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Perez-Alday EA, Bender A, German D, Mukundan SV, Hamilton C, Thomas JA, Li-Pershing Y, Tereshchenko LG. Dynamic predictive accuracy of electrocardiographic biomarkers of sudden cardiac death within a survival framework: the Atherosclerosis Risk in Communities (ARIC) study. BMC Cardiovasc Disord 2019; 19:255. [PMID: 31726979 PMCID: PMC6854807 DOI: 10.1186/s12872-019-1234-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/23/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The risk of sudden cardiac death (SCD) is known to be dynamic. However, the accuracy of a dynamic SCD prediction is unknown. We aimed to measure the dynamic predictive accuracy of ECG biomarkers of SCD and competing non-sudden cardiac death (non-SCD). METHODS Atherosclerosis Risk In Community study participants with analyzable ECGs in sinus rhythm were included (n = 15,716; 55% female, 73% white, age 54.2 ± 5.8 y). ECGs of 5 follow-up visits were analyzed. Global electrical heterogeneity and traditional ECG metrics (heart rate, QRS, QTc) were measured. Adjudicated SCD was the primary outcome; non-SCD was the competing outcome. Time-dependent area under the receiver operating characteristic curve (ROC(t) AUC) analysis was performed to assess the prediction accuracy of a continuous biomarker in a period of 3,6,9 months, and 1,2,3,5,10, and 15 years using a survival analysis framework. Reclassification improvement as compared to clinical risk factors (age, sex, race, diabetes, hypertension, coronary heart disease, stroke) was measured. RESULTS Over a median 24.4 y follow-up, there were 577 SCDs (incidence 1.76 (95%CI 1.63-1.91)/1000 person-years), and 829 non-SCDs [2.55 (95%CI 2.37-2.71)]. No ECG biomarkers predicted SCD within 3 months after ECG recording. Within 6 months, spatial ventricular gradient (SVG) elevation predicted SCD (AUC 0.706; 95%CI 0.526-0.886), but not a non-SCD (AUC 0.527; 95%CI 0.303-0.75). SVG elevation more accurately predicted SCD if the ECG was recorded 6 months before SCD (AUC 0.706; 95%CI 0.526-0.886) than 2 years before SCD (AUC 0.608; 95%CI 0.515-0.701). Within the first 3 months after ECG recording, only SVG azimuth improved reclassification of the risk beyond clinical risk factors: 18% of SCD events were reclassified from low or intermediate risk to a high-risk category. QRS-T angle was the strongest long-term predictor of SCD (AUC 0.710; 95%CI 0.668-0.753 for ECG recorded within 10 years before SCD). CONCLUSION Short-term and long-term predictive accuracy of ECG biomarkers of SCD differed, reflecting differences in transient vs. persistent SCD substrates. The dynamic predictive accuracy of ECG biomarkers should be considered for competing SCD risk scores. The distinction between markers predicting short-term and long-term events may represent the difference between markers heralding SCD (triggers or transient substrates) versus markers identifying persistent substrate.
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Affiliation(s)
- Erick A. Perez-Alday
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Rd; UHN62, Portland, OR 97239 USA
- Department of Biomedical Informatics, Emory University, Atlanta, GA USA
| | - Aron Bender
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Rd; UHN62, Portland, OR 97239 USA
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA USA
| | - David German
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Rd; UHN62, Portland, OR 97239 USA
| | - Srini V. Mukundan
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Rd; UHN62, Portland, OR 97239 USA
- Rush University, Chicago, IL USA
| | - Christopher Hamilton
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Rd; UHN62, Portland, OR 97239 USA
- Rosalind Franklin University of Medicine and Science, North Chicago, IL USA
| | - Jason A. Thomas
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Rd; UHN62, Portland, OR 97239 USA
- University of Washington, Seattle, WA USA
| | - Yin Li-Pershing
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Rd; UHN62, Portland, OR 97239 USA
| | - Larisa G. Tereshchenko
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Rd; UHN62, Portland, OR 97239 USA
- Cardiovascular Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
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Tereshchenko LG, Sotoodehnia N, Sitlani CM, Ashar FN, Kabir M, Biggs ML, Morley MP, Waks JW, Soliman EZ, Buxton AE, Biering-Sørensen T, Solomon SD, Post WS, Cappola TP, Siscovick DS, Arking DE. Genome-Wide Associations of Global Electrical Heterogeneity ECG Phenotype: The ARIC (Atherosclerosis Risk in Communities) Study and CHS (Cardiovascular Health Study). J Am Heart Assoc 2018; 7:e008160. [PMID: 29622589 PMCID: PMC6015433 DOI: 10.1161/jaha.117.008160] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/07/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND ECG global electrical heterogeneity (GEH) is associated with sudden cardiac death. We hypothesized that a genome-wide association study would identify genetic loci related to GEH. METHODS AND RESULTS We tested genotyped and imputed variants in black (N=3057) and white (N=10 769) participants in the ARIC (Atherosclerosis Risk in Communities) study and CHS (Cardiovascular Health Study). GEH (QRS-T angle, sum absolute QRST integral, spatial ventricular gradient magnitude, elevation, azimuth) was measured on 12-lead ECGs. Linear regression models were constructed with each GEH variable as an outcome, adjusted for age, sex, height, body mass index, study site, and principal components to account for ancestry. GWAS identified 10 loci that showed genome-wide significant association with GEH in whites or joint ancestry. The strongest signal (rs7301677, near TBX3) was associated with QRS-T angle (white standardized β+0.16 [95% CI 0.13-0.19]; P=1.5×10-26), spatial ventricular gradient elevation (+0.11 [0.08-0.14]; P=2.1×10-12), and spatial ventricular gradient magnitude (-0.12 [95% CI -0.15 to -0.09]; P=5.9×10-15). Altogether, GEH-SNPs explained 1.1% to 1.6% of GEH variance. Loci on chromosomes 4 (near HMCN2), 5 (IGF1R), 11 (11p11.2 region cluster), and 7 (near ACTB) are novel ECG phenotype-associated loci. Several loci significantly associated with gene expression in the left ventricle (HMCN2 locus-with HMCN2; IGF1R locus-with IGF1R), and atria (RP11-481J2.2 locus-with expression of a long non-coding RNA and NDRG4). CONCLUSIONS We identified 10 genetic loci associated with ECG GEH. Replication of GEH GWAS findings in independent cohorts is warranted. Further studies of GEH-loci may uncover mechanisms of arrhythmogenic remodeling in response to cardiovascular risk factors.
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Affiliation(s)
- Larisa G Tereshchenko
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA
| | - Colleen M Sitlani
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA
| | - Foram N Ashar
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Muammar Kabir
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Mary L Biggs
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Michael P Morley
- Penn Cardiovascular Institute and Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan W Waks
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, MA
| | - Elsayed Z Soliman
- Cardiology Section, Division of Public Health Sciences and Department of Medicine, Epidemiological Cardiology Research Center, Wake Forest School of Medicine, Winston Salem, NC
| | - Alfred E Buxton
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, MA
| | | | - Scott D Solomon
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas P Cappola
- Penn Cardiovascular Institute and Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Dan E Arking
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Tereshchenko LG, Cheng A, Park J, Wold N, Meyer TE, Gold MR, Mittal S, Singh J, Stein KM, Ellenbogen KA. Novel measure of electrical dyssynchrony predicts response in cardiac resynchronization therapy: Results from the SMART-AV Trial. Heart Rhythm 2015; 12:2402-10. [PMID: 26272523 DOI: 10.1016/j.hrthm.2015.08.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) reduces mortality and morbidity in selected heart failure patients. However, not all patients respond to CRT. OBJECTIVE We hypothesized that a novel measure of electrical dyssynchrony, sum absolute QRST integral (SAI QRST), predicts CRT response independent of QRS duration and morphology. METHODS We retrospectively analyzed baseline 12-lead electrocardiograms of SmartDelay Determined AV Optimization: A comparison to other AV delay methods used in cardiac resynchronization therapy (SMART-AV) trial study participants (N = 234; mean age 67 years; 163 (70%) men; 140 (60%) ischemic cardiomyopathy; mean left ventricular ejection fraction 25%; mean QRS duration 152 ms; 179 (77%) had left bundle branch block). Baseline pre-implant electrocardiograms were digitized, transformed into orthogonal XYZ, and analyzed automatically by customized MATLAB software. SAI QRST was measured as an averaged arithmetic sum of absolute areas under the QRST curve. Patients were followed prospectively 6 months after CRT-defibrillator implantation. Patients with a decrease in left ventricular end-systolic volume ≥15 mL after 6 months of CRT were considered responders. The logistic regression model was adjusted for age, sex, bundle branch block morphology, left ventricular ejection fraction, cardiomyopathy type, and QRS duration. RESULTS Patients with the high mean SAI QRST (third tertile) had 2.5 times greater odds of response than those with the low mean SAI QRST (first tertile: odds ratio [OR] 2.5; 95% confidence interval [CI] 1.3-5.0; P = .010) and 1.9 times greater than the lower 2 tertiles combined (OR 1.9; 95% CI 1.1-3.5; P = .03). Adjustment for renal function (OR 2.33; 95% CI 1.32-4.11; P = .003) and left ventricular lead position in right anterior oblique and left anterior oblique views (OR 1.7; 95% CI 0.9-3.2; P = .087) did not attenuate association of SAI QRST with outcome. CONCLUSION High SAI QRST independently predicts CRT response in the SMART-AV study.
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Affiliation(s)
- Larisa G Tereshchenko
- Johns Hopkins University School of Medicine, Baltimore, Maryland; Oregon Health and Science University, Knight Cardiovascular Institute, Portland, Oregon.
| | - Alan Cheng
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason Park
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Jagmeet Singh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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