle from Reduced-Lead ECGs. SENSORS (BASEL, SWITZERLAND) 2022; 22:5414. [PMID: 35891094 PMCID: PMC9328169 DOI: 10.3390/s22145414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/16/2022] [Accepted: 07/18/2022] [Indexed: 06/15/2023]
Abstract
The spatial QRS-T angle is a promising health indicator for risk stratification of sudden cardiac death (SCD). Thus far, the angle is estimated solely from 12-lead electrocardiogram (ECG) systems uncomfortable for ambulatory monitoring. Methods to estimate QRS-T angles from reduced-lead ECGs registered with consumer healthcare devices would, therefore, facilitate ambulatory monitoring. (1) Objective: Develop a method to estimate spatial QRS-T angles from reduced-lead ECGs. (2) Approach: We designed a deep learning model to locate the QRS and T wave vectors necessary for computing the QRS-T angle. We implemented an original loss function to guide the model in the 3D space to search for each vector's coordinates. A gradual reduction of ECG leads from the largest publicly available dataset of clinical 12-lead ECG recordings (PTB-XL) is used for training and validation. (3) Results: The spatial QRS-T angle can be estimated from leads {I, II, aVF, V2} with sufficient accuracy (absolute mean and median errors of 11.4° and 7.3°) for detecting abnormal angles without sacrificing patient comfortability. (4) Significance: Our model could enable ambulatory monitoring of spatial QRS-T angles using patch- or textile-based ECG devices. Populations at risk of SCD, like chronic cardiac and kidney disease patients, might benefit from this technology.
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Affiliation(s)
- Ana Santos Rodrigues
- Biomedical Engineering Institute, Kaunas University of Technology, 51423 Kaunas, Lithuania;
| | - Rytis Augustauskas
- Department of Automation, Kaunas University of Technology, 51367 Kaunas, Lithuania;
| | - Mantas Lukoševičius
- Faculty of Informatics, Kaunas University of Technology, 51368 Kaunas, Lithuania;
| | - Pablo Laguna
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) Group, Aragón Institute of Engineering Research (I3A), IIS Aragón, University of Zaragoza, 50018 Zaragoza, Spain;
- Biomedical Research Networking Center (CIBER), 50018 Zaragoza, Spain
| | - Vaidotas Marozas
- Biomedical Engineering Institute, Kaunas University of Technology, 51423 Kaunas, Lithuania;
- Faculty of Electrical and Electronics Engineering, Kaunas University of Technology, 51367 Kaunas, Lithuania
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15
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Vondrak J, Penhaker M. Review of Processing Pathological Vectorcardiographic Records for the Detection of Heart Disease. Front Physiol 2022; 13:856590. [PMID: 36213240 PMCID: PMC9536877 DOI: 10.3389/fphys.2022.856590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/04/2022] [Indexed: 11/23/2022] Open
Abstract
Vectorcardiography (VCG) is another useful method that provides us with useful spatial information about the electrical activity of the heart. The use of vectorcardiography in clinical practice is not common nowadays, mainly due to the well-established 12-lead ECG system. However, VCG leads can be derived from standard 12-lead ECG systems using mathematical transformations. These derived or directly measured VCG records have proven to be a useful tool for diagnosing various heart diseases such as myocardial infarction, ventricular hypertrophy, myocardial scars, long QT syndrome, etc., where standard ECG does not achieve reliable accuracy within automated detection. With the development of computer technology in recent years, vectorcardiography is beginning to come to the forefront again. In this review we highlight the analysis of VCG records within the extraction of functional parameters for the detection of heart disease. We focus on methods of processing VCG functionalities and their use in given pathologies. Improving or combining current or developing new advanced signal processing methods can contribute to better and earlier detection of heart disease. We also focus on the most commonly used methods to derive a VCG from 12-lead ECG.
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Affiliation(s)
- Jaroslav Vondrak
- Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava, Czech Republic
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16
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Using QRS loop descriptors to characterize the risk of sudden cardiac death in patients with structurally normal hearts. PLoS One 2022; 17:e0263894. [PMID: 35171953 PMCID: PMC8849494 DOI: 10.1371/journal.pone.0263894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022] Open
Abstract
The predictive value of non-invasive electrocardiographic examination findings for the risk of sudden cardiac death (SCD) in populations with structurally normal hearts remains unclear. This study aimed to investigate the characteristics of the QRS vectorcardiography of surface electrocardiography in patients with structurally normal hearts who experienced SCD. We consecutively enrolled patients who underwent vectorcardiography between March 2017 and December 2018 in a tertiary referral medical center. These patients didn’t have structural heart diseases, histories of congestive heart failure, or reduced ejection fraction, and they were classified into SCD (with aborted SCD history and cerebral performance category score of 1) and control groups (with an intervention for atrioventricular node reentrant tachycardia and without SCD history). A total of 162 patients (mean age, 54.3±18.1 years; men, 75.9%), including 59 in the SCD group and 103 in the control group, underwent propensity analysis. The baseline demographic variables, underlying diseases, QRS loop descriptors (the percentage of the loop area, loop dispersion, and inter-lead QRS dispersion), and other electrocardiographic parameters were compared between the two groups. In the univariate and multivariate analyses, a smaller percentage of the loop area (odds ratio, 0.0003; 95% confidence interval, 0.00–0.02; p<0.001), more significant V4-5 dispersion (odds ratio, 1.04; 95% confidence interval, 1.02–1.07; p = 0.002), and longer QRS duration (odds ratio, 1.05; 95% confidence interval, 1.00–1.10; p = 0.04) were associated with SCD. In conclusion, the QRS loop descriptors of surface electrocardiography could be used as non-invasive markers to identify patients experiencing aborted SCD from a healthy population. A decreased percentage of loop area and elevated V4-5 QRS dispersion values assessed using vectorcardiography were associated with an increased risk of SCD in patients with structurally normal hearts.
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17
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Jaber S, Nussinovitch U, Stahi T, Arnson Y. Association between T wave morphology parameters and abnormal cardiac SPECT imaging. J Electrocardiol 2021; 70:65-69. [PMID: 34929606 DOI: 10.1016/j.jelectrocard.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND T-wave morphology dispersion (TMD) described the electrocardiographic T-wave heterogeneity during a single cardiac cycle. Total cosine R-to-T (TCRT) is the average of the cosines of the angles between the QRS and T vectors on the ECG. We examine the predictive value of TMD and TCRT calculation to assess abnormal myocardial perfusion. METHODS Retrospective single center cohort study including all patients referred for evaluation of ischemia by myocardial SPECT scanning with no known history of ischemic heart disease, from 1 January 2019 to 31 December 2019. Study endpoint was the correlation between the calculated TMD and TCRT values and detection of myocardial injury or ischemia by myocardial SPECT. RESULTS Among 606 patients, calculated TCRT was 0.401 ± 0.53 for the normal group and 0.283 ± 0.62 for the abnormal group (p = 0.007). Measured TMD was 22.9 ± 16.6 degrees (p < 0.001) in the normal group, compared to 31.5 ± 22.8 degrees (p < 0.001) for the abnormal group. CONCLUSIONS The results demonstrate a correlation between the decreased TCRT values and increase TMD and myocardial ischemia seen in SPECT results. The TCRT and TMD can be used as simple and non-invasive markers to predict abnormal SPECT results and ischemic heart disease in patients with no known cardiac history.
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Affiliation(s)
- Samer Jaber
- Internal Medicine "F", Meir Medical Center, Kfar Sava, Israel
| | - Udi Nussinovitch
- Department of Cardiology, Meir Medical Center, Kfar Sava, Israel; Applicative Cardiovascular Research Center (ACRC), Meir Medical Center, Kfar Sava, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Tomer Stahi
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Yoav Arnson
- Department of Cardiology, Meir Medical Center, Kfar Sava, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
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18
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Romero D, Calvo M, Le Rolle V, Béhar N, Mabo P, Hernández A. Multivariate ensemble classification for the prediction of symptoms in patients with Brugada syndrome. Med Biol Eng Comput 2021; 60:81-94. [PMID: 34709544 DOI: 10.1007/s11517-021-02448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 09/18/2021] [Indexed: 10/20/2022]
Abstract
Identification of asymptomatic patients at higher risk for suffering cardiac events remains controversial and challenging in Brugada syndrome (BS). In this work, we proposed an ECG-based classifier to predict BS-related symptoms, by merging the most predictive electrophysiological features derived from the ventricular depolarization and repolarization periods, along with autonomic-related markers. The initial feature space included local and dynamic ECG markers, assessed during a physical exercise test performed in 110 BS patients (25 symptomatic). Morphological, temporal and spatial properties quantifying the ECG dynamic response to exercise and recovery were considered. Our model was obtained by proposing a two-stage feature selection process that combined a resampled-based regularization approach with a wrapper model assessment for balancing, simplicity and performance. For the classification step, an ensemble was constructed by several logistic regression base classifiers, whose outputs were fused using a performance-based weighted average. The most relevant predictors corresponded to the repolarization interval, followed by two autonomic markers and two other makers of depolarization dynamics. Our classifier allowed for the identification of novel symptom-related markers from autonomic and dynamic ECG responses during exercise testing, suggesting the need for multifactorial risk stratification approaches in order to predict future cardiac events in asymptomatic BS patients. Graphical abstract Pipeline for feature selection and predictive modeling of symptoms in Brugada syndrome.
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Affiliation(s)
- Daniel Romero
- Institute for Bioengineering of Catalonia (IBEC), Campus Besòs EEBE-UPC, Ave. E. Maristany 16, Building C, L5.3, Barcelona, E-08019, Spain
| | - Mireia Calvo
- Institute for Bioengineering of Catalonia (IBEC), Campus Besòs EEBE-UPC, Ave. E. Maristany 16, Building C, L5.3, Barcelona, E-08019, Spain
| | - Virginie Le Rolle
- CHU Rennes, Inserm, University of Rennes, LTSI - UMR 1099, F-35000, Rennes, France
| | - Nathalie Béhar
- CHU Rennes, Inserm, University of Rennes, LTSI - UMR 1099, F-35000, Rennes, France
| | - Phillipe Mabo
- CHU Rennes, Inserm, University of Rennes, LTSI - UMR 1099, F-35000, Rennes, France
| | - Alfredo Hernández
- CHU Rennes, Inserm, University of Rennes, LTSI - UMR 1099, F-35000, Rennes, France.
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19
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Stahi T, Kaminer K, Gur E, Yao I, Nussinovitch U. T-wave morphology descriptors in patients with bulimia nervosa. Eat Weight Disord 2021; 26:661-666. [PMID: 32356143 DOI: 10.1007/s40519-020-00905-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/09/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Bulimia nervosa (BN) is associated with increased risk of cardiovascular disease and arrhythmias. Some reports found abnormal electrocardiographic markers of arrhythmias in BN, while others did not. This study investigated novel parameters of T-wave morphology that were reported to be associated with adverse cardiovascular outcomes in other patient groups, among patients with BN under medical care. METHOD Thirty-five BN patients and 76 healthy controls were included. Total cosine R to T (TCRT) and T-wave Morphology Dispersion (TMD) parameters were computed according to accepted standards for an average beat and a random beat. Patients were followed for 11.1 ± 0.1 years for the emergence of arrhythmias or events of sudden death. RESULTS Twenty-five (71.4%) BN patients were hospitalized when enrolled, for a mean duration of 1.1 ± 0.2 months. The rest were ambulatory patients. The BN group had lower blood pressure, more smokers, and used antidepressants, neuroleptic drugs and benzodiazepines more than controls did. Other demographic parameters were comparable between groups. TCRT and TMD parameters were statistically similar and within the normal ranges reported by other research groups. None of the BN patients had prolonged QTc interval or electrolyte abnormalities on inclusion. During the follow-up period, no clinical symptoms suggestive of arrhythmias were reported, and no cardiovascular-related hospitalizations or deaths occurred in either group. CONCLUSION Medically treated BN patients have normal T-wave morphology parameters and hence, low risk for repolarization-associated malignant ventricular arrhythmias. The prognostic importance of these novel repolarization parameters remains to be explored among untreated patients, those who ingest emetic substances and patients with electrolyte imbalance. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Tomer Stahi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren Kaminer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Endocrinology, Rabin Medical Center, Petach Tikva, Israel
| | - Eitan Gur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Eating Disorders Department, Sheba Medical Center, Tel Hashomer, Israel
| | - Isaac Yao
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Udi Nussinovitch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. .,Department of Cardiology and the Applicative Cardiovascular Research Center (ACRC), Meir Medical Center, 4428164, Kfar Saba, Israel.
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20
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Abstract
The normal physiologic range of QRS complex duration spans between 80 and 125 ms with known differences between females and males which cannot be explained by the anatomical variations of heart sizes. To investigate the reasons for the sex differences as well as for the wide range of normal values, a technology is proposed based on the singular value decomposition and on the separation of different orthogonal components of the QRS complex. This allows classification of the proportions of different components representing the 3-dimensional representation of the electrocardiographic signal as well as classification of components that go beyond the 3-dimensional representation and that correspond to the degree of intricate convolutions of the depolarisation sequence. The technology was applied to 382,019 individual 10-s ECG samples recorded in 639 healthy subjects (311 females and 328 males) aged 33.8 ± 9.4 years. The analyses showed that QRS duration was mainly influenced by the proportions of the first two orthogonal components of the QRS complex. The first component demonstrated statistically significantly larger proportion of the total QRS power (expressed by the absolute area of the complex in all independent ECG leads) in females than in males (64.2 ± 11.6% vs 59.7 ± 11.9%, p < 0.00001—measured at resting heart rate of 60 beats per minute) while the second component demonstrated larger proportion of the QRS power in males compared to females (33.1 ± 11.9% vs 29.6 ± 11.4%, p < 0.001). The analysis also showed that the components attributable to localised depolarisation sequence abnormalities were significantly larger in males compared to females (2.85 ± 1.08% vs 2.42 ± 0.87%, p < 0.00001). In addition to the demonstration of the technology, the study concludes that the detailed convolution of the depolarisation waveform is individual, and that smoother and less intricate depolarisation propagation is the mechanism likely responsible for shorter QRS duration in females.
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21
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Rahola JT, Kiviniemi AM, Ukkola OH, Tulppo MP, Junttila MJ, Huikuri HV, Kenttä TV, Perkiömäki JS. Temporal variability of T-wave morphology and risk of sudden cardiac death in patients with coronary artery disease. Ann Noninvasive Electrocardiol 2021; 26:e12830. [PMID: 33486851 PMCID: PMC8164143 DOI: 10.1111/anec.12830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 12/16/2022] Open
Abstract
Background The possible relationship between temporal variability of electrocardiographic spatial heterogeneity of repolarization and the risk of sudden cardiac death (SCD) in patients with coronary artery disease (CAD) is not completely understood. Methods The standard deviation of T‐wave morphology dispersion (TMD‐SD), of QRST angle (QRSTA‐SD), and of T‐wave area dispersion (TW‐Ad‐SD) were analyzed on beat‐to‐beat basis from 10 min period of the baseline electrocardiographic recording in ARTEMIS study patients with angiographically verified CAD. Results After on average of 8.6 ± 2.3 years of follow‐up, a total of 66 of the 1,678 present study subjects (3.9%) had experienced SCD or were resuscitated from sudden cardiac arrest (SCA). TMD‐SD was most closely associated with the risk for SCD and was significantly higher in patients who had experienced SCD/SCA compared with those who remained alive (3.61 ± 2.83 vs. 2.64 ± 2.52, p = .008, respectively), but did not differ significantly between the patients who had experienced non‐SCD (n = 71, 4.2%) and those who remained alive (3.20 ± 2.73 vs. 2.65 ± 2.53, p = .077, respectively) or between the patients who succumbed to non‐cardiac death (n = 164, 9.8%) and those who stayed alive (2.64 ± 2.17 vs. 2.68 ± 2.58, p = .853). After adjustments with relevant clinical risk indicators of SCD/SCA, TMD‐SD still predicted SCD/SCA (HR 1.107, 95% CIs 1.035–1.185, p = .003). Conclusions Temporal variability of electrocardiographic spatial heterogeneity of repolarization represented by TMD‐SD independently predicts long‐term risk of SCD/SCA in patients with CAD.
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Affiliation(s)
- Janne T Rahola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mikko P Tulppo
- Department of Physiology, Research Unit of Biomedicine, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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22
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Andršová I, Hnatkova K, Šišáková M, Toman O, Smetana P, Huster KM, Barthel P, Novotný T, Schmidt G, Malik M. Heart Rate Dependency and Inter-Lead Variability of the T Peak - T End Intervals. Front Physiol 2021; 11:595815. [PMID: 33384609 PMCID: PMC7769826 DOI: 10.3389/fphys.2020.595815] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/14/2020] [Indexed: 11/24/2022] Open
Abstract
The electrocardiographic (ECG) assessment of the T peak–T end (Tpe) intervals has been used in many clinical studies, but several related physiological aspects have not been reported. Specifically, the sources of the Tpe differences between different ECG leads have not been systematically researched, the relationship of Tpe duration to underlying heart rate has not been firmly established, and little is known about the mutual correspondence of Tpe intervals measured in different ECG leads. This study evaluated 796,620 10-s 12-lead ECGs obtained from long-term Holters recorded in 639 healthy subjects (311 female) aged 33.8 ± 9.4 years. For each ECG, transformation to orthogonal XYZ lead was used to measure Tpe in the orthogonal vector magnitude (used as a reference for lead-to-lead comparisons) and to construct a three-dimensional T wave loop. The loop roundness was expressed by a ratio between its circumference and length. These ratios were significantly related to the standard deviation of Tpe durations in different ECG leads. At the underlying heart rate of 60 beats per minute, Tpe intervals were shorter in female than in male individuals (82.5 ± 5.6 vs 90.0 ± 6.5 ms, p < 0.0001). When studying linear slopes between Tpe intervals measured in different leads and the underlying heart rate, we found only minimal heart rate dependency, which was not systematic across the ECG leads and/or across the population. For any ECG lead, positive Tpe/RR slope was found in some subjects (e.g., 79 and 25% of subjects for V2 and V4 measurements, respectively) and a negative Tpe/RR slope in other subjects (e.g., 40 and 65% for V6 and V5, respectively). The steepest positive and negative Tpe/RR slopes were found for measurements in lead V2 and V4, respectively. In all leads, the Tpe/RR slope values were close to zero, indicating, on average, Tpe changes well below 2 ms for RR interval changes of 100 ms. On average, longest Tpe intervals were measured in lead V2, the shortest in lead III. The study concludes that the Tpe intervals measured in different leads cannot be combined. Irrespective of the measured ECG lead, the Tpe interval is not systematically heart rate dependent, and no heart rate correction should be used in clinical Tpe investigations.
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Affiliation(s)
- Irena Andršová
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Katerina Hnatkova
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Martina Šišáková
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Ondřej Toman
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | | | - Katharina M Huster
- Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Petra Barthel
- Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Tomáš Novotný
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Georg Schmidt
- Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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23
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Evaluation of a Proarrhythmic Repolarization Marker (Total Cosine R to T) in Patients With Uncomplicated Familial Mediterranean Fever. J Clin Rheumatol 2020; 26:334-337. [PMID: 32649405 DOI: 10.1097/rhu.0000000000001465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Familial Mediterranean fever (FMF) is a systemic autoinflammatory disorder characterized by recurrent attacks of fever and serous inflammation. The association between FMF and risk of cardiac arrhythmia is continuously questioned; some studies report abnormal cardiac repolarization, while others do not. Considering this controversy, we aim to perform in a large cohort of FMF patients a total cosine R to T (TCRT) analysis, a previously unexplored repolarization marker in this disorder. METHODS The study group included 56 FMF patients without amyloidosis, diagnosed with FMF according to published criteria and 131 control subjects, unaffected with FMF. A 12-lead electrocardiogram (ECG) was performed according to strict standards. Electrocardiogram files were processed with Python-based computer software. Patients were followed for 10 to 12 years, and the rate of cardiac complications was evaluated. RESULTS Other than FMF and prescription of colchicine, both groups had similar medical and demographic background. TCRT results were similar for a randomly selected beat (0.40 ± 0.06 vs 0.50 ± 0.04, p > 0.05) and for an averaged beat (0.39 ± 0.06 vs 0.50 ± 0.04, p > 0.05) in FMF patients and control subjects, respectively. Correction of average TCRT for heart rate also resulted in similar TCRTc values in patients and control groups (0.42 ± 0.07 s vs 0.51 ± 0.05 s, respectively, p > 0.05). During the follow-up period, none of the patients died, and no patient developed clinical symptoms suggestive of ventricular arrhythmias. CONCLUSIONS Colchicine treated uncomplicated FMF patients have normal TCRT and TCRTc values, implying low risk for cardiac arrhythmias in this population. Future studies should evaluate the sensitivity and specificity of this marker in high-risk FMF populations, such as those who developed AA amyloidosis.
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24
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Stahi T, Kaminer K, Gur E, Nussinovitch U. T-wave morphology among medically treated patients with Anorexia Nervosa. J Psychiatr Res 2020; 130:43-47. [PMID: 32781372 DOI: 10.1016/j.jpsychires.2020.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/12/2020] [Accepted: 07/20/2020] [Indexed: 11/28/2022]
Abstract
Anorexia nervosa (AN) has the highest rate of mortality of any psychiatric disorder, and cardiovascular complications occur in up to 80% of patients with AN and account for up to 30% of mortality. A controversy exists as to whether patients with AN are prone to develop electrocardiographic abnormalities related to repolarization. We aim to study previously unexplored T wave morphology markers in medically-treated patients with AN. Fifty-eight patients with AN (32 with restricting type and 26 with binge-eating/purging type) and 82 healthy controls were included in the study. ECGs were conducted under strict conditions and total cosine R-to-T (TCRT) and T-wave morphology dispersion (TMD) were computed according to accepted standards for a random beat and for an averaged beat. Forty-six AN patients were hospitalized (79.3%) during the study for a mean duration of 1.5 ± 1.1 months. AN patients had comparable QTc, TCRT, mean TMD, TMDpre, TMDpost and TCRTc values to those of healthy adults. Flattened T wave occurred slightly more often among AN patients than in controls (1.57 ± 1.23 leads affected compared with 1.11 ± 0.80 leads, respectively, p = 0.017). QTc, TCRT and TMD parameters' values were unaffected by the clinical type of AN. In conclusion, weight-restored AN patients are characterized by T wave flattening, but normal other T wave morphology parameters, which seemingly reflects an overall low risk of repolarization-associated ventricular arrhythmias. Long-term follow-up studies should be conducted to evaluate the prognostic significance of these novel repolarization markers in untreated patients or early in the refeeding phase.
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Affiliation(s)
- Tomer Stahi
- Sackler Faculty of Medicine, Tel Aviv University Tel Aviv, Israel.
| | - Keren Kaminer
- Sackler Faculty of Medicine, Tel Aviv University Tel Aviv, Israel; Department of Endocrinology, Rabin Medical Center, Petach Tikva, Israel.
| | - Eitan Gur
- Sackler Faculty of Medicine, Tel Aviv University Tel Aviv, Israel; Department of Eating Disorders, Sheba Medical Center, Tel Hashomer, Israel.
| | - Udi Nussinovitch
- Sackler Faculty of Medicine, Tel Aviv University Tel Aviv, Israel; Department of Cardiology, Applicative Cardiovascular Research Center (ACRC), Meir Medical Center, Kfar Saba, 4428164, Israel.
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25
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Bystricky W, Maier C, Gintant G, Bergau D, Carter D. Identification of Drug-Induced Multichannel Block and Proarrhythmic Risk in Humans Using Continuous T Vector Velocity Effect Profiles Derived From Surface Electrocardiograms. Front Physiol 2020; 11:567383. [PMID: 33071822 PMCID: PMC7530300 DOI: 10.3389/fphys.2020.567383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/27/2020] [Indexed: 01/07/2023] Open
Abstract
We present continuous T vector velocity (TVV) effect profiles as a new method for identifying drug effects on cardiac ventricular repolarization. TVV measures the temporal change in the myocardial action potential distribution during repolarization. The T vector dynamics were measured as the time required to reach p percent of the total T vector trajectory length, denoted as Tr(p), with p in {1, …, 100%}. The Tr(p) values were individually corrected for heart rate at each trajectory length percentage p. Drug effects were measured by evaluating the placebo corrected changes from baseline of Tr(p)c jointly for all p using functional mixed effects models. The p-dependent model parameters were implemented as cubic splines, providing continuous drug effect profiles along the entire ventricular repolarization process. The effect profile distributions were approximated by bootstrap simulations. We applied this TVV-based analysis approach to ECGs available from three published studies that were conducted in the CiPA context. These studies assessed the effect of 10 drugs and drug combinations with different ion channel blocking properties on myocardial repolarization in a total of 104 healthy volunteers. TVV analysis revealed that blockade of outward potassium currents alone presents an effect profile signature of continuous accumulation of delay throughout the entire repolarization interval. In contrast, block of inward sodium or calcium currents involves acceleration, which accumulates during early repolarization. The balance of blocking inward versus outward currents was reflected in the percentage pzero of the T vector trajectory length where accelerated repolarization transitioned to delayed repolarization. Binary classification using a threshold pzero = 43% separated predominant hERG channel blocking drugs with potentially higher proarrhythmic risk (moxifloxacin, dofetilide, quinidine, chloroquine) from multichannel blocking drugs with low proarrhythmic risk (ranolazine, verapamil, lopinavir/ritonavir) with sensitivity 0.99 and specificity 0.97. The TVV-based effect profile provides a detailed view of drug effects throughout the entire ventricular repolarization interval. It enables the evaluation of drug-induced blocks of multiple cardiac repolarization currents from clinical ECGs. The proposed pzero parameter enhances identification of the proarrhythmic risk of a drug beyond QT prolongation, and therefore constitutes an important tool for cardiac arrhythmia risk assessment.
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Affiliation(s)
- Werner Bystricky
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, United States
| | - Christoph Maier
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, United States.,Department of Medical Informatics, Heilbronn University, Heilbronn, Germany
| | - Gary Gintant
- Integrated Sciences and Technology, AbbVie, Inc., North Chicago, IL, United States
| | - Dennis Bergau
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, United States
| | - David Carter
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, United States
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26
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Hekkanen JJ, Kenttä TV, Haukilahti MAE, Rahola JT, Holmström L, Vähätalo J, Tulppo MP, Kiviniemi AM, Pakanen L, Ukkola OH, Junttila MJ, Huikuri HV, Perkiömäki JS. Increased Beat-to-Beat Variability of T-Wave Heterogeneity Measured From Standard 12-Lead Electrocardiogram Is Associated With Sudden Cardiac Death: A Case-Control Study. Front Physiol 2020; 11:1045. [PMID: 32982784 PMCID: PMC7477294 DOI: 10.3389/fphys.2020.01045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/29/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction The prognostic significance of beat-to-beat variability of spatial heterogeneity of repolarization measured from standard 12-lead ECG is not well-understood. Methods We measured the short-term variability of repolarization parameters, such as T-wave heterogeneity in leads V4–V6 (TWH) and QT interval (QT), from five consecutive beats of previously recorded standard 12-lead ECG in 200 victims of unexpected sudden cardiac death (SCD) confirmed to be due to complicated atherosclerotic coronary artery disease (CAD) in medico-legal autopsy and 200 age- and sex-matched controls with angiographically confirmed CAD. The short-term variability of repolarization heterogeneity was defined as the standard deviation (SD) of the measured repolarization parameters. All ECGs were in sinus rhythm, and no premature ventricular contractions were included in the measured segment. Results TWH-SD and QT-SD were significantly higher in SCD victims than in subjects with CAD (6.9 ± 5.6 μV vs. 3.8 ± 2.6 μV, p = 1.8E-11; 8.3 ± 13.1 ms vs. 3.8 ± 7.1 ms, p = 0.00003, respectively). After adjusting in the multivariate clinical model with factors, such as diabetes, RR interval, and beta blocker medication, TWH-SD and QT-SD retained their significant power in discriminating between the victims of SCD and the patients with CAD (p = 0.00003, p = 0.006, respectively). TWH-SD outperformed QT-SD in identifying the SCD victims among the study subjects (area under the curve in the receiver operating characteristics curve 0.730 vs. 0.679, respectively). Conclusion Increased short-term variability of repolarization heterogeneity measured from standard 12-lead ECG is associated with SCD.
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Affiliation(s)
- Jenni J Hekkanen
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Mira Anette E Haukilahti
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Janne T Rahola
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Lauri Holmström
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juha Vähätalo
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Mikko P Tulppo
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Lasse Pakanen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Oulu, Finland.,Research Unit of Internal Medicine, Department of Forensic Medicine, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
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27
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Huang HC, Chien KL, Chang YC, Lin LY, Wang J, Liu YB. Increases in repolarization heterogeneity predict left ventricular systolic dysfunction and response to cardiac resynchronization therapy in patients with left bundle branch block. J Cardiovasc Electrophysiol 2020; 31:1770-1778. [PMID: 32275338 DOI: 10.1111/jce.14488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/30/2020] [Accepted: 04/07/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION This study aimed to investigate the association between T-wave morphology and impaired left ventricular ejection fraction (LVEF) in patients with complete left bundle branch block (cLBBB), and the predictive value of T-wave morphology for response to cardiac resynchronization therapy (CRT). METHODS AND RESULTS We enrolled 189 patients with cLBBB on electrocardiogram performed between January 2007 and December 2011 who underwent standard echocardiography. Repolarization parameters, including the QRS-to-T angle (TCRT), T-wave morphology dispersion (TMD), T-wave loop area (PL), and T-wave residuum (TWR), were reconstructed from digital standard 12-lead electrocardiograms by T-wave morphology analysis. CRT response was defined as ≥15% reduction in left ventricular end-systolic volume at 12 months after CRT implantation. The clinical outcome endpoint was a composite of heart failure hospitalization, heart transplantation, or death during follow up (mean, 5.8 years). On logistic regression, a higher heart rate, longer QRS duration, increased TMD, and larger TWR were all independently associated with LVEF < 40%. Among 40 patients who underwent CRT, those with a larger TMD (P = .007), larger PL (P = .025), and more negative TCRT (P = .015) had better response to CRT. A large TMD (P = .018) and large PL (P = .003) were also independent predictors of the clinical outcome endpoint. CONCLUSIONS Increases in repolarization heterogeneity in patients with cLBBB are associated with impaired LVEF. A large TMD and large PL may be useful as additional predictors of response to CRT, improving patient selection for CRT.
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Affiliation(s)
- Hui-Chun Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuo-Liong Chien
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.,Institute of Epidemiology, College of Public Health, Taipei, Taiwan
| | - Yi-Chung Chang
- Institute of Communication Engineering, National Taiwan University, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jui Wang
- Institute of Epidemiology, College of Public Health, Taipei, Taiwan
| | - Yen-Bin Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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28
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Nussinovitch U. Normal ranges and potential modifiers of T-wave morphology parameters among healthy individuals: A meta-analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:655-663. [PMID: 32285458 DOI: 10.1111/pace.13918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/18/2020] [Accepted: 04/07/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND T-wave morphology parameters, such as total cosine R-to-T (TCRT), T-wave loop dispersion (TWLD), T-wave morphology dispersion (TMD), and T-wave residuum (TWR), were suggested to be robust markers for adverse cardiovascular outcomes. Yet, the normal range of these parameters is unknown. This study aimed to evaluate the weighted normal values of T-wave morphology parameters of healthy individuals and study the effect of potential modifiers. METHODS A systematic search of studies published in PubMed was conducted. Only those reporting on control groups of healthy individuals were included. Weighted means were calculated for TCRT, TWLD, TMD, and TWR. Linear regression analysis was conducted for age, percentage of males, heart rate, and QTc. RESULTS The weighted TCRT was 0.40 ± 0.05, significantly higher than the various cutoffs previously suggested to identify high risk. There was some overlap between the results of weighted normal TMD (19.42 ± 6.77°), TWLD (38.51 ± 0.31), and relative TWR (0.118 ± 0.056%) and reports on the same parameters from patients with cardiovascular disease. Women were also characterized by higher TWLD, TMD, and relative TWR. TCRT was negatively correlated with age and heart rate, and positively correlated with QTc duration, although all associations were weak (R2 < 0.9). CONCLUSIONS T-wave morphology parameters reported in the medical literature span a broad range of values in healthy individuals. Seemingly abnormal values of TWLD, TMD, and relative TWR were often reported in healthy adults. The variability between studies may stem from methodological issues. Therefore, standardizing the methodology for measuring T-wave morphology is imperative.
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Affiliation(s)
- Udi Nussinovitch
- Department of Cardiology and Applicative Cardiovascular Research Center (ACRC), Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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29
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Sánez Tähtisalo H, Hiltunen TP, Kenttä T, Junttila J, Oikarinen L, Virolainen J, Kontula KK, Porthan K. Effect of four classes of antihypertensive drugs on cardiac repolarization heterogeneity: A double-blind rotational study. PLoS One 2020; 15:e0230655. [PMID: 32208439 PMCID: PMC7092984 DOI: 10.1371/journal.pone.0230655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/04/2020] [Indexed: 11/21/2022] Open
Abstract
Background T-wave area dispersion (TW-Ad) is a novel electrocardiographic (ECG) repolarization marker associated with sudden cardiac death. However, limited data is available on the clinical correlates of TW-Ad. In addition, there are no previous studies on cardiovascular drug effects on TW-Ad. In this study, we examined the relation between TW-Ad and left ventricular mass. We also studied the effects of four commonly used antihypertensive drugs on TW-Ad. Methods A total of 242 moderately hypertensive males (age, 51±6 years; office systolic/diastolic blood pressure during placebo, 153±14/100±8 mmHg), participating in the GENRES study, were included. Left ventricular mass index was determined by transthoracic echocardiography. Antihypertensive four-week monotherapies (a diuretic, a beta-blocker, a calcium channel blocker, and an angiotensin receptor antagonist) were administered in a randomized rotational fashion. Four-week placebo periods preceded all monotherapies. The average value of measurements (over 1700 ECGs in total) from all available placebo periods served as a reference to which measurements during each drug period were compared. Results Lower, i.e. risk-associated TW-Ad values correlated with a higher left ventricular mass index (r = −0.14, p = 0.03). Bisoprolol, a beta-blocker, elicited a positive change in TW-Ad (p = 1.9×10−5), but the three other drugs had no significant effect on TW-Ad. Conclusions Our results show that TW-Ad is correlated with left ventricular mass and can be modified favorably by the use of bisoprolol, although demonstration of any effects on clinical endpoints requires long-term prospective studies. Altogether, our results suggest that TW-Ad is an ECG repolarization measure of left ventricular arrhythmogenic substrate.
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Affiliation(s)
- Heini Sánez Tähtisalo
- Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Timo P. Hiltunen
- Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- * E-mail:
| | - Tuomas Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Lasse Oikarinen
- Division of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Juha Virolainen
- Division of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Kimmo K. Kontula
- Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Kimmo Porthan
- Division of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Department of Medicine, University of Helsinki and Minerva Foundation Institute for Medical Research, Helsinki, Finland
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30
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Skampardoni S, Poulikakos D, Malik M, Green D, Kalra PA. The potential of electrocardiography for cardiac risk prediction in chronic and end-stage kidney disease. Nephrol Dial Transplant 2020; 34:1089-1098. [PMID: 30085289 DOI: 10.1093/ndt/gfy255] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Indexed: 11/14/2022] Open
Abstract
Cardiovascular mortality is very high in chronic and end-stage kidney disease (ESKD). However, risk stratification data are lacking. Sudden cardiac deaths are among the most common cardiovascular causes of death in these populations. As a result, many studies have assessed the prognostic potential of various electrocardiographic parameters in the renal population. Recent data from studies of implantable loop recordings in haemodialysis patients from five different countries have shed light on a pre-eminent bradyarrhythmic risk of mortality. Importantly, heart block addressed by permanent pacing system was detected in a proportion of patients during the prolonged recording periods. Standard electrocardiogram is inexpensive, non-invasive and easily accessible. Hence, risk prediction models using this simple investigation tool could easily translate into clinical practice. We believe that electrocardiographic assessment is currently under-valued in renal populations. For this review, we identified studies from the preceding 10 years that assessed the use of conventional and novel electrocardiographic biomarkers as risk predictors in chronic and ESKD. The review indicates that conventional electrocardiographic markers are not reliable for risk stratification in the renal populations. Novel parameters have shown promising results in smaller studies, but further validation in larger populations is required.
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Affiliation(s)
- Sofia Skampardoni
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Renal Department, Salford Royal NHS Trust, Salford, UK
| | - Dimitrios Poulikakos
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Renal Department, Salford Royal NHS Trust, Salford, UK
| | - Marek Malik
- National Heart and Lung Institute, Imperial College, London, UK
| | - Darren Green
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Renal Department, Salford Royal NHS Trust, Salford, UK
| | - Philip A Kalra
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Renal Department, Salford Royal NHS Trust, Salford, UK
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Lombardi F, Vicenzi M, Hnatkova K, Schmidt G, Malik M. The search for non-invasive markers of cardiac diseases comes back to the 12-lead electrocardiogram. Int J Cardiol 2020; 298:55-56. [DOI: 10.1016/j.ijcard.2019.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/07/2019] [Indexed: 11/26/2022]
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Palacios S, Caiani EG, Landreani F, Martínez JP, Pueyo E. Long-Term Microgravity Exposure Increases ECG Repolarization Instability Manifested by Low-Frequency Oscillations of T-Wave Vector. Front Physiol 2019; 10:1510. [PMID: 31920714 PMCID: PMC6928004 DOI: 10.3389/fphys.2019.01510] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/29/2019] [Indexed: 11/13/2022] Open
Abstract
Ventricular arrhythmias and sudden cardiac death during long-term space missions are a major concern for space agencies. Long-duration spaceflight and its ground-based analog head-down bed rest (HDBR) have been reported to markedly alter autonomic and cardiac functioning, particularly affecting ventricular repolarization of the electrocardiogram (ECG). In this study, novel methods are developed, departing from previously published methodologies, to quantify the index of Periodic Repolarization Dynamics (PRD), an arrhythmic risk marker that characterizes sympathetically-mediated low-frequency oscillations in the T-wave vector. PRD is evaluated in ECGs from 42 volunteers at rest and during an orthostatic tilt table test recorded before and after 60-day –6° HDBR. Our results indicate that tilt test, on top of enhancing sympathetic regulation of heart rate, notably increases PRD, both before and after HDBR, thus supporting previous evidence on PRD being an indicator of sympathetic modulation of ventricular repolarization. Importantly, long-term microgravity exposure is shown to lead to significant increases in PRD, both when evaluated at rest and, even more notably, in response to tilt test. The extent of microgravity-induced changes in PRD has been associated with arrhythmic risk in prior studies. An exercise-based, but not a nutrition-based, countermeasure is able to partially reverse microgravity-induced effects on PRD. In conclusion, long-term exposure to microgravity conditions leads to elevated low-frequency oscillations of ventricular repolarization, which are potentiated following sympathetic stimulation and are related to increased risk for repolarization instabilities and arrhythmias. Tested countermeasures are only partially effective in counteracting microgravity effects.
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Affiliation(s)
- Saúl Palacios
- BSICoS Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Enrico G Caiani
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Federica Landreani
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Juan Pablo Martínez
- BSICoS Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain.,CIBER en Bioingeniería, Biomateriales y Nanomedicina, Madrid, Spain
| | - Esther Pueyo
- BSICoS Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain.,CIBER en Bioingeniería, Biomateriales y Nanomedicina, Madrid, Spain
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Nortamo S, Laitinen I, Passi J, Tulppo M, Ukkola OH, Junttila MJ, Kiviniemi AM, Kenttä T, Huikuri HV, Perkiömäki JS. Prognostic significance of P-wave morphology in patients with coronary artery disease. J Cardiovasc Electrophysiol 2019; 30:2051-2060. [PMID: 31310355 DOI: 10.1111/jce.14066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The prognostic significance of P-wave morphology in patients with coronary artery disease (CAD) is not well-known. METHODS A total of 1946 patients with angiographically verified CAD were included in the Innovation to reduce Cardiovascular Complications of Diabetes at the Intersection (ARTEMIS) study. The P-wave morphology could be analyzed in 1797 patients. RESULTS During 7.4 ± 2.0 years, a total of 168 (9.3%) patients died or experienced resuscitation from sudden cardiac arrest (SCA), 43 (2.4%) patients experienced sudden cardiac death (SCD) or were resuscitated from SCA, 37 (2.1%) patients succumbed to non-SCD (NSCD), and 88 (4.9%) patients to noncardiac death (NCD). Of the P-wave parameters, the absolute P-wave residuum (PWR), the heterogeneity of the P-wave morphology (PWH), and the P-wave duration (Pdur) had the closest univariate association with the risk of SCD/SCA (0.0038 ± 0.0026 vs 0.0022 ± 0.0017, P < .001; 11.0 ± 5.2 vs 8.6 ± 3.6, P < .01; 142.7 ± 16.9 vs 134.8 ± 14.3 milliseconds, P < .01; SCD/SCA vs no SCD/SCA, respectively). After adjustments with factors that were associated with the risk of SCD/SCA, such as diabetes, smoking, left bundle branch block, high-sensitivity C-reactive protein, and high-sensitivity troponin T, PWR (P < .001), PWH (P < .05), and Pdur (P < 0.01) still predicted SCD/SCA but not non-sudden cardiac death. When these parameters were added to the SCD/SCA clinical risk model, the discrimination and reclassification accuracy of the risk model increased significantly (P < .05, P < .001) and the C-index increased from 0.745 to 0.787. CONCLUSION The P-wave morphology parameters independently predict SCD/SCA in patients with CAD.
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Affiliation(s)
- Santeri Nortamo
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Idamaria Laitinen
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jussi Passi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mikko Tulppo
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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Bystricky W, Maier C, Gintant G, Bergau D, Kamradt K, Welsh P, Carter D. T vector velocity: A new ECG biomarker for identifying drug effects on cardiac ventricular repolarization. PLoS One 2019; 14:e0204712. [PMID: 31283756 PMCID: PMC6613676 DOI: 10.1371/journal.pone.0204712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 06/04/2019] [Indexed: 11/23/2022] Open
Abstract
Background We present a new family of ECG biomarkers for assessing drug effects on ventricular repolarization. We show that drugs blocking inward (depolarizing) ion currents cause a relative increase of the T vector velocity (TVV) and accelerate repolarization, while drugs blocking outward ion currents cause a relative decrease of the TVV and delay repolarization. The results suggest a link between the TVV and the instantaneous change of the cellular action potentials that may contribute to bridge the gap between the surface ECG and myocardial cellular processes. Methods We measure TVV as the time required to reach X% of the total Trajectory length of the T vector loop, denoted as TrX. Applied to data from two FDA funded studies (22+22 subjects, 5232+4208 ECGs) which target ECG effects of various ion-channel blocking drugs, the TrX effect profiles indicate increasingly delayed electrical activity over the entire repolarization process for drugs solely reducing outward potassium current (dofetilide, moxifloxacin). For drugs eliciting block of the inward sodium or calcium currents (mexiletine, lidocaine), the TrX effect profiles were consistent with accelerated electrical activity in the initial repolarization phase. For multichannel blocking drugs (ranolazine) or drug combinations blocking multiple ion currents (dofetilide + mexiletine, dofetilide + lidocaine), the overall TrX effect profiles indicate a superposition of the individual TrX effect profiles. Results The parameter Tr40c differentiates pure potassium channel blocking drugs from multichannel blocking drugs with an area under the ROC curve (AUC) of 0.90, CI = [0.88 to 0.92]. This is significantly better than the performance of J-Tpeakc (0.81, CI = [0.78 to 0.84]) identified as the best parameter in the second FDA study. Combining the ten parameters Tr10c to Tr100c in a logistic regression model further improved the AUC to 0.94, CI = [0.92 to 0.96]. Conclusions TVV analysis substantially improves assessment of drug effects on cardiac repolarization, providing a plausible and improved mechanistic link between drug effects on ionic currents and overall ventricular repolarization reflected in the body surface ECG. TVV contributes to an enhanced appraisal of the proarrhythmic risk of drugs beyond QTc prolongation and J-Tpeakc.
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Affiliation(s)
- Werner Bystricky
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - Christoph Maier
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America.,Department of Medical Informatics, Heilbronn University, Heilbronn, Germany
| | - Gary Gintant
- Integrated Sciences and Technology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - Dennis Bergau
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - Kent Kamradt
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - Patrick Welsh
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
| | - David Carter
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, United States of America
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35
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Lipponen JA, Kurl S, Laukkanen JA. Global electrical heterogeneity as a predictor of cardiovascular mortality in men and women. Europace 2019; 20:1841-1848. [PMID: 29868797 DOI: 10.1093/europace/euy113] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 04/20/2018] [Indexed: 11/14/2022] Open
Abstract
Aims The aim of this study was to investigate the contribution of depolarization and repolarization abnormalities, specially abnormalities in global electrical heterogeneity of heart in cardiovascular disease (CVD) and all-cause mortality. Methods and results Eight hundred and forty men and 911 women, average age of 63 years participated in this study with average follow-up was 14 years. Six electrocardiogram/vector electrocardiogram (ECG/VECG) markers QRS-duration, QTc-interval, QRST-angle, sum of absolute QRST integral (SAI QRST), T-wave roundness, and TV1-amplitude were estimated from VECG measurements. Hazard ratios (HRs) for CVD events (164 deaths) and all-cause mortality (383 deaths) for ECG parameters were calculated. Electrocardiogram or vector electrocardiogram parameter models adjusted for risk clinical factors showed that strongest predictors for CVD mortality were QRST-angle (HR 3.44, 95% confidence interval 2.12-5.36), QTc-interval (2.72, 1.73-4.29), and T-wave roundness (2.09, 1.26-3.46) among men. The strongest ECG/VECG parameters for CVD death were QRST-angle (2.47, 1.37-4.45), SAI QRST (2.37, 1.23-4.6), and QTc-interval (2.15, 1.16-4.01) among female participants. Multivariable adjusted models revealed that strongest independent ECG predictors for CVD death were QRST-angle, QTc-interval, resting heart rate, and T-roundness for men, QRST-angle and SAI QRST for women. QRST-angle, QTc-interval, resting heart rate, and T-roundness were associated with all-cause mortality in male population, although none of the ECG/VECG parameters predicted all-cause mortality among women. Conclusion Characteristics of global electrical heterogeneity QRST-angle and QTc-interval in men and QRST-angle and SAI QRST among females were strong and independent risk markers for cardiovascular mortality. These parameters provide new additional ECG tools for cardiovascular risk stratification.
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Affiliation(s)
- Jukka A Lipponen
- Department of Applied Physics, University of Eastern Finland, Yliopistonranta 1, Kuopio, Finland
| | - Sudhir Kurl
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Jari A Laukkanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.,Department of Internal Medicine, Central Finland Health Care District, Jyväskylä, Finland.,Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
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36
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Hnatkova K, Seegers J, Barthel P, Novotny T, Smetana P, Zabel M, Schmidt G, Malik M. Clinical value of different QRS-T angle expressions. Europace 2019; 20:1352-1361. [PMID: 29016907 PMCID: PMC6075511 DOI: 10.1093/europace/eux246] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/06/2017] [Indexed: 01/28/2023] Open
Abstract
Aims Increased spatial angle between QRS complex and T wave loop orientations has repeatedly been shown to predict cardiac risk. However, there is no consensus on the methods for the calculation of the angle. This study compared the reproducibility and predictive power of three most common ways of QRS-T angle assessment. Methods and results Electrocardiograms of 352 healthy subjects, 941 survivors of acute myocardial infarction (MI), and 605 patients recorded prior to the implantation of automatic defibrillator [implantable cardioverter defibrillator (ICD)] were used to obtain QRS-T angle measurements by the maximum R to T (MRT), area R to T (ART), and total cosine R to T (TCRT) methods. The results were compared in terms of physiologic reproducibility and power to predict mortality in the cardiac patients during 5-year follow-up. Maximum R to T results were significantly less reproducible compared to the other two methods. Among both survivors of acute MI and ICD recipients, TCRT method was statistically significantly more powerful in predicting mortality during follow-up. Among the acute MI survivors, increased spatial QRS-T angle (TCRT assessment) was particularly powerful in predicting sudden cardiac death with the area under the receiver operator characteristic of 78% (90% confidence interval 63-90%). Among the ICD recipients, TCRT also predicted mortality significantly among patients with prolonged QRS complex duration when the spatial orientation of the QRS complex is poorly defined. Conclusion The TCRT method for the assessment of spatial QRS-T angle appears to offer important advantages in comparison to other methods of measurement. This approach should be included in future clinical studies of the QRS-T angle. The TCRT method might also be a reasonable candidate for the standardization of the QRS-T angle assessment.
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Affiliation(s)
- Katerina Hnatkova
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, UK
| | - Joachim Seegers
- Division of Cardiology, Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, Germany
| | - Petra Barthel
- Innere Medizin I, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, Germany
| | - Tomas Novotny
- Department of internal medicine and cardiology, Faculty of Medicine, University Hospital Brno, Masaryk University, Jihlavska 20, Brno, Czech Republic
| | - Peter Smetana
- Medizinische Abteilung mit Kardiologie, Wilhelminenspital der Stadt Wien, Montleartstraße 37, Vienna, Austria
| | - Markus Zabel
- Department of Cardiology and Pneumology, Heart Center, University Medical Center Göttingen, Robert-Koch-Str. 40, Göttingen, Germany
| | - Georg Schmidt
- Innere Medizin I, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, UK
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Skampardoni S, Green D, Hnatkova K, Malik M, Kalra PA, Poulikakos D. QRS-T Angle Predicts Cardiac Risk and Correlates With Global Longitudinal Strain in Prevalent Hemodialysis Patients. Front Physiol 2019; 10:145. [PMID: 30858805 PMCID: PMC6397862 DOI: 10.3389/fphys.2019.00145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 02/07/2019] [Indexed: 12/31/2022] Open
Abstract
Background: Cardiovascular disease is the commonest cause of death in hemodialysis (HD) patients but accurate risk prediction is lacking. The spatial QRS – T angle is a promising electrophysiological marker for sudden cardiac death risk stratification. The aim of this study was to assess the prognostic value of spatial QRS-T angle derived from standard 12 lead electrocardiograms (ECG) and its association with echocardiographic parameters in HD patients. Methods: This prospective study of 178 prevalent HD patients (aged 67 ± 14 years, 72% men) collected ECG and echocardiographic data on an annual basis. Baseline echocardiograms at study entry were used for cross-sectional comparisons with ECGs. Study endpoints were all-cause mortality, cardiovascular mortality, and major adverse cardiac events (MACE). The QRS – T angle was calculated from standard 10-s ECG as the total cosine R to T (TCRT) using singular value decomposition and expressed in degrees. TCRT above 100° was defined as abnormal. Results: During a follow-up period of 36 ± 19 months, 74 patients died, including 17 cardiac deaths, and 54 suffered from MACE. In multivariate Cox regression analysis, QRS-T angle by TCRT at baseline was associated with increased cardiovascular mortality both as a continuous value and dichotomized below or above 100° (HR 1.016, p = 0.029, CI: 1.002–1.030 and HR 3.506, CI: 1.118–10.995, p = 0.031 respectively) and with MACE dichotomized at 100° (HR 1.902, CI: 1.046–3.459; p = 0.035). In multivariate regression analysis including baseline parameters, echocardiographic global longitudinal strain (GLS) was significantly correlated with TCRT (F 9.648, r2 = 0.192, standardized β = 0.331, unstandardized β = 3.567, t = 4.4429, CI: 1.976–5.157, p < 0.001). Conclusion: TCRT correlates with GLS and is independently associated with cardiac deaths and MACE in HD patients.
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Affiliation(s)
- Sofia Skampardoni
- Department of Renal Medicine, Salford Royal NHS Foundation Trust and The University of Manchester, Manchester, United Kingdom
| | - Darren Green
- Department of Renal Medicine, Salford Royal NHS Foundation Trust and The University of Manchester, Manchester, United Kingdom
| | - Katerina Hnatkova
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust and The University of Manchester, Manchester, United Kingdom
| | - Dimitrios Poulikakos
- Department of Renal Medicine, Salford Royal NHS Foundation Trust and The University of Manchester, Manchester, United Kingdom
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Cankar K, Melik Z, Kobal J, Starc V. Evidence of cardiac electrical remodeling in patients with Huntington disease. Brain Behav 2018; 8:e01077. [PMID: 30028085 PMCID: PMC6085913 DOI: 10.1002/brb3.1077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/29/2018] [Accepted: 07/01/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Although Huntington's disease (HD) is a disease of the central nervous system, HD mortality surveys indicate heart disease as a major cause of death. Cardiac dysfunction in HD might be a primary consequence of peripherally expressed mutant huntingtin or secondary to either a general decline in health or the onset of neurological dysfunction. The aim of the study was to clarify the heart muscle involvement. MATERIALS AND METHODS We measured conventional and advanced resting ECG indices. Thirty-one subjects with a confirmed huntingtin gene mutation and 31 age- and gender-matched controls were included. The HD subjects were divided into four groups based on their Unified Huntington Disease Rating Scale (UHDRS) motor score. RESULTS We detected changes in advanced ECG variables connected with electrical ventricular remodeling (t test, p < 0.01). The increase in the unexplained part of both QT variability and the standard deviation of normal-to-normal QT intervals, presumably reflecting beat-to-beat changes in repolarization, was most pronounced. Further, both variables correlated with the product of the cytosine-adenine-guanine (CAG) triplets' repeat length and the subjects' age (CAP), the former R = 0.423 (p = 0.018) and the latter R = 0.499 (p = 0.004). There was no correlation between the CAP score and any of variables representing autonomic nervous system activity. CONCLUSIONS Both autonomic nervous system dysfunction and cardiac electrical remodeling are present in patients with HD. The changes in advanced ECG variables observed in the study evolve with HD progression. The increased values of QT unexplained variability may be a marker of temporal inhomogeneity in ventricular repolarization associated with malignant ventricular arrhythmias.
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Affiliation(s)
- Ksenija Cankar
- Faculty of medicineInstitute of PhysiologyUniversity of LjubljanaLjubljanaSlovenia
| | - Ziva Melik
- Faculty of medicineInstitute of PhysiologyUniversity of LjubljanaLjubljanaSlovenia
| | - Jan Kobal
- Division of NeurologyUniversity Medical Centre LjubljanaLjubljanaSlovenia
| | - Vito Starc
- Faculty of medicineInstitute of PhysiologyUniversity of LjubljanaLjubljanaSlovenia
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Malik M. Shallow meta analysis. Ann Noninvasive Electrocardiol 2018; 23:e12543. [DOI: 10.1111/anec.12543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Marek Malik
- National Heart and Lung Institute; Imperial College; London England UK
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40
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Poulikakos D, Hnatkova K, Banerjee D, Malik M. Association of QRS-T angle and heart rate variability with major cardiac events and mortality in hemodialysis patients. Ann Noninvasive Electrocardiol 2018; 23:e12570. [PMID: 29938866 DOI: 10.1111/anec.12570] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/02/2018] [Accepted: 05/14/2018] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Mortality in hemodialysis (HD) patients is high with significant proportion attributed to fatal arrhythmias. In a pilot study, we showed that intradialytic electrocardiographic (ECG) monitoring can yield stable profiles of selected repolarisation descriptors and heart rate variability (HRV) parameters. This study investigated the relationship of these ECG markers with major adverse cardiac events (MACE) and mortality. METHODS Continuous ECGs were obtained during HD and repeated five times at 2-week intervals. The QRS-T angle calculated as Total Cosine R to T (TCRT) and T-wave morphology dispersion (TMD) were calculated in overlapping 10 s ECG segments. High- (HF) and low (LF)-frequency components and the LF/HF ratio of HRV were calculated every 5 min. These indices were averaged during the first hour of dialysis and subsequently overall recordings in each subject. RESULTS All ECG parameters were available in 72 patients aged 61 ± 15, 23 (31.9%) females and 26 (36.1%) diabetics. After a median follow up of 54.8 months, 16 patients died, 20 were transplanted, and 9 suffered MACE. TCRT (in degrees) was higher and LF/HF was lower in patients who died compared to survivors (112 ± 30 vs. 73 ± 35, p = 0.000 and 0.222 ± 0.418 vs. 0.401 ± 0.274, p = 0.000, respectively) and in MACE positive compared to negative (117 ± 40 vs. 77 ± 34, p = 0.017 and 0.125 ± 0.333 vs.0.401 ± 0.274, p = 0.007 respectively). In multivariate Cox regression analysis of mortality risk adjusted for age, diabetes mellitus, and coronary artery disease, TCRT and LF/HF remained significant predictors (p < 0.05). CONCLUSION QRS-T angle and HRV may serve risk assessment in future prospective studies in HD patients.
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Affiliation(s)
- Dimitrios Poulikakos
- Renal Unit, Centre for Cardiac Research, Institute of Cardiovascular Sciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | | | - Debasish Banerjee
- Renal and Transplantation Unit, St. Georges University Hospital NHS Foundation Trust, Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Marek Malik
- Imperial College, National Heart and Lung Institute, London, UK
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41
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Tse G, Gong M, Wong CW, Chan C, Georgopoulos S, Chan YS, Yan BP, Li G, Whittaker P, Ciobanu A, Ali‐Hasan‐Al‐Saegh S, Wong SH, Wu WKK, Bazoukis G, Lampropoulos K, Wong WT, Tse LA, Baranchuk AM, Letsas KP, Liu T. Total cosine R-to-T for predicting ventricular arrhythmic and mortality outcomes: A systematic review and meta-analysis. Ann Noninvasive Electrocardiol 2018; 23:e12495. [PMID: 28901628 PMCID: PMC6931891 DOI: 10.1111/anec.12495] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/27/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The total cosine R-to-T (TCRT), a vectorcardiographic marker reflecting the spatial difference between the depolarization and repolarization wavefronts, has been used to predict ventricular tachycardia/fibrillation (VT/VF) and sudden cardiac death (SCD) in different clinical settings. However, its prognostic value has been controversial. OBJECTIVE This systematic review and meta-analysis evaluated the significance of TRCT in predicting arrhythmic and/or mortality endpoints. METHODS PubMed and Embase databases were searched through December 31, 2016. RESULTS Of the 890 studies identified initially, 13 observational studies were included in our meta-analysis. A total of 11,528 patients, mean age 47 years old, 72% male, were followed for 43 ± 6 months. Data from five studies demonstrated lower TCRT values in myocardial infarction patients with adverse events (syncope, ventricular arrhythmias, or sudden cardiac death) compared to those without these events (mean difference = -0.36 ± 0.05, p < .001; I2 = 48%). By contrast, only two studies analyzed outcomes in heart failure, and pooled meta-analysis did not demonstrate significant difference in TCRT between event-positive and event-negative patients (mean difference = -0.01 ± 0.10, p > .05; I2 = 80%). CONCLUSION TCRT is lower in MI patients at high risk of adverse events when compared to those free from such events. It can provide additional risk stratification beyond the use of clinical parameters and traditional electrocardiogram markers. Its value in other diseases such as heart failure requires further studies.
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Affiliation(s)
- Gary Tse
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong Kong SARChina
- Faculty of MedicineLi Ka Shing Institute of Health SciencesChinese University of Hong KongHong Kong SARChina
| | - Mengqi Gong
- Department of CardiologyTianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular diseaseTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Cheuk Wai Wong
- Li Ka Shing Faculty of MedicineUniversity of Hong KongHong Kong SARChina
| | - Cynthia Chan
- Li Ka Shing Faculty of MedicineUniversity of Hong KongHong Kong SARChina
| | - Stamatis Georgopoulos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensAthensGreece
| | - Yat Sun Chan
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong Kong SARChina
| | - Bryan P. Yan
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong Kong SARChina
| | - Guangping Li
- Department of CardiologyTianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular diseaseTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Paula Whittaker
- Division of Population HealthHealth Services Research and Primary CareSchool of Health SciencesUniversity of ManchesterManchesterUnited Kingdom
| | - Ana Ciobanu
- Department of CardiologyTheodor Burghele Clinical HospitalCarol Davila University of Medicine and PharmacyBucharestRomania
| | | | - Sunny H. Wong
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong Kong SARChina
- Faculty of MedicineLi Ka Shing Institute of Health SciencesChinese University of Hong KongHong Kong SARChina
| | - William K. K. Wu
- Faculty of MedicineLi Ka Shing Institute of Health SciencesChinese University of Hong KongHong Kong SARChina
- Department of Anesthesia and Intensive CareState Key Laboratory of Digestive DiseaseThe Chinese University of Hong KongHong KongChina
| | - George Bazoukis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensAthensGreece
| | - Konstantinos Lampropoulos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensAthensGreece
| | - Wing Tak Wong
- School of Life SciencesThe Chinese University of Hong KongHong KongChina
| | - Lap Ah Tse
- Division of Occupational and Environmental HealthJC School of Public Health and Primary CareThe Chinese University of Hong KongHong KongChina
| | - Adrian M. Baranchuk
- Department of MedicineKingston General HospitalQueen's UniversityKingstonONCanada
| | - Konstantinos P. Letsas
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensAthensGreece
| | - Tong Liu
- Department of CardiologyTianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular diseaseTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
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Pirkola JM, Konttinen M, Kenttä TV, Holmström LTA, Junttila MJ, Ukkola OH, Huikuri HV, Perkiömäki JS. Prognostic value of T-wave morphology parameters in coronary artery disease in current treatment era. Ann Noninvasive Electrocardiol 2018; 23:e12539. [PMID: 29484764 DOI: 10.1111/anec.12539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/10/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The prognostic value of T-wave morphology parameters in coronary artery disease in the current treatment era is not well established. METHODS The Innovation to reduce Cardiovascular Complications of Diabetes at the Intersection (ARTEMIS) study included 1,946 patients with angiographically verified coronary artery disease (CAD). The study patients underwent thorough examinations including 12-lead digital electrocardiogram (ECG) at baseline. RESULTS During a follow-up period of 73 ± 22 months, a total of 201 (10.3%) patients died. Of the study patients, 95 (4.9%) experienced cardiac death (CD) consisting of 44 (2.3%) sudden cardiac deaths (SCD) and 51 (2.6%) nonsudden cardiac deaths (NSCD), and 106 (5.4%) patients experienced noncardiac death (NCD). T-wave morphology dispersion (TMD), T-wave area dispersion (TWAD), and total cosine R-to-T (TCRT) had a significant association with CD even after adjustment with relevant clinical risk markers in the Cox regression analysis (multivariate HRs: 1.015, 95% CI 1.007-1.023, p = .0003; 0.474, 95% CI 0.305-0.737, p = .0009; 0.598, 95% CI 0.412-0.866, p = .006, respectively). When including these parameters to the clinical risk model for CD, the C-index increased from 0.810 to 0.823 improving the discrimination significantly (integrated discrimination index [IDI] = 0.0118, 95% CI 0.0028-0.0208, p = .01). These parameters were more closely associated with NSCD (multivariate p-values from .016 to .001) than with SCD (univariate/multivariate p-values for TMD .015/.197 and for TCRT .012/.43). CONCLUSION T-wave morphology parameters describing repolarization heterogeneity improve the predictive power of the clinical risk model for CD in patients with CAD in the current treatment era.
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Affiliation(s)
- Joni M Pirkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Maija Konttinen
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Lauri T A Holmström
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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Kenttä TV, Sinner MF, Nearing BD, Freudling R, Porthan K, Tikkanen JT, Müller-Nurasyid M, Schramm K, Viitasalo M, Jula A, Nieminen MS, Peters A, Salomaa V, Oikarinen L, Verrier RL, Kääb S, Junttila MJ, Huikuri HV. Repolarization Heterogeneity Measured With T-Wave Area Dispersion in Standard 12-Lead ECG Predicts Sudden Cardiac Death in General Population. Circ Arrhythm Electrophysiol 2018; 11:e005762. [DOI: 10.1161/circep.117.005762] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 12/18/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Tuomas V. Kenttä
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Moritz F. Sinner
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Bruce D. Nearing
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Rebecca Freudling
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Kimmo Porthan
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Jani T. Tikkanen
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Martina Müller-Nurasyid
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Katharina Schramm
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Matti Viitasalo
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Antti Jula
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Markku S. Nieminen
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Annette Peters
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Veikko Salomaa
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Lasse Oikarinen
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Richard L. Verrier
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Stefan Kääb
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - M. Juhani Junttila
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Heikki V. Huikuri
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
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Hsieh WH, Lin CY, Te ALD, Lo MT, Wu CI, Chung FP, Chang YC, Chang SL, Lin C, Lo LW, Hu YF, Liao JN, Chen YY, Jhuo SJ, Raharjo SB, Lin YJ, Chen SA. A novel noninvasive surface ECG analysis using interlead QRS dispersion in arrhythmogenic right ventricular cardiomyopathy. PLoS One 2017; 12:e0182364. [PMID: 28771538 PMCID: PMC5542590 DOI: 10.1371/journal.pone.0182364] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 07/17/2017] [Indexed: 11/19/2022] Open
Abstract
Background This study investigated the feasibility of using the precordial surface ECG lead interlead QRS dispersion (IQRSD) in the identification of abnormal ventricular substrate in arrhythmogenic right ventricular cardiomyopathy (ARVC). Methods Seventy-one consecutive patients were enrolled and reclassified into 4 groups: definite ARVC with epicardial ablation (Group 1), ARVC with ventricular tachycardia (VT, Group 2), idiopathic right ventricular outflow tract VT without ARVC (Group 3), and controls without VT (Group 4). IQRSD was quantified by the angular difference between the reconstruction vectors obtained from the QRS-loop decomposition, based on a principal component analysis (PCA). Electroanatomic mapping and simulated ECGs were used to investigate the relationship between QRS dispersion and abnormal substrate. Results The percentage of the QRS loop area in the Group 1–2 was smaller than the controls (P = 0.01). The IQRSD between V1-V2 could differentiate all VTs from control (P<0.01). Group 1–2 had a greater IQRSD than the Group 3–4 (V4-V5,P = 0.001), and Group 1 had a greater IQRSD than Group 3–4 (V6-Lead I, P<0.001). Both real and simulated data had a positive correlation between the maximal IQRSD (γ = 0.62) and the extent of corresponding abnormal substrate (γ = 0.71, both P<0.001). Conclusions The IQRSD of the surface ECG precordial leads successfully differentiated ARVC from controls, and could be used as a noninvasive marker to identify the abnormal substrate and the status of ARVC patients who can benefit from epicardial ablation.
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Affiliation(s)
- Wan-Hsin Hsieh
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Translational and Interdisciplinary Medicine and Department of Biomedical Sciences and Engineering, National Central University, Chung-Li, Taiwan
| | - Chin-Yu Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Medicine, Taipei Veterans General Hospital, Yuan-Shan Branch, I-Lan, Taiwan
| | - Abigail Louise D. Te
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- HB Calleja Heart and Vascular Institute, St. Luke’s Medical Center, Quezon City, Philippines
| | - Men-Tzung Lo
- Institute of Translational and Interdisciplinary Medicine and Department of Biomedical Sciences and Engineering, National Central University, Chung-Li, Taiwan
| | - Cheng-I Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Chung Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chen Lin
- Institute of Translational and Interdisciplinary Medicine and Department of Biomedical Sciences and Engineering, National Central University, Chung-Li, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yun-Yu Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Jie Jhuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sunu Budhi Raharjo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail: (YJL); (SAC)
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail: (YJL); (SAC)
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Ramirez J, Orini M, Tucker JD, Pueyo E, Laguna P. Variability of Ventricular Repolarization Dispersion Quantified by Time-Warping the Morphology of the T-Waves. IEEE Trans Biomed Eng 2017; 64:1619-1630. [DOI: 10.1109/tbme.2016.2614899] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Verrier RL, Huikuri H. Tracking interlead heterogeneity of R- and T-wave morphology to disclose latent risk for sudden cardiac death. Heart Rhythm 2017; 14:1466-1475. [PMID: 28610987 DOI: 10.1016/j.hrthm.2017.06.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Indexed: 01/10/2023]
Abstract
Sudden cardiac death (SCD) due primarily to ventricular fibrillation claims 1.5 million lives worldwide each year. In 45%-50% of cases, it is the first manifestation of underlying heart disease. Traditional risk factors including smoking, hypertension, age, sex, as well as depressed left ventricular ejection fraction lack sufficient sensitivity and specificity to forewarn of impending life-threatening arrhythmias. There has been a decades-long search for electrocardiographic (ECG) markers of SCD risk. Several interval-based indices such as QT dispersion and Tpeak-Tend interval held initial promise but ultimately yielded mixed results. Recently, the focus has been on interlead heterogeneity of R- and T-wave morphology. The new approaches have involved advanced analytical tools including vectorcardiographic techniques and second central moment analysis of QRS-aligned templates to quantify heterogeneity of depolarization and repolarization waveforms. The results of current studies appear to be robust and worthy of further exploration. This review examines the electrophysiological underpinnings of heterogeneity-based risk assessment and provides an update of clinical techniques. We also discuss future directions whereby tracking heterogeneity may help to disclose latent risk for SCD not only in ECG recordings made at rest but also during ambulatory ECG monitoring and exercise tolerance testing.
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Affiliation(s)
- Richard L Verrier
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Heikki Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Chow E, Bernjak A, Walkinshaw E, Lubina-Solomon A, Freeman J, Macdonald IA, Sheridan PJ, Heller SR. Cardiac Autonomic Regulation and Repolarization During Acute Experimental Hypoglycemia in Type 2 Diabetes. Diabetes 2017; 66:1322-1333. [PMID: 28137792 PMCID: PMC5860266 DOI: 10.2337/db16-1310] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/25/2017] [Indexed: 02/03/2023]
Abstract
Hypoglycemia is associated with increased cardiovascular mortality in trials of intensive therapy in type 2 diabetes mellitus (T2DM). We previously observed an increase in arrhythmias during spontaneous prolonged hypoglycemia in patients with T2DM. We examined changes in cardiac autonomic function and repolarization during sustained experimental hypoglycemia. Twelve adults with T2DM and 11 age- and BMI-matched control participants without diabetes underwent paired hyperinsulinemic clamps separated by 4 weeks. Glucose was maintained at euglycemia (6.0 mmol/L) or hypoglycemia (2.5 mmol/L) for 1 h. Heart rate, blood pressure, and heart rate variability were assessed every 30 min and corrected QT intervals and T-wave morphology every 60 min. Heart rate initially increased in participants with T2DM but then fell toward baseline despite maintained hypoglycemia at 1 h accompanied by reactivation of vagal tone. In control participants, vagal tone remained depressed during sustained hypoglycemia. Participants with T2DM exhibited greater heterogeneity of repolarization during hypoglycemia as demonstrated by T-wave symmetry and principal component analysis ratio compared with control participants. Epinephrine levels during hypoglycemia were similar between groups. Cardiac autonomic regulation during hypoglycemia appears to be time dependent. Individuals with T2DM demonstrate greater repolarization abnormalities for a given hypoglycemic stimulus despite comparable sympathoadrenal responses. These mechanisms could contribute to arrhythmias during clinical hypoglycemic episodes.
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Affiliation(s)
- Elaine Chow
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, U.K
| | - Alan Bernjak
- INSIGNEO Institute for In Silico Medicine, University of Sheffield, Sheffield, U.K
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, U.K
| | - Emma Walkinshaw
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, U.K
| | | | - Jenny Freeman
- Leeds Institute of Health Sciences, University of Leeds, Leeds, U.K
| | - Ian A Macdonald
- School of Life Sciences, University of Nottingham, Nottingham, U.K
| | - Paul J Sheridan
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, U.K
| | - Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, U.K.
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T-wave loop area from a pre-implant 12-lead ECG is associated with appropriate ICD shocks. PLoS One 2017; 12:e0173868. [PMID: 28291831 PMCID: PMC5349693 DOI: 10.1371/journal.pone.0173868] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 02/28/2017] [Indexed: 11/19/2022] Open
Abstract
Aims In implantable cardioverter-defibrillator (ICD) patients, predictors of ICD shocks and mortality are needed to improve patient selection. Electrocardiographic (ECG) markers are simple to obtain and have been demonstrated to predict mortality. We aimed to assess the association of T-wave loop area and circularity with ICD shocks. Methods The study investigated patients with ICDs implanted between 1998 and 2010 for whom digital 12-lead ECGs (Schiller CS200 ECG-Network) of sufficient quality were obtained within 1 month prior to the implantation. T-wave loop area and circularity were calculated. Follow-up data of appropriate shocks were obtained during ICD clinic visits that included reviews of device stored electrograms. Results A total of 605 patients (82% males) were included; 68% had ischemic cardiomyopathy and 72% were treated for primary prevention. Over 3.8±1.4 years of follow-up, 114 patients (19%) experienced appropriate shock(s). Those with smaller T-wave loop area received fewer shocks (TLA, hazard ratio, HR, per increase of 1 technical unit, 0.71; [95% confidence interval, 0.53–0.94]; P = 0.02) and those with larger T-wave loop circularity (TLC) representing rounder T wave loop received more shocks (HR per 1% TLC increase 2.96; [0.85–10.36]; P = 0.09). When the quartile containing the largest TLA and TLC values, respectively, were compared to the remaining cases, TLA remained significantly associated with fewer and TLC with more frequent shocks also after multivariate adjustment for clinical variables (HR, 0.59 [0.35–0.99], P = 0.044; and 1.64 [1.08–2.49], P = 0.021, respectively). Conclusions The size and shape of the T-wave loop calculated from pre-implantation 12-lead ECGs are associated with appropriate ICD shocks.
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50
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Effect of Loss of Heart Rate Variability on T-Wave Heterogeneity and QT Variability in Heart Failure Patients: Implications in Ventricular Arrhythmogenesis. Cardiovasc Eng Technol 2017; 8:219-228. [DOI: 10.1007/s13239-017-0299-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 02/25/2017] [Indexed: 11/25/2022]
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