Predictive value of a fragmented QRS complex in patients undergoing primary angioplasty for ST elevation myocardial infarction

Significance of fragmented QRS and predictors of outcome in ST-elevation myocardial infarction

Background

Fragmented QRS (fQRS) might be associated with certain characteristics in ST-elevation myocardial infarction (STEMI) patients and inhospital adverse events.

Materials and Methods

A sum of 500 patients were gone over retrospectively. Patients with STEMI, all undergone percutaneous coronary intervention, were grouped as fQRS (-) and fQRS (+). Characteristics of the patients, major adverse cardiac event (MACE), death in hospital, nonfatal myocardial infarction (MI), stent thrombosis, slow flow myocardial perfusion, development of ventricular tachycardia (VT) and fibrillation, cardiogenic shock and cardiopulmonary arrest were filtered.

Results

FQRS (-) group was composed of 207 patients whose mean age was 61.1 ± 12.1, whereas 293 patients were there in fQRS (+) with a mean age of 66.7 ± 10.6 (P < 0.001). Thrombolysis in MI (TIMI) (P < 0.01), the global registry of acute coronary events (GRACE) (P < 0.01) scores, white blood cell count, neutrophil/lymphocyte ratio, MACE and the ratio of death in hospital and VT in the hospital were significantly higher in fQRS (+) group (P < 0.001, for remaining all). In multivariate logistic regression analysis, TIMI scores above 2 and GRACE scores above 109 were determined as independent predictors of MACE in the entire patient group (odds ratio [OR]: 2.022; 95% confidence interval [CI]; 1.321-3.424, P = 0.003; OR: 1.712; 95% CI: 1.156-2.804, P = 0.008).

Conclusion

FQRS (+) and fQRS (-) patients markedly differ from each other in terms of certain demographic and clinical features and TIMI and GRACE scores have a significant predictive value for MACE in all STEMI patients' group.

Correlation of left ventricular ejection fraction drop and fragmented QRS with ST-segment elevation myocardial infarction

BACKGROUND

Fragmented QRS (fQRS) is an electrocardiographic parameter, which could be assessed easily and non-invasively using surface electrocardiogram (ECG) and may have significant prognostic value. The present study aimed to evaluate the correlation between left ventricular ejection fraction (LVEF) and fQRS in surface ECG.

METHODS

This study was conducted on 186 patients with acute ST-elevation myocardial infarction (STEMI). After primary percutaneous coronary intervention (PCI) and transferring the patients to the cardiac care unit (CCU), the patients were examined using echocardiography, and ejection fraction (EF) was assessed using the Simpson's method by a single cardiologist. Data analysis was performed using SPSS software.

RESULTS

Among 186 eligible patients, 113 cases showed fQRS in the surface ECG. In total, 84.9% of these patients were men, and 15.1% were women (P < 0.05). No significant correlation was observed between age and fQRS (P > 0.05), as well as coronary artery disease (CAD) severity and fQRS (P > 0.05). On the other hand, a statistically significant, reverse correlation was denoted between EF and fQRS in the surface ECG (P < 0.05). In addition, significant relations were observed between the rate of ST-segment elevation and depression and fQRS (P < 0.05).

CONCLUSION

According to the obtained results, EF significantly decreased in the echocardiography of the patients with STEMI and fQRS in the surface ECG. Considering the cost-efficiency and accessibility of fQRS evaluation, it could be used for the assessment of various parameters in cardiology modalities such as cardiac magnetic resonance imaging (CMRI) and computed tomography (CT).

Predicting efficacy of combined assessment with fragmented QRS and severely depressed heart rate variability on outcome of patients with acute myocardial infarction

The association between fragmented QRS (fQRS) and autonomic nervous dysfunction, and major adverse cardiovascular events (MACE) is not fully clear in patients with acute myocardial infarction (AMI). This study aimed to observe whether combined assessment with fQRS and cardiac autonomic nervous function could enhance the predicting efficacy on outcome in AMI patients. A total of 153 consecutive hospitalized AMI patients were included in this retrospective study. Patients were divided into non-fQRS (nfQRS) group and fQRS group according to 12-lead electrocardiogram, into sHRV [severely depressed heart rate variability (HRV): standard deviation of NN intervals (SDNN) < 100 ms and very low frequency (VLF) < 26.7 ms] group and nsHRV (non-severely depressed HRV) group according to 24 h Holter monitoring, and into non-MACE (nMACE) group and MACE group according to 12 months’ follow-up results. The incidence of sHRV was significantly higher in the fQRS group than in the nfQRS group (71.9 vs. 39.3%, p < 0.05). The incidences of MACE were 7.4, 22.2, 25.7 and 56.5%, respectively, in nsHRV + nfQRS group, nsHRV + fQRS group, sHRV + nfQRS group and sHRV + fQRS group (p < 0.05). Multivariable Cox regression analysis showed that patients in the sHRV + fQRS group had a sixfold higher risk of MACE compared to patients in the nsHRV + nfQRS group (HR = 6.228, 95% CI 1.849–20.984, p = 0.003). The predicting sensitivity and specificity on MACE were 81.4 and 58.2% by sHRV, 69.8 and 69.1% by fQRS in these AMI patients. The specificity (81.8%) was the highest with the combination of sHRV and fQRS. Adding sHRV and fQRS to clinical data offered incremental prognostic value. Present results indicate that fQRS is closely related to sHRV, suggesting significant impairment of sympathetic nerve function in AMI patients with fQRS. Combined assessment with fQRS and sHRV enhances the predicting efficacy on outcome in AMI patients.

Fragmented QRS complexes are associated with subclinical left ventricular dysfunction in patients with Behcet's disease: Four-dimensional speckle tracking echocardiography

BACKGROUND

Behcet's disease (BD) is a chronic systemic inflammatory disease in which early detection of cardiac involvement is essential. The aim of this study was to assess the left ventricular (LV) functions in BD patients using four-dimensional (4D) speckle tracking echocardiography (STE) and to test the correlation between LV dysfunction and the presence of QRS fragmentation.

METHODS

This cross-sectional study included 64 Behcet's patients and 48 healthy volunteers. The BD group was divided into two subgroups depending on the presence (fQRS+) or absence (fQRS-) of fragmented QRS (fQRS). In both groups, left ventricular global area strain (LV-GAS), global radial strain (GRS), global longitudinal strain (GLS), and global circumferential strain (GCS) were obtained with 4D echocardiography.

RESULTS

GAS, GRS, GLS, and GCS values were significantly different in Behcet's patients and in healthy volunteers. GLS and GAS values were lower in the fQRS+ than in the fQRS- group (-15.8 ± 1.8 and -17.9 ± 1.6, P = .001 vs -25.0 ± 3.1 and -29.2 ± 4.2, P < .001, respectively). The duration of disease was longer in fQRS+ than in fQRS- patients (120.8 ± 67.4 vs 71.0 ± 40.5, P < .001). Multiple linear regression analysis showed that fQRS and disease duration were independent predictors of LV-GAS.

CONCLUSIONS

Four-dimensional STE may be helpful for the prediction of early cardiac dysfunction in patients with BD. The presence of fQRS may be an indicator of subclinical LV dysfunction.

The Predictive Value of Fragmented QRS for Cardiovascular Events in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

Objective: Fragmented QRS (fQRS) have been reported as a predictor of major adverse cardiac events (MACE) and mortality in several studies on cardiovascular disease. However, most studies have yielded discrepant results. This study aimed to explore the correlation between fQRS and cardiovascular events in patients with acute myocardial infarction (AMI) during their hospital stay and follow-up period, and the predictive value of fQRS in the prognosis of AMI. Methods: We searched for relevant studies in four databases, Medline, Embase, PubMed, and the Cochrane Library from January 2010 to March 2020. Our initial search yielded 585 articles. Of these, we screened 19 studies, and finally included a total of 6,914 patients in this analysis, comparing death events or MACE in AMI patients with or without fQRS. Results: Fragmented QRS was significantly associated with a higher risk of in-hospital mortality (OR, 3.97; 95% CI, 2.45-6.44; p < 0.00001), long-term mortality (OR, 2.93; 95% CI, 1.76-4.88; p < 0.0001), in-hospital MACE (OR, 2.48; 95% CI, 1.62-3.80; p < 0.0001), and long-term MACE (OR, 3.81; 95% CI, 2.21-6.57; p < 0.00001). In particular, it demonstrated a higher predictive value for in-hospital cardiovascular mortality and long-term all-cause mortality in AMI patients and in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI). Moreover, fQRS was also associated with an increased risk of ventricular arrhythmias (OR, 2.76; 95% CI, 1.72-4.43; p < 0.0001) and heart failure (OR, 1.65; 95% CI, 1.02-2.66; p = 0.04). Fragmented QRS was negatively associated with left ventricular ejection function (LVEF) (MD, -5.47; CI, [-7.03, -3.91]; p < 0.00001) and positively associated with a high incidence of coronary artery triple vessel lesions (OR, 2.14; 95% CI, 1.31-3.51; p = 0.002) in AMI patients. Conclusion: Fragmented QRS is significantly associated with in-hospital and long-term mortality and MACE in patients with AMI, as well as ventricular arrhythmias and heart failure. Furthermore, it may be a marker of mortality and MACE risk. Moreover, fQRS also indicates a reduced LVEF and a high incidence of coronary artery triple vessel lesions in AMI patients. Meta-analysis Registration: https://www.crd.york.ac.uk/prospero; ID: CRD42020171668.

Fragmented QRS predicts reperfusion failure and in-hospital mortality in ST-Elevation myocardial infarction: a systematic review and meta-analysis

Objective: Recent studies have shown that fragmented QRS (fQRS) is associated with unfavourable outcomes in STEMI patients. However, there is controversy amongst studies. We performed a systematic review and meta-analysis to explore the effect of fQRS on reperfusion failure and in-hospital mortality among this population.Methods: We searched the databases of MEDLINE and EMBASE from inception to October 2018. Included studies were published cohort studies of STEMI patients that underwent primary percutaneous coronary intervention (pPCI) and thrombolysis. Data from each study were combined using the random-effects model.Results: Ten studies from January 2011 to October 2018 (2753 patients, 1075 patients with fQRS), were included. The fQRS was associated with higher risk of reperfusion failure in pPCI when defined by ST-segment resolution (OR = 3.08, 95% CI = 1.27-7.46, p-value = .013) but not when defined by TIMI flow grade (pooled OR = 1.45, 95% CI = 0.83-2.54, p-value = .192). In thrombolysis, fQRS was associated with higher risk of reperfusion failure when defined by both ST-segment resolution (pooled OR = 4.35, 95% CI = 1.80-10.49, p-value = .001) and TIMI flow grade (OR = 3.70, 95% CI = 2.10-6.53, p-value < .001). The fQRS was also associated with an increased risk of in-hospital mortality in both pPCI (pooled OR = 4.41, 95% CI = 1.60-12.16, p-value = .004) and thrombolysis (pooled OR = 2.38, 95% CI = 1.06-5.35, p-value = .036).Conclusions: Our meta-analysis demonstrated that fQRS in STEMI patients was associated with reperfusion failure as well as in-hospital mortality.

Association between fragmented QRS complexes and left-ventricular dysfunction in anabolic androgenic steroid users

Background: Anabolic androgen steroid (AS) use has adverse effects on left ventricular functions, such as fibrosis development. Fragmented QRS is an important marker of myocardial fibrosis, while speckle-tracking echocardiographyis a method used to show subclinical left ventricle dysfunction. In this study, we examined the the ability of fQRS + to detect left ventricle fibrosis by speckle tracking echocardiography (STE) in AS users.Methods: The study included a total of 181 healthy athletes. Athletes were divided into two groups as AS users (n = 89) and non-AS users (n = 92). Then, athletes using AS were divided into two groups as fQRS+ (n = 52) and fQRS- (n = 37). In both groups, the arithmetic mean of three images was used to obtain the left ventricle global longitudinal strain (LV-GLS). The E/SRe ratio was also calculated and analysed.Results: There were significant differences between the AS users and non-AS users in terms of, E/SRe (55.7 ± 17.9 vs 50.3 ± 14.8; p = 0.015), LV-GLS (23.1 ± 1.9 vs 24.0 ± 1.7; p = 0.001), and fQRS (18.5% vs 6%; p = 0.005). When subgroup analysis was performed, both LV-GLS and E/SRivr were found to be poor in the fQRS + group. When multiple linear regression analysis was performed, we determined fQRS as an independent predictor for LV-GLS and E/SRivr ratio.Conclusion: In conclusion, our study demonstrated that fQRS is a parameter that can beused to determine left ventricle subclinical systolic and diastolic dysfunction in AS users. It can be used for cessation of drug use, especially in long-term use.

Predictive value of fragmented QRS for ventricular tachyarrhythmias in patients with acute myocardial infarction: A meta-analysis

BACKGROUND

Recent studies indicated that fragmented QRS (fQRS) is associated with malignant cardiac arrhythmias in patients with acute myocardial infarction (AMI). However, a systematic review and meta-analysis on this issue still have not been conducted. Thus, we performed a systematic review and meta-analysis to access the predictive value of fQRS for ventricular tachyarrhythmias (VTAs) in patients with AMI.

MATERIALS AND METHODS

We searched the databases of PubMed, Embase and Cochrane Library for relevant studies until 8 June 2019. We included studies which compared VTAs in AMI patients with fQRS vs without fQRS.

RESULTS

Six studies enrolling 2218 ST-segment elevation myocardial infarction (STEMI) patients were included in this meta-analysis. The fQRS was significantly associated with greater risk of VTAs in STEMI patients (Odds ratio [OR] 2.81, 95% confidence interval (CI) 1.99-3.95, P < .00001; I²  = 30%). This association was still significant both in prospective (OR 3.25, 95% CI 1.94-5.46, P < .00001; I²  = 0%) and retrospective (OR 2.40, 95% CI 1.22-4.74, P = .01; I²  = 54%) studies. In particularly, fQRS in patients with low left ventricular ejection fraction (≤50%) (OR 2.97, 95% CI 1.88-4.70, P < .00001; I²  = 21%) or <60 years old (OR 3.07, 95% CI 2.02-4.66, P < .00001; I²  = 0%) tripled the risk of VTAs during AMI.

CONCLUSION

Our meta-analysis demonstrated that fQRS increases the risk of developing VTAs in patients with STEMI.

Fragmented QRS - Its significance

Fragment QRS (fQRS) complex is a myocardial conduction abnormality that indicates myocardial scar. It is defined as additional notches in the QRS complex. Though initially fQRS was defined in the setting of normal QRS duration (<120 m s), later it has been expanded to include conditions with wide QRS complexes as in bundle branch block, ventricular ectopy and paced rhythm, when more than 2 notches are present. It is an important, yet often overlooked marker of mortality and arrhythmic events in many cardiac diseases. The significance of fQRS lies in the fact that it just requires a surface ECG for its recording and the value of information about the condition of the heart it dispenses based on the clinical setting. We review the role of fQRS in predicting adverse cardiac events in various conditions.

The presence of fragmented QRS is associated with increased epicardial adipose tissue and subclinical myocardial dysfunction in healthy individuals

AIM

The aim of this study was to measure epicardial adipose tissue (EAT) and to assess left ventricular (LV) systolic and diastolic function in a healthy population grouped according to the presence of fragmented QRS (fQRS).

METHODS

In this prospective case-control study, the study population consisted of 308 healthy individuals who were divided into two groups according to the existence of fQRS: 180 fQRS(+) individuals (with fQRS), and 128 age- and gender-matched fQRS(-) individuals (without fQRS). These individuals were assessed for EAT thickness and subclinical myocardial dysfunction using transthoracic echocardiography including strain imaging.

RESULTS

The baseline clinical characteristics were similar between groups. EAT thickness was significantly increased in fQRS(+) individuals (0.59 vs. 0.44 mm, p<0.001). LV global longitudinal strain, reflecting systolic function (19.62±3.05 vs. 20.95±2.36, p<0.001) and E/A ratio, reflecting diastolic function (0.95±0.30 vs. 1.10±0.37, p<0.001), were decreased, revealing subclinical myocardial dysfunction, in fQRS(+) individuals.

CONCLUSIONS

The presence of fQRS on the admission ECG is associated with increased EAT and pronounced subclinical LV systolic and diastolic dysfunction in a healthy population. Further studies with larger patient groups are needed to clarify the exact pathophysiological mechanisms underlying these findings in healthy populations.

Association between fragmented QRS complexes and left ventricular dysfunction in healthy smokers

OBJECTIVE

Smoking is a known risk factor for cardiovascular diseases and may cause myocardial damage independently of coronary artery disease. Fragmented QRS (fQRS) is an important marker of myocardial fibrosis, while speckle-tracking echocardiography is a method used to show subclinical left ventricle dysfunction.

METHODS

Our study included 230 healthy individuals aged 18-40 years. The patients included were separated into two groups: those smokers (n = 130) and non-smokers (n = 100). After that healthy smokers group were divided into two groups: those with fQRS (n = 24) and those without (n = 106). In both groups, the arithmetic mean of three images was used to obtain the left ventricle global longitudinal strain (LV-GLS). The E/SRe ratio was also calculated and analyzed.

RESULTS

There were significant differences between the smokers and non-smokers in terms of, E/SRe (55.7 ± 17.9 vs 50.3 ± 14.8; P = 0.015), LV-GLS (23.1 ± 1.9 vs 24.0 ± 1.7; P = 0.001), and fQRS (18.5% vs 6%; P = 0.005). As a result of subgroup analysis, pack-year history was higher in the fQRS positive group (16.7 ± 3.7 vs 11.2 ± 3.7, P < 0.001). While a negative correlation was observed between pack-year history and LV-GLS (r = -0.678, P < 0.001), there was a positive correlation between pack-year history and E/SRe (r = 0.730, P < 0.001).

CONCLUSION

In conclusion, our study demonstrated that fQRS is a parameter that can be used to determine left ventricle subclinical systolic and diastolic dysfunction in smokers, and that left ventricle dysfunction is related to the duration and intensity of smoking.

Fragmented QRS complexes are associated with left ventricular dysfunction in patients with type-2 diabetes mellitus: a two-dimensional speckle tracking echocardiography study

Background: Heart failure may develop independently of coronary artery disease in diabetes mellitus (DM) patients. Fragmented QRS (fQRS) is a marker of myocardial fibrosis or scar tissue and is related to an increase in cardiovascular adverse events. In this study, we examined the utility of speckle tracking echocardiography (STE) in assessing LV function in DM patients with fQRS. Methods and Results: The current study included 178 consecutive patients diagnosed with type-2 DM. The patients included were separated into two groups: those with (n = 50) and without (n = 128) fQRS. The two groups were compared by obtaining LV strain values with STE. Statistically significant differences were also identified between fQRS(-) and fQRS (+) groups with respect to Lv-GLS (p < .001), maxLAVI (p = .020), minLAVI (p < .001), E velocity (p < .001), Em velocity (0.002), E/Em ratio (<0.001) SRe (p < .001), SRe/SRa ratio (p < .001), SRivr (p < .001) and E/SRivr ratio (p < .001). In the multiple linear regression analysis, fQRS (β = -2.077, p = .002) and DM duration (β = -0.216, p = .021) were identified as independent predictors of Lv-GLS. However, fQRS (β = 4.557, p = .001) and minLAVI (β = -2.198, p = .031) were also found to be independent predictors of E/SRivr. We also performed multiple logistic regression analysis and identified Lv-GLS (β = -0.557, p = .001), minLAVI (β = -0.769, p = .001), E/Em ratio (β = 0.650, p = .001) and E/SRivr (β = 0.105, p = .001) as independent predictors of fQRS. Conclusıons: The results of this study revealed that subclinical LV dysfunction was more common in diabetic patients with fQRS. Therefore, determination of fQRS could be an indicator of the diabetic CMP in patients with DM.

Prognostic significance of fragmented QRS in patients with ST-elevation myocardial infarction undergoing revascularization

BACKGROUND & OBJECTIVES

This longitudinal study was carried out to evaluate the prognostic significance of fragmented QRS (fQRS) in patients with acute ST elevation myocardial infarction (STEMI) undergoing revascularization.

METHODS

This study included 103 STEMI patients belonging to Killip class I and II who underwent primary revascularization. All patients underwent twelve lead ECG at admission before PCI. Serial ECG were done after PCI at 3 hours, 6 hours, 24 hours, 48 hours and at discharge for detection of fQRS and echocardiography on day 3 post revascularization. Patients developing fQRS within 48 hours and with persistence of fQRS till discharge were included in "persistent fQRS" group. They were followed up after 30 days for major adverse cardiac events (MACE) and assessment of LV function by echocardiography.

RESULTS

fQRS was present in 64 patients (61.5%) of study population with 37 patients (57.8%) having persistent fQRS. MACE rates were low (4.8%) and did not differ with respect to fQRS. fQRS significantly correlated with LV dysfunction at 30 days on univariate analysis (p-0.003) but not on multivariate analysis (p -0.10). fQRS was significantly related to impaired myocardial reperfusion as assessed by ΣSTR (percent of total ST segment resolution) (adjusted odds ratio, 95% CI [4.265 (1.034 - 17.58)], p = 0.04).

CONCLUSION

In our study, fQRS did not predict MACE and LV dysfunction in acute STEMI patients belonging to Killip class I and II on short term follow-up of 30 days. But, fQRS independently predicted impaired microvascular myocardial reperfusion as assessed by ΣSTR.

Fragmented QRS and mortality in patients undergoing percutaneous intervention for ST-elevation myocardial infarction: Systematic review and meta-analysis

BACKGROUND

Fragmented QRS reflects disturbances in the myocardium predisposing the heart to ventricular tachyarrhythmias. Recent studies suggest that fragmented QRS (fQRS) is associated with mortality in ST-elevation myocardial infarction (STEMI) patients who underwent percutaneous coronary intervention (PCI). However, a systematic review and meta-analysis of the literature has not been done. We assessed the association between fQRS and overall mortality in STEMI patients who subsequently underwent PCI by a systematic review and meta-analysis.

METHODS

We comprehensively searched the databases of MEDLINE and EMBASE from inception to September 2017. Studies included in our analysis were published cohort (prospective or retrospective) and case-control studies that compared overall mortality among STEMI patient with and without fQRS who underwent PCI. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian, and Laird to calculate risk ratios and 95% confidence intervals.

RESULTS

Six studies from 2014 to 2017 were included in this meta-analysis involving 2,516 subjects with STEMI who underwent PCI (888 fQRS and 1,628 non-fQRS). Fragmented QRS was associated with overall mortality in STEMI patients who underwent PCI (pooled risk ratio = 3.87; 95% CI 1.96-7.66, I²  = 43%).

CONCLUSION

Fragmented QRS was associated with increased overall mortality up to threefold. Our study suggests that fQRS could be an important tool for risk assessment in STEMI patients who underwent PCI.

Association between metabolic syndrome and fragmented QRS complexes: Speckle tracking echocardiography study

BACKGROUND

Metabolic syndrome (MetS) is an endocrinological disease with both metabolic and physiological components. Previous studies have shown a relationship between MetS and left ventricular (LV) dysfunction. A fragmented QRS (fQRS) is a reliable electrocardiogram (ECG) finding with the importance of an indicator of myocardial fibrosis and scarring. In this study, we examined the utility of speckle tracking echocardiography (STE) in assessing LV function in MetS patients with fQRS.

METHODS

The 164 consecutive MetS patients included in the study. They were separated into two groups; those with (n=33) and those without (n=131) fQRS. The two groups were compared by obtaining LV strain values with STE.

RESULTS

Statistically significant differences between the fQRS (-) and fQRS (+) groups were identified for LV global longitudinal strain (LV-GLS) (p<0.001), maximum left atrial volume index (maxLAVI) (p≤0.001), strain rate during isovolumic relaxation period (SRivr) (p<0.001), and the E/SRivr ratio (p<0.001). In the multiple linear regression analysis, fQRS (β=-1.456, p=0.003), diabetes mellitus (β=-0.973, p=0.015), hypertension (β=-0.820, p=0.015) and MaxLAVI (β=-0.142, p=0.018) were independent predictors of LV-GLS. However, fQRS (β=21.995, p<0.001), MaxLAVI (β=3.090, p<0.001), and E/Em ratio (β=3.326, p<0.001) were also independent predictors of E/SRivr.

CONCLUSIONS

The results of this study showed that LV dysfunction was more common in MetS patients with fQRS. MetS patients, and especially those who are fQRS (+), should thus be closely monitored for subclinical LV systolic and diastolic dysfunction.

Assessment of the association between the presence of fragmented QRS and the predicted risk score of sudden cardiac death at 5 years in patients with hypertrophic cardiomyopathy

OBJECTIVE

It has been shown that the presence of fragmented QRS (fQRS) is associated with poor prognosis in many cardiovascular diseases and in patients with hypertrophic cardiomyopathy (HCM). However, no study has shown an association with the absolute risk score of sudden cardiac death. The aim of this study was to determine the relationship between QRS and the predicted risk score of sudden cardiac death at 5 years (HCM Risk-SCD) in HCM patients.

METHODS

In total, 115 consecutive HCM patients were included in this prospective observational study. The patients were divided into two groups according to the presence [fQRS(+) group (n=65)] or absence [fQRS(-) group (n=50)] of fQRS on a 12-lead electrocardiogram (ECG).

RESULTS

The HCM Risk-SCD (%) HCM Risk-SCD (>6%) values and some echocardiographic parameters, including ventricular extrasystole, ventricular tachycardia, cardiopulmonary resuscitation, implantable cardioverter defibrillator implantation, appropriate shock, and heart failure at the time of admission, were significantly higher in the fQRS(+) group than in the fQRS(-) group (all p<0.05). Both univariate and multivariate analyses revealed fQRS and New York Heart Association (NYHA) class as independent predictors of HCM Risk-SCD. In a receiver operating characteristic (ROC) curve analysis, an HCM Risk-SCD value of >4 was identified as an effective cut-off point in fQRS for HCM. An HCM Risk-SCD value of >4 yielded a sensitivity of 77% and a specificity of 76%.

CONCLUSION

fQRS is determined to be an independent high-risk indicator of HCM Risk-SCD. It seems to be associated with increased ventricular arrhythmias and some echocardiographic parameters.

Tp-e Interval, Tp-e/QTc Ratio, and Fragmented QRS Are Correlated with the Severity of Liver Cirrhosis

BACKGROUND

Arrhythmias and electrocardiographic changes are reported in several noncardiac diseases, including liver cirrhosis (LC). We intended to evaluate the interval from the peak to the end of the electrocardiographic T wave (Tp-e), Tp-e/QTc ratio, and fQRS as presumed markers of arrhythmias in LC.

METHODS

In this cross-sectional study, a total of 88 consecutive patients with LC according to clinical, biological, ultrasonographic, or histological criteria and 73 control subjects were enrolled. The severity of cirrhosis was classified according to Pugh-Child's classification and Model for End-Stage Liver Disease (MELD) score. Tp-e interval, Tp-e/QTc ratio, and fQRS rates were measured from the 12-lead electrocardiogram.

RESULTS

Tp-e interval, Tp-e/QTc ratio and fQRS rates were significantly increased in parallel to the severity of LC (P < 0.001, P < 0.001, and P = 0.003, respectively). In correlation analysis, Pugh-Child stage showed a significantly positive correlation with Tp-e interval (r = 0.462, P < 0.001), QTc interval (r = 0.373, P < 0.001), Tp-e/QTc ratio (r = 0.352, P < 0.001), and fQRS (r = 0.407, P < 0.001). Furthermore, Tp-e interval (r = 0.414, P < 0.001) and Tp-e/QTc ratio (r = 0.426, P< 0.001) had significant positive correlation with MELD score.

CONCLUSIONS

Our study demonstrated that Tp-e interval, Tp-e/QTc ratios, and fQRS rates were significantly increased in parallel to the severity of LC. Thus, these findings may implicate that Tp-e interval, Tp-e/QTc ratio, and fQRS may be novel and useful indicators for prediction of arrhythmias in LC.

Prognostic Value of QRS Fragmentation in Patients with Acute Myocardial Infarction: A Meta-Analysis

AIMS

Fragmented QRS has emerged as a novel electrocardiographic parameter associated with adverse clinical events in various diseases. The aim of this study was to investigate the association of fQRS with in-hospital and long-term cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI).

METHODS AND RESULTS

We searched PubMed, Embase, Web of Science, and Cochrane Library up to October 2015 for eligible studies. We selected studies with fQRS defined with 12-lead ECG during the index hospitalization of STEMI/NSTEMI. Primary outcomes were in-hospital and long-term cardiovascular events. In-hospital mortality was significantly higher in fQRS (+) group (99/733; 13.5%) compared to fQRS (-) group (47/1293; 3.6%) (OR 4.03 95% CI 1.81-8.94; P = 0.0006). Long-term mortality rate was higher in fQRS (+) group (89/473; 18.8%) compared to fQRS (-) group (54/1009; 5.3%) (OR 3.93 95% CI 1.92-8.05; P = 0.0002). In addition the frequency of long-term MACE was higher in fQRS (+) group (46.9%) compared to fQRS (-) group (14.6%) (OR 5.13 95% CI 2.77-9.51; P < 0.00001) CONCLUSION: Presence of fQRS on admission ECG was found to be predictor of mortality, MACE, deterioration of LV function, and presence of multivessel disease in patients with STEMI and NSTEMI.

The Importance of the Number of Leads with fQRS for Predicting In-Hospital Mortality in Acute STEMI Patients Treated with Primary PCI

BACKGROUND

Fragmented QRS (fQRS) has been shown to be related to increased cardiovascular mortality and morbidity. However, limited data are available for evaluating the relationship between the number of leads with fQRS and in-hospital all-cause mortality in patients with acute ST segment elevation myocardial infarction (STEMI). The aim of our study is to investigate the prognostic importance of the number of leads with fQRS in acute STEMI patients treated by primary percutaneous coronary intervention (PCI).

METHODS

Two hundred ten eligible patients with acute STEMI that underwent primary PCI were enrolled in this study. Each patient's 12-lead electrocardiography (ECG) taken in the first 48 hours was analyzed and the number of leads with fQRS were recorded.

RESULTS

The number derivations with fQRS were significantly higher in patients who developed in-hospital mortality than the patients who did not develop in-hospital mortality (2.6 ± 2.6 vs 0.9 ± 1.3; P = 0.002). Also, patients with ≥3 leads with fQRS had higher rate of in-hospital all-cause mortality (23.5% vs 7.4%, P = 0.009), higher frequency of Q wave (67.6% vs 36.9%, P = 0.001), and higher frequency of fQRS with Q wave (67.6% vs 15.9%, P < 0.001) than those patients with <3 leads with fQRS. By a multivariate regression analysis, the number of leads with fQRS was found to be an independent predictor of in-hospital all-cause mortality (odds ratio: 1.415, 95% confidence interval: 1.049-1.909, P = 0.023).

CONCLUSIONS

The number of leads with fQRS on 12-lead ECG is an independent predictor of in-hospital all-cause mortality in patients with acute STEMI treated by primary PCI.

Total Mortality, Major Adverse Cardiac Events, and Echocardiographic-Derived Cardiac Parameters with Fragmented QRS Complex

BACKGROUND

Fragmented QRS complex (fQRS), an easily evaluated noninvasive electrocardiographic parameter, is associated with worse outcomes in patients with several cardiovascular conditions. The presence of fQRS on ECG may be an indicator of myocardial damage in patients with coronary artery disease (CAD). In this article, we performed a meta-analysis in order to characterize the presence of fQRS on ECG in patients with CAD.

METHODS

We searched English-language randomized controlled trials involving fQRS on ECG in patients with CAD (n = 3279 patients, 12 trials). Two reviewers independently extracted data. Data on LVEF, LVESD, LVEDD, LVESV, LVEDV, total mortality, stroke, and MACE were collected. fQRS was performed a comparison with non-fQRS, calculating pooled relatives risk (RRs) and weighted mean difference (WMD), and associated 95% confidence intervals (CIs).

RESULTS

fQRS was associated with significant increased WMD of LVEDD (WMD, 2.26; 95%CI, 0.92 to 0.36, P = 0.0009), LVESD (WMD, 2.71; 95%CI, 1.23 to 4.19, P = 0.0003), LVEDV (WMD, 31.37; 95%CI, 24.82 to 37.92, P < 0.00001), and LVESV (WMD, 28.45; 95%CI, 22.92 to 33.98, P < 0.00001). As compared to non-fQRS, fQRS increased risk of total mortality (RR, 3.09; 95%CI, 1.76 to 5.44, P < 0.0001) and MACE (RR, 2.85; 95%CI, 1.98 to 4.09, P < 0.00001) in patients with CAD. However, a decreased trend was observed for LVEF (WMD, -3.59; 95%CI, -7.05 to -0.12, P = 0.04). For the incidence of stoke, there was no difference between fQRS and non-fQRS group.

CONCLUSIONS

Our findings indicate that fQRS is a valuable factor to predict total mortality and MACE in patients with CAD.

Fragmented QRS on Admission Electrocardiography Predicts Long-Term Mortality in Patients with Non-ST-Segment Elevation Myocardial Infarction

BACKGROUND

Early diagnosis and identification of high-risk non-ST elevation myocardial infarction (NSTEMI) is an important issue. Fragmented QRS (fQRS) complexes are defined as various RSR' patterns on 12-lead resting electrocardiography (ECG). Previous studies revealed that fQRS is related with increased ventricular arrhythmias and cardiovascular mortality. The relation between fQRS and mortality in acute coronary syndromes, mitral valve disease severity and structural heart disease has been shown in different studies. The aim of this study was to investigate relation between fQRS and long-term cardiovascular mortality in NSTEMI patients.

METHODS

Patients who admitted to our emergency unit and diagnosed NSTEMI between 2012 and 2013, 433 patients were included prospectively. fQRS complexes determined in 85 patients. Patients were divided into two groups according to fQRS existence. All patients evaluated for their clinical, laboratory, electrocardiographic, and echocardiographic characteristics. Angiographic features of 315 patients who underwent coronary angiography was also recorded. In-hospital, 30-day and 12-month mortality was compared between these groups.

RESULTS

Demographic characteristics and cardiovascular risk factors were similar in both groups except hyperlipidemia. GRACE risk score was higher in patients with fQRS and positively correlated with existence of fQRS. In hospital and 30-days mortality were similar but late mortality was higher in fQRS group. Predictors of late mortality were found to be age, heart rate, male sex in addition to fQRS.

CONCLUSION

We found a relation between fQRS and late mortality. Fragmented QRS may be seen as a cautionary signal for extensive myocardial damage and thereby increased long-term mortality for patients with NSTEMI.