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Robyns T, Nuyens D, Lu HR, Gallacher DJ, Vandenberk B, Garweg C, Ector J, Pagourelias E, Van Cleemput J, Janssens S, Willems R. Prognostic value of electrocardiographic time intervals and QT rate dependence in hypertrophic cardiomyopathy. J Electrocardiol 2018; 51:1077-1083. [PMID: 30497734 DOI: 10.1016/j.jelectrocard.2018.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/26/2018] [Accepted: 09/11/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Preventing sudden cardiac death (SCD) is one of the main goals in hypertrophic cardiomyopathy (HCM). Many variables have been proposed, however the European and American guidelines do not incorporate any ECG or Holter monitoring derived variables other than the presence of ventricular arrhythmia in their risk stratification models. In the present study we evaluated electrocardiographic parameters in risk stratification of HCM. METHODS AND RESULTS Novel electrocardiographic parameters including the index of cardio-electrophysiological balance (iCEB), individualized QT correction (QTi) and QT rate dependence were evaluated along with established risk factors. A composite endpoint of SCD was defined as out of hospital cardiac arrest, appropriate ICD shock and sustained ventricular tachycardia. Cox regression analysis was used to evaluate predictors of SCD. Out of the 466 HCM patients, 31 reached the composite endpoint during a follow up of 75 ± 86 months. In a multivariate model, nor iCEB, QTi or QT rate dependence were predictors of SCD. Only male gender (p < 0.01; OR 13.1; CI 1.74-98.83), negative T waves in the inferior leads (p = 0.04; OR 2.51; CI 1.03-6.13) and familial sudden death (p < 0.01; OR 3.03; CI 1.39-6.59) were significant predictors. On top of either the ESC risk score or the 3 traditional 'American risk factors', only male gender was a significant predictor of SCD. CONCLUSION No ECG or Holter monitoring parameters added in risk stratification for SCD in HCM. However, male gender and negative T waves in the inferior leads are promising novel markers to evaluate in larger cohorts.
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Affiliation(s)
- Tomas Robyns
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Belgium; The University Hospitals of Leuven are Member of the European Reference Network for Rare and Complex Diseases of the Heart (ERN GUARD-HEART).
| | - Dieter Nuyens
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Hua Rong Lu
- Global Safety Pharmacology, Discovery Sciences, Janssen Research and Development a Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - David J Gallacher
- Global Safety Pharmacology, Discovery Sciences, Janssen Research and Development a Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Bert Vandenberk
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Christophe Garweg
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Joris Ector
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Efstathios Pagourelias
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Johan Van Cleemput
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Rik Willems
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Belgium
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Jalanko M, Väänänen H, Tarkiainen M, Sipola P, Jääskeläinen P, Lauerma K, Laitinen T, Laitinen T, Laine M, Heliö T, Kuusisto J, Viitasalo M. Fibrosis and wall thickness affect ventricular repolarization dynamics in hypertrophic cardiomyopathy. Ann Noninvasive Electrocardiol 2018; 23:e12582. [PMID: 29974557 DOI: 10.1111/anec.12582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 05/11/2018] [Accepted: 06/06/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is characterized by ventricular repolarization abnormalities and risk of ventricular arrhythmias. Our aim was to study the association between the phenotype and ventricular repolarization dynamics in HCM patients. METHODS HCM patients with either the MYBPC3-Q1061X or TPM1-D175N mutation (n = 46) and control subjects without mutation and hypertrophy (n = 35) were studied with 24-hr ambulatory ECG recordings by measuring time intervals of rate-adapted QT (QTe), maximal QT, and T-wave apex to wave end (TPE) intervals and the QTe/RR slope. Findings were correlated to specified echocardiographic and cardiac magnetic resonance imaging (CMRI) findings. RESULTS Rate-adapted QTe interval was progressively longer in HCM patients with decreasing heart rates compared to control subjects (p = 0.020). The degree of hypertrophy correlated with measured QTe values. HCM patients with maximal wall thickness higher than the mean (20.6 mm) had longer maximum QTe and median TPE intervals compared to control subjects and HCM patients with milder hypertrophy (p < 0.001 and p = 0.014, respectively). HCM patients with late gadolinium enhancement (LGE) on CMRI had steeper QTe/RR slopes compared to HCM patients without LGE and control subjects (p = 0.044 and p = 0.001, respectively). LGE was an independent predictor of QTe/RR slope (p = 0.023, B = 0.043). CONCLUSION Dynamics of ventricular repolarization in HCM are affected by hypertrophy and fibrosis. LGE may confer an independent effect on QT dynamics which may increase the arrhythmogenic potential in HCM.
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Affiliation(s)
- Mikko Jalanko
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Heikki Väänänen
- Department of Neuroscience and Biomedical Engineering, Aalto University, Espoo, Finland
| | - Mika Tarkiainen
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Petri Sipola
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland
| | | | - Kirsi Lauerma
- Department of Radiology, Helsinki University Hospital, Helsinki, Finland
| | - Tiina Laitinen
- Department of Clinical Physiology, Kuopio University Hospital, Kuopio, Finland
| | - Tomi Laitinen
- Department of Clinical Physiology, Kuopio University Hospital, Kuopio, Finland
| | - Mika Laine
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tiina Heliö
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Johanna Kuusisto
- Centre for Medicine and Clinical Research, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Matti Viitasalo
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Sugrue A, Killu AM, DeSimone CV, Chahal AA, Vogt JC, Kremen V, Hai J, Hodge DO, Acker NG, Geske JB, Ackerman MJ, Ommen SR, Lin G, Noseworthy PA, Brady PA. Utility of T-wave amplitude as a non-invasive risk marker of sudden cardiac death in hypertrophic cardiomyopathy. Open Heart 2017; 4:e000561. [PMID: 28409011 PMCID: PMC5384475 DOI: 10.1136/openhrt-2016-000561] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 11/18/2016] [Accepted: 11/22/2016] [Indexed: 01/21/2023] Open
Abstract
Objective Sudden cardiac arrest (SCA) is the most devastating outcome in hypertrophic cardiomyopathy (HCM). We evaluated repolarisation features on the surface electrocardiogram (ECG) to identify the potential risk factors for SCA. Methods Data was collected from 52 patients with HCM who underwent implantable cardioverter defibrillator (ICD) implantation. Leads V2 and V5 from the ECG closest to the time of ICD implant were utilised for measuring the Tpeak-Tend interval (Tpe), QTc, Tpe/QTc, T-wave duration and T-wave amplitude. The presence of the five traditional SCA-associated risk factors was assessed, as well as the HCM risk-SCD score. Results 16 (30%) patients experienced aborted cardiac arrest over 8.5±4.1 years, with 9 receiving an ICD shock and 7 receiving ATP. On univariate analysis, T-wave amplitude was associated with appropriate ICD therapy (HR per 0.1 mV 0.79, 95% CI 0.56 to 0.96, p=0.02). Aborted SCA was not associated with a greater mean QTc duration, Tpeak-Tend interval, T-wave duration, or Tpe/QT ratio. Multivariate analysis (adjusting for cardinal HCM SCA-risk factors) showed T-wave amplitude in Lead V2 was an independent predictor of risk (adjusted HR per 0.1 mV 0.74, 95% CI 0.57 to 0.97, p=0.03). Addition of T-wave amplitude in Lead V2 to the traditional risk factors resulted in significant improvement in risk stratification (C-statistic from 0.65 to 0.75) but did not improve the performance of the HCM SCD-risk score. Conclusions T-wave amplitude is a novel marker of SCA in this high risk HCM population and may provide incremental predictive value to established risk factors. Further work is needed to define the role of repolarisation abnormalities in predicting SCA in HCM.
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Affiliation(s)
- Alan Sugrue
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ammar M Killu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Anwar A Chahal
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Josh C Vogt
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vaclav Kremen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Mayo Clinic Graduate School of Medicine, Rochester, Minnesota, USA
| | - JoJo Hai
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - David O Hodge
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Nancy G Acker
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey B Geske
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Ackerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Specialty Registrar, Cardiology and Internal Medicine, London Deanery, University College London Partners, UK
| | - Steve R Ommen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Grace Lin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter A Brady
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Ventricular repolarization is a complex electrical phenomenon which represents a crucial stage in electrical cardiac activity. It is expressed on the surface electrocardiogram by the interval between the start of the QRS complex and the end of the T wave or U wave (QT). Several physiological, pathological and iatrogenic factors can influence ventricular repolarization. It has been demonstrated that small perturbations in this process can be a potential trigger of malignant arrhythmias, therefore the analysis of ventricular repolarization represents an interesting tool to implement risk stratification of arrhythmic events in different clinical settings. The aim of this review is to critically revise the traditional methods of static analysis of ventricular repolarization as well as those for dynamic evaluation, their prognostic significance and the possible application in daily clinical practice.
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Monitillo F, Leone M, Rizzo C, Passantino A, Iacoviello M. Ventricular repolarization measures for arrhythmic risk stratification. World J Cardiol 2016; 8:57-73. [PMID: 26839657 PMCID: PMC4728107 DOI: 10.4330/wjc.v8.i1.57] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 09/04/2015] [Accepted: 11/04/2015] [Indexed: 02/06/2023] Open
Abstract
Ventricular repolarization is a complex electrical phenomenon which represents a crucial stage in electrical cardiac activity. It is expressed on the surface electrocardiogram by the interval between the start of the QRS complex and the end of the T wave or U wave (QT). Several physiological, pathological and iatrogenic factors can influence ventricular repolarization. It has been demonstrated that small perturbations in this process can be a potential trigger of malignant arrhythmias, therefore the analysis of ventricular repolarization represents an interesting tool to implement risk stratification of arrhythmic events in different clinical settings. The aim of this review is to critically revise the traditional methods of static analysis of ventricular repolarization as well as those for dynamic evaluation, their prognostic significance and the possible application in daily clinical practice.
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