Frequency of fragmented QRS in ankylosing spondylitis : a prospective controlled study

High prevalence of fragmented QRS on electrocardiography in Japanese patients with diabetes irrespective of metabolic syndrome

AIMS/INTRODUCTION

Fragmented QRS (fQRS) on electrocardiography is a marker of myocardial fibrosis and myocardial scar formation. This study aimed to clarify the relationship of fQRS with diabetes mellitus and metabolic syndrome (MetS) in Japanese patients.

MATERIALS AND METHODS

Approximately 702 individuals who had a routine health checkup at the Hokuriku Health Service Association (Toyama, Japan) in October 2014 were enrolled and categorized into one of the following four groups based on MetS and diabetes mellitus status: with diabetes mellitus (+) MetS+ (164 participants); diabetes mellitus+ without MetS (Mets-; 103 participants); diabetes mellitus- MetS+ (133 participants); and diabetes mellitus- MetS- (302 participants). fQRS was assessed using the results of electrocardiography.

RESULTS

The prevalence of fQRS was statistically higher in patients with diabetes mellitus+ MetS+ (37%) and diabetes mellitus+ MetS- (35%), than those with diabetes mellitus- MetS+ (14%) or diabetes mellitus- MetS- (10%; P < 0.0001). Significant differences were observed between the fQRS(+) and fQRS(-) groups for age, sex, waist circumference, heart rate, hypertension, hemoglobin A1c, total cholesterol, MetS and diabetes mellitus. The area under the receiver operating characteristic curve for traditional risk factors and diabetes mellitus was 0.72 (P = 0.0007, 95% confidence interval 0.67-0.76), and for traditional risk factors and MetS it was 0.67 (P = 0.28, 95% confidence interval 0.62-0.72). Patients with diabetes mellitus had more than threefold higher likelihood of showing fQRS (odds ratio 3.41; 95% confidence interval 2.25-5.22; P < 0.0001) compared with the reference group without diabetes mellitus, after adjusting for age, sex, dyslipidemia, hypertension and waist circumference.

CONCLUSIONS

fQRS was observed more frequently in diabetes mellitus patients than in MetS and control individuals. Diabetes mellitus was the most significant determinant for fQRS among MetS and other traditional metabolic risk factors.

Heart Involvement in a Moroccan Population with Spondyloarthritis: A Cross-sectional Study

OBJECTIVES

The aim of this study was to investigate the prevalence of cardiac manifestations and their predictive factors in Moroccan patients with spondyloarthritis (SpA).

METHODS

We have conducted a cross-sectional study over four months at the Department of Rheumatology in Mohammed VI University Hospital of Oujda, Morocco. All SpA patients fulfilled the 2009 Assessment SpondyloArthritis international Society (ASAS) criteria. Every patient had a cardiac check up including clinical examination, 12-lead electrocardiogram (ECG) and transthoracic echocardiography (TTE). Multiple logistic regression was used to analyze the associated factors with cardiac manifestations.

RESULTS

We included 64 men and 30 women with a mean age of 37.32 ± 12.65 years old. The mean disease duration was 10.60 ± 7.61 years. Patients had a mean Ankylosing Spondylitis Disease Activity Score (ASDAS) CRP of 2.25 ± 1.38, a mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of 2.88 ± 2.26 and a mean Bath Ankylosing Spondylitis Functional Index (BASFI) of 33.52 ± 30.49. Traditional cardiovascular risk factors (CVRF) included dyslipidemia in 14.9%, hypertension in 9.6% and type 2 diabetes in 7.4% of the cases. Eight patients (8.5%) smoked and 3 patients (3.2%) used alcohol whereas 20 patients (21.3%) had a history of smoking and 5 patients (6.3%) a history of alcohol. Cardiac manifestations were found in 12 patients (13.3%): 3.3% had aortic regurgitation (AR), 1.1% had aortic dilatation, 1.1% had aortic valve thickening (AVT), 2.2% had mitral thickening, 1.1% had mitral regurgitation (MR), 1.1% had mitral stenosis (MS), 3.3 had pericarditis and 2.2% had complete right bundle branch block (RBBB). In multivariate analysis, cardiac involvement was significantly associated with extra-articular manifestations (OR = 6.05; 95% CI: 1.197-30.607, p = 0.029).

CONCLUSION

Based on these results, cardiac involvement was common and associated with the severity of the disease; hence, early detection of cardiac abnormalities and targeted treatment strategies of SpA and comorbidities are necessary to control the systemic inflammation and improve the excess of cardiovascular mortality in this group of patients.

Fragmented QRS complex in patients with systemic lupus erythematosus at the time of diagnosis and its relationship with disease activity

Objective

Cardiovascular disease is an important contributor to the mortality rate of patients with systemic lupus erythematosus (SLE), which is related to SLE disease activity. Fragmented QRS (fQRS) complexes, defined by additional spikes in the QRS complex, are useful for identifying myocardial scars on electrocardiography and can be an independent predictor of cardiac events. We aimed to assess the relationship between disease activity in patients with SLE and fQRS at the time of diagnosis.

Methods

Forty-four patients with SLE were included. Patients with cardiac diseases, other rheumatic diseases, and prior treatment at the time of electrocardiography measurement were excluded. The appearance of fQRS represented exposure. The primary outcome was SLE Disease Activity Index 2000 (SLEDAI-2K). Multiple regression analysis was conducted to assess the association between fQRS and SLEDAI-2K adjusted for age, sex, and time from the estimated onset date to the date of diagnosis.

Results

Among patients with SLE at diagnosis, 26 (59.1%) had fQRS. The median SLEDAI-2K was 18 (interquartile range [IQR], 12–22) and 9 (IQR, 8–15) in the fQRS(+) and fQRS(-) groups, respectively. SLEDAI-2K was significantly higher in the fQRS(+) group than in the fQRS(-) group (regression coefficient, 2.69; 95% confidence interval, 0.76–4.61; p = 0.008).

Conclusion

Our results suggested that fQRS(+) patients with SLE had high disease activity. fQRS could likely detect subclinical myocardial involvement in patients with SLE and predict long-term occurrence of cardiac events.

[Fragmented QRS. Relevance in clinical practice]

The QRS complex represents the electrical depolarization of ventricular myocardium. In the case of an undisturbed depolarization, the QRS complex has a normal configuration and duration, but abnormal electrical conduction leads to widening of the QRS complex. The block of one of the Tawara branches results in a typical bundle branch block pattern. A QRS complex that cannot be classified as bundle branch block due to an atypical configuration and contains notched R or S waves is called a fragmented QRS. The underlying pathophysiologies are manifold and include myocardial scars induced by ischemic heart disease, myocardial fibrosis due to other diseases, primary cardiac pathologies as well as systemic diseases with cardiac involvement. Pathologies on the cellular level, such as ion channel dysfunctions, also correlate with fragmented QRS. Besides the diagnostic relevance, fragmented QRS is known to have prognostic properties, for example in identifying high risk patients with coronary artery disease, cardiomyopathy, Brugada syndrome and acquired long QT syndrome; however, fragmented QRS may also be detected in ECGs of healthy individuals.

Frequency of fragmented QRS in patient with psoriasis vulgaris without cardiovascular disease

Myocardial fibrosis causes the fragmentation of QRS complexes on electrocardiogram. We hypothesized that the frequency of fragmented QRS (fQRS) could be more common in patients with psoriasis vulgaris than in healthy control subjects. In this prospective study, 100 patients with psoriasis vulgaris who did not have any cardiovascular disease were compared with 50 healthy volunteers in control group. The Psoriasis Area Severity Index (PASI) was used for expressing the severity of psoriasis. Patients with psoriasis were categorized according to presence of fQRS in ECG [fQRS (+) group and fQRS (-) group]. Patients with psoriasis had higher frequency of fQRS, higher levels of C reactive protein (CRP) and sedimentation rate (ESR) than the control group (n = 49, 49 % vs. n = 3, 6 %, p < 0.001; 9.91 ± 17.86 vs. 3.59 ± 0.79 mg/dL, p = 0.014; 17.37 ± 17.40 vs. 5.66 ± 5.22 mm/h, p < 0.001, respectively). Within the patient group there was no statistically significant difference between fQRS (+) and fQRS (-) subgroups with regards to sex, disease duration, CRP, ESR, medications and PASI score. It was suggested that presence of fQRS in ECG may be related with myocardial fibrosis in patients with psoriasis who do not have cardiovascular disease. For this reason, in our opinion, fQRS could be used as a predictive marker for myocardial fibrosis in patients with psoriasis.

The Anthropometric Measurement of Schober's Test in Normal Taiwanese Population

The measurement of lower back mobility is essential in the assessment of lower back pain including ankylosing spondylitis. Original Schober's test (OST) and modified Schober's test (MST) are popularly conducted in daily rheumatology and orthopedics clinical practices. To our knowledge, this report is the only anthropometric reference study in a normal oriental population. The OST declined with age from 5.0 cm in the youngest (20–30 years old) to 3.1 cm in the aged (70–80 years old) male subjects and from 3.6 cm to 2.4 cm in the female subjects. The male OST was significantly more than the female OST. There was a good correlation between OST and MST in each of the three age groups of both sexes.

The importance of fragmented QRS in the early detection of cardiac involvement in patients with systemic sclerosis

Objective:

Systemic sclerosis (SSc) is an autoimmune connective tissue disorder characterized by fibrosis. The prognosis of the disease is bad when clinically symptomatic cardiac dysfunction is occurred, therefore early detection of cardiac dysfunction is important in patients with SSc. The aim of this study was to investigate the frequency of fQRS in superficial electrocardiography in cardiacally asymptomatic patients with SSc and its relation to the systolic pulmonary artery pressure (sPAP).

Methods:

This study included 31 cardiacally asymptomatic patients with SSc (23 females, 40.4±9.2 years) and 41 healthy volunteers as the control (31 females, 38.2±11.8 years). The ECGs with 12 derivations and transthoracic echocardiographies of the patients were evaluated. The presence of fQRS in the superficial ECG, and its relation to systolic pulmonary artery pressure (sPAP) were investigated.

Results:

The mean sPAP value in the SSc group was observed to be higher than that of the control group (26 mm Hg and 20 mm Hg, respectively, p<0.001). The presence of fQRS in the SSc group was more frequent than the control group (55% and 10%, respectively, p<0.001). In SSc patients presence of fQRS become relevant with ≥24 mm Hg sPAP by 88% sensitivity and 79% specificity.

Conclusion:

In our study, the presence of fQRS in SSc patients, were more frequent than in the normal population. Since pulmonary hypertension is the primary cause of mortality in patients with SSc, the correlation of fQRS with sPAP should also be considered.

Fragmented QRS is associated with frequency of premature ventricular contractions in patients without overt cardiac disease

Objective:

In this study, we aimed to demonstrate whether the presence of fragmented QRS (fQRS) is associated with the frequency of premature ventricular contractions (PVCs).

Methods:

We retrospectively analyzed 282 cases by 24-hour Holter monitorings (HMs) between August 2012 and February 2013. Firstly, the patients were divided into 2 groups with respect to presence of fQRS and then divided into 3 groups with respect to frequency of PVCs as Group 1: seldom PVC (<120 PVCs/day), Group 2: moderate-frequency PVC (120-720 PVCs/day), and Group 3: frequent PVC (>720 PVCs/day). We investigated the predictors of frequent PVCs by using multinomial logistic regression analysis.

Results:

Ninety-eight patients had fQRS. There was no difference between the 2 groups with respect to body mass index, gender, hypertension, and diabetes mellitus. Patients with fQRS were older (54.9±15.6 vs. 47.0±16.3, p<0.001) and had more family history of coronary artery disease (25% vs. 13%, p=0.012). Patients with fQRS was more likely to be on aspirin therapy (28.6% vs. 10.4%, p<0.001) and have a larger left atrium diameter (33.5±5.7 vs. 30.4±5.8, p=0.001). Presence of fQRS was significantly associated with the frequency of PVCs (for frequent PVC 27.7% vs. 7.6%, p<0.001; for moderate-frequency PVC 18.4% vs. 11.4%, p=0.012); 26.2% of Group 1 (n=202) had fQRS, 46.2% of Group 2 (n=39) had fQRS, and 65.9% of Group 3 (n=41) had fQRS. In the multinomial regression analysis, only age (odds ratio: 4.24, 95% confidence interval 2.08-8.64, p=0.001) and fQRS (odds ratio: 2.11, 95% confidence interval 1.00-4.45, p=0.05) were predictors of frequent PVCs.

Conclusion:

This study demonstrated that the presence of fQRS is associated with frequent PVCs in patients without overt structural heart disease.