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Allescher J, Sinnecker D, von Goeldel B, Barthel P, Müller A, Hapfelmeier A, Martens E, Laugwitz K, Schmidt G, Steger A. QRS fragmentation does not predict mortality in survivors of acute myocardial infarction. Clin Cardiol 2024; 47:e24218. [PMID: 38269630 PMCID: PMC10797824 DOI: 10.1002/clc.24218] [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: 10/21/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Despite advances in coronary revascularization and in heart failure management, myocardial infarction survivors remain at substantially increased mortality risk. Precise risk assessment and risk-adapted follow-up care are crucial to improve their outcomes. Recently, the fragmented QRS complex, i.e. the presence of additional spikes within the QRS complexes on a 12-lead electrocardiogram, has been discussed as a potential non-invasive risk predictor in cardiac patients. HYPOTHESIS The aim of this study was to evaluate the prognostic meaning of the fragmented QRS complex in myocardial infarction survivors. METHODS 609 patients with narrow QRS complexes <120 ms were included in a prospective cohort study while hospitalized for myocardial infarction and followed for 5 years. RESULTS The prevalence of the fragmented QRS complex in these patients amounted to 46.8% (285 patients). These patients had no increased hazard of all-cause death (HR 0.84, 95%-CI 0.45-1.57, p = 0.582) with a mortality rate of 6.0% compared to 7.1% in patients without QRS fragmentations. Furthermore, the risks of cardiac death (HR 1.28, 95%-CI 0.49-3.31, p = 0.613) and of non-cardiac death (HR 0.6, 95%-CI 0.26-1.43, p = 0.25) were not significantly different in patients with QRS fragmentations. However, patients with QRS fragmentations had increased serum creatine kinase concentrations (1438U/l vs. 1160U/l, p = 0.039) and reduced left ventricular ejection fractions (52% vs. 54%, p = 0.011). CONCLUSIONS The hypothesis that QRS fragmentation might be a prognostic parameter in survivors of myocardial infarction was not confirmed. But those with QRS fragmentation had larger myocardial infarctions, as measured by creatine kinase and left ventricular ejection fraction.
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Affiliation(s)
- Julia Allescher
- Klinik und Poliklinik für Innere Medizin I, University HospitalTechnical University of MunichMunichGermany
| | - Daniel Sinnecker
- Klinik und Poliklinik für Innere Medizin I, University HospitalTechnical University of MunichMunichGermany
- DZHK (German Centre for Cardiovascular Research)Partner Site Munich Heart AllianceMunichGermany
- Medizinisches Versorgungszentrum (MVZ) HarzGoslarGermany
| | - Bernhard von Goeldel
- Klinik und Poliklinik für Innere Medizin I, University HospitalTechnical University of MunichMunichGermany
| | - Petra Barthel
- Klinik und Poliklinik für Innere Medizin I, University HospitalTechnical University of MunichMunichGermany
| | - Alexander Müller
- Klinik und Poliklinik für Innere Medizin I, University HospitalTechnical University of MunichMunichGermany
| | - Alexander Hapfelmeier
- School of Medicine, Institute of AI and Informatics in MedicineTechnical University of MunichMunichGermany
- School of Medicine, Institute of General Practice and Health Services ResearchTechnical University of MunichMunichGermany
| | - Eimo Martens
- Klinik und Poliklinik für Innere Medizin I, University HospitalTechnical University of MunichMunichGermany
| | - Karl‐Ludwig Laugwitz
- Klinik und Poliklinik für Innere Medizin I, University HospitalTechnical University of MunichMunichGermany
- DZHK (German Centre for Cardiovascular Research)Partner Site Munich Heart AllianceMunichGermany
| | - Georg Schmidt
- Klinik und Poliklinik für Innere Medizin I, University HospitalTechnical University of MunichMunichGermany
- DZHK (German Centre for Cardiovascular Research)Partner Site Munich Heart AllianceMunichGermany
| | - Alexander Steger
- Klinik und Poliklinik für Innere Medizin I, University HospitalTechnical University of MunichMunichGermany
- DZHK (German Centre for Cardiovascular Research)Partner Site Munich Heart AllianceMunichGermany
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Yang N, Han X, Zhang J, Zhang S, Sun J. What can we find in QRS in patients with ST-segment-elevation myocardial infarction? J Electrocardiol 2022. [DOI: 10.1016/j.jelectrocard.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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The relationship between fragmented QRS and mortality in without reversible defects patients with scintigraphical myocardial infarction diagnosis. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1013404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background/Aim: Evidence of increased mortality in perfusion abnormalities on myocardial perfusion scintigraphy (MPS) can be found. However, electrocardiography (ECG) is a cheaper and more easily accessible examination than MPS. Fragmented QRS (fQRS) is also considered to be associated with mortality in some cardiological diseases. The present study aimed to analyze the relationship between fQRS based on electrocardiography (ECG) and mortality in patients without reversible defects whose fixed hypoperfusion/perfusion defects were diagnosed and associated with myocardial infarction (MI) based on myocardial perfusion scintigraphy (MPS).
Methods: Non-ischemic patients (2289 patients) with MI diagnoses based on scintigraphy were selected based on retrospective scintigraphy reports. The presence of fQRS was investigated in 85 patients whose 12-lead electrocardiographs could be accessed from the hospital archive, and their deaths due to all causes were questioned from the death information system. The relationship between left ventricular ejection fraction (LVEF), fQRS, type of exercise, number of leukocytes, other parameters, and mortality rates was analyzed.
Results: The numbers of living (n = 69) and deceased (n = 16) patients were obtained. They were divided into two groups: (1) surviving patients (n = 69, number of fQRS positive 42) and (2) deceased (n = 16, number of fQRS positive 11). No distributional differences were found between mortality rates and fQRS and demographic features between groups (P = 0.558). However, a statistically significant effect was observed between mortality rates and low LVEF levels, pharmacological stress, number of leukocytes, and a low HDL level.
Conclusion: The present study suggests that it may be useful to define benign features of fQRS. LVEF levels may be a very important parameter in decision-making for pharmacological stress, and its role in prediction of mortality may be higher than that obtained by fQRS.
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Predicting efficacy of combined assessment with fragmented QRS and severely depressed heart rate variability on outcome of patients with acute myocardial infarction. Heart Vessels 2021; 37:239-249. [PMID: 34424362 PMCID: PMC8794902 DOI: 10.1007/s00380-021-01930-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022]
Abstract
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.
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Torales JM, Centurión OA, Aquino NJ, Chávez CO, Alderete JF, Scavenius KE, Sequeira OR, Miño LM, Candia JC, Cáceres C, Lovera OA, Martínez JE. The relation between QRS complex fragmentation and segmental abnormalities of the myocardial contractility in patients with coronary artery disease. Indian Heart J 2021; 73:325-330. [PMID: 34154750 PMCID: PMC8322790 DOI: 10.1016/j.ihj.2021.03.010] [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: 05/30/2020] [Revised: 02/15/2021] [Accepted: 03/23/2021] [Indexed: 11/12/2022] Open
Abstract
Background Fragmented QRS (fQRS) is defined as any QRS complex with duration of less than 120 ms (ms) and at least one notch in the R or S wave in two or more leads belonging to the same coronary territory. The fQRS represents a delay in ventricular conduction caused by a myocardial scar associated to arrhythmic events. Methods This is a descriptive, retrospective, cross-sectional study of a total of 123 patientsadmitted with ischemic heart disease. The aim was to correlate the presence of fQRS in a conventional 12-leads electrocardiogram (ECG) with myocardial regional motility disorders. Results A total of 62% of the patients were male, the mean age was 63 ± 12 SD. fQRS was observed in 44% (64% men and 36% women), the most frequent location being the inferior wall (61%), followed by the anteroseptal and lateral walls (14% for both). Of the 36 patients with fQRS, 30 had segmental disorders, while 6 did not. Of the 45 patients without fQRS, 28 had segmental disorders, but 17 did not, which gives us a sensitivity of 52% (moderate SnNout) and specificity of 74% (high SpPin), with a positive predictive value of 83%, a negative predictive value of 38% and a prevalence of 72%. Conclusion The presence of fQRS in the ECG has high specificity and a high positive predictive value of the existence of segmental myocardial motility disorders in patients with documented coronary artery disease.
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Affiliation(s)
- Judith María Torales
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay; Department of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de La Mora, Paraguay
| | - Osmar Antonio Centurión
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay; Department of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de La Mora, Paraguay.
| | - Nelson J Aquino
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay
| | - Christian O Chávez
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay
| | - José F Alderete
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay; Department of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de La Mora, Paraguay
| | - Karina E Scavenius
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay; Department of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de La Mora, Paraguay
| | - Orlando R Sequeira
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay
| | - Luis M Miño
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay; Department of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de La Mora, Paraguay
| | - José C Candia
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay
| | - Cristina Cáceres
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay
| | - Oscar A Lovera
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay
| | - Jorge E Martínez
- Department of Cardiology, Hospital de Clínicas, Asunción National University (UNA), San Lorenzo, Paraguay
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The effect of the severity COVID-19 infection on electrocardiography. Am J Emerg Med 2020; 46:317-322. [PMID: 33059987 PMCID: PMC7539927 DOI: 10.1016/j.ajem.2020.10.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/06/2020] [Accepted: 10/02/2020] [Indexed: 01/08/2023] Open
Abstract
Objective Acute myocardial damage is detected in a significant portion of patients with coronavirus 2019 disease (COVID-19) infection, with a reported prevalence of 7–28%. The aim of this study was to investigate the relationship between electrocardiographic findings and the indicators of the severity of COVID-19 detected on electrocardiography (ECG). Methods A total of 219 patients that were hospitalized due to COVID-19 between April 15 and May 5, 2020 were enrolled in this study. Patients were divided into two groups according to the severity of COVID-19 infection: severe (n = 95) and non-severe (n = 124). ECG findings at the time of admission were recorded for each patient. Clinical characteristics and laboratory findings were retrieved from electronic medical records. Results Mean age was 65.2 ± 13.8 years in the severe group and was 57.9 ± 16.0 years in the non-severe group. ST depression (28% vs. 14%), T-wave inversion (29% vs. 16%), ST-T changes (36% vs. 21%), and the presence of fragmented QRS (fQRS) (17% vs. 7%) were more frequent in the severe group compared to the non-severe group. Multivariate analysis revealed that hypertension (odds ratio [OR]: 2.42, 95% confidence interval [CI]:1.03–5.67; p = 0.041), the severity of COVID-19 infection (OR: 1.87, 95% CI: 1.09–2.65; p = 0.026), presence of cardiac injury (OR: 3.32, 95% CI: 1.45–7.60; p = 0.004), and d-dimer (OR: 3.60, 95% CI: 1.29–10.06; p = 0.014) were independent predictors of ST-T changes on ECG. Conclusion ST depression, T-wave inversion, ST-T changes, and the presence of fQRS on admission ECG are closely associated with the severity of COVID-19 infection.
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Luo G, Li Q, Duan J, Peng Y, Zhang Z. The Predictive Value of Fragmented QRS for Cardiovascular Events in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis. Front Physiol 2020; 11:1027. [PMID: 33117185 PMCID: PMC7574772 DOI: 10.3389/fphys.2020.01027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/27/2020] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Gongming Luo
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
- Heart Center, the First Hospital of Lanzhou University, Lanzhou, China
| | - Qian Li
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Jingwei Duan
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
- Heart Center, the First Hospital of Lanzhou University, Lanzhou, China
| | - Yu Peng
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
- Gansu Key Laboratory of Cardiovascular Disease, Lanzhou, China
| | - Zheng Zhang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
- Heart Center, the First Hospital of Lanzhou University, Lanzhou, China
- Gansu Key Laboratory of Cardiovascular Disease, Lanzhou, China
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Kewcharoen J, Trongtorsak A, Kittipibul V, Prasitlumkum N, Kanitsoraphan C, Putthapiban P, Mekraksakit P, Pattison RJ, Rattanawong P. Fragmented QRS predicts reperfusion failure and in-hospital mortality in ST-Elevation myocardial infarction: a systematic review and meta-analysis. Acta Cardiol 2020; 75:298-311. [PMID: 31021694 DOI: 10.1080/00015385.2019.1584696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Jakrin Kewcharoen
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | | | | | - Narut Prasitlumkum
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | | | | | | | - Robert J. Pattison
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | - Pattara Rattanawong
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Dehghani MR, Rostamzadeh A, Abbasnezhad A, Shariati A, Nejatisafa S, Rezaei Y. Fragmented QRS and subclinical left ventricular dysfunction in individuals with preserved ejection fraction: A speckle-tracking echocardiographic study. J Arrhythm 2020; 36:335-340. [PMID: 32256883 PMCID: PMC7132185 DOI: 10.1002/joa3.12284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/15/2019] [Accepted: 11/09/2019] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Fragmented QRS (fQRS) complex on routine 12-lead electrocardiogram (ECG) predicts adverse outcomes in patients with cardiovascular diseases. In addition, it has been found to be associated with subclinical myocardial dysfunction in chronic diseases. We sought to investigate the relationship between the presence of fQRS with the myocardial functions in individuals free from known systemic cardiovascular diseases. METHODS In a case-control study, we evaluated normal individuals from March 2017 to February 2018. All participants underwent a 2-dimensional transthoracic echocardiographic examination using tissue Doppler imaging (TDI) and speckle-tracking echocardiography. In addition, all participants were examined using a 12-lead surface ECG, and patients with fQRS and a group of age- and sex-matched controls without fQRS were enrolled in our study. RESULTS The patients' mean age was 40.3 ± 10.7 and 35.4 ± 11.2 years in fQRS-positive and fQRS-negative groups, respectively (P = .110). Patients with fQRS had significantly lower values of apical left ventricular global longitudinal strain (LV GLS) in 2-chamber (16.9 ± 2.5 vs. 20.5 ± 3.3, P < .001), 4-chamber (16.9 ± 3.4 vs. 20.1 ± 3, P = .001), LAX views (17.7 ± 2.8 vs. 20.8 ± 3.5, P = .001), and averaged LV GLS (17 ± 2.6 vs. 20.4 ± 2.7, P < .001) values compared to patients without fQRS. In a multivariate analysis, averaged LV GLS and smoking history were independent predictors for positive fQRS. CONCLUSION The presence of fQRS on 12-lead ECG in healthy population was associated with lower values of LV GLS compared to normal individuals without fQRS.
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Affiliation(s)
| | | | - Ali Abbasnezhad
- Department of Cardiology Urmia University of Medical Sciences Urmia Iran
| | - Akram Shariati
- Department of Cardiology Urmia University of Medical Sciences Urmia Iran
| | - Saeid Nejatisafa
- Department of Cardiology Urmia University of Medical Sciences Urmia Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center Rajaie Cardiovascular Medical and Research Center Iran University of Medical Sciences Tehran Iran
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Relationship between fragmented QRS complexes and ejection fraction recovery in anterior ST-segment elevation myocardial infarction patients undergoing thrombolytic treatment. Coron Artery Dis 2020; 31:417-423. [PMID: 32168047 DOI: 10.1097/mca.0000000000000878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute anterior ST-segment elevation myocardial infarction (STEMI) is a life-threatening disease. Adverse cardiac events of acute anterior STEMI include cardiovascular death or worsening congestive heart failure. This study investigated the role of fragmented QRS complex (fQRS) in predicting insufficient ejection fraction (EF) recovery in acute anterior STEMI. METHODS Patients with acute anterior STEMI who received thrombolytic therapy were prospectively enrolled in this study. Twelve-lead electrocardiography (ECG) was obtained from all patients during admission and 24 and 48 h after admission. We divided the patients into two groups according to the presence of fQRS appearance within 48 h: absence of fQRS in any lead (fQRS-), and its presence in two or more contiguous leads (fQRS+). All patients were evaluated with transthoracic echocardiography at admission, and at follow-up 6 and 12 months later. RESULTS A total of 138 consecutive patients were included in the study. Seventy-three patients (52.9%) had fQRS in the ECG. EF recovery in the fQRS(+) group was significantly lower than that of the fQRS(-) group (39% vs. 43.9%, P < 0.001). Multiple logistic regression analysis showed that the fQRS (odds ratio: 4.147, 95% confidence interval: 1.607-10.697, P = 0.003) were an independent predictor of poor EF recovery. CONCLUSION The presence of fQRS is an independent predictor for inadequate EF recovery in acute anterior STEMI patients undergoing thrombolytic treatment. Assessment of fQRS on surface ECG may be used in determining high-risk patients for poor EF recovery after acute anterior STEMI.
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Tanık VO, Çınar T, Şimşek B, Güngör B, Avcı İ, Tanboga İH, Karabay CY. Long-term clinical outcomes and prognoses of ST-segment elevation myocardial infarction patients who present with tombstoning ST-segment elevation. Ann Noninvasive Electrocardiol 2020; 25:e12725. [PMID: 31707765 PMCID: PMC7358892 DOI: 10.1111/anec.12725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 09/07/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Although patients with tombstoning ST-segment elevation (Tomb-ST) usually have poor in-hospital and short-term survival rates, no studies have examined the long-term clinical outcomes and prognosis of ST-segment elevation myocardial infarction (STEMI) patients who have this electrocardiographic pattern. Therefore, we aimed to evaluate the long-term clinical events and mortality of such patients in this study. METHODS In this retrospective analysis, we included 335 consecutive patients who were diagnosed with acute anterior wall-STEMI from January 2015 to June 2018. The criteria for the definition of Tomb-ST were accepted as provided in a previous study. Endpoints of the study were the incidence of significant in-hospital and long-term major adverse clinical events (MACE) including the composite of total death, myocardial reinfarction, and hospitalizations due to heart failure. RESULTS Patients who presented with Tomb-ST had significantly higher in-hospital and long-term mortality (10% [n = 12 patients] vs. 2.3% [n = 5 patients]; p < 0.001and 6.5% [n = 7 patients] vs. 1.9% [n = 4 patients]; p = .04, respectively). In a multivariate traditional and penalized Cox proportional hazard regression analysis, this type of electrocardiographic pattern was found as independent predictor of long-term MACE (Odds ratio [OR]: 3.82, 95% confidence interval [CI]: 1.91-7.63, p < .001 and OR: 4.36, 95% CI: 1.97-9.66, p < .001, respectively). CONCLUSION In the present study, we observed that the presence of Tomb-ST might be an independent predictor of long-term MACE in STEMI patients. To the best of our knowledge, this is the first study to evaluate the long-term MACE of such patients.
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Affiliation(s)
- Veysel Ozan Tanık
- Department of CardiologyAnkara Dışkapı Yıldırım Beyazıt Training and Research HospitalAnkaraTurkey
| | - Tufan Çınar
- Department of CardiologySultan Abdülhamid Han Training and Research HospitalHealth Science UniversityIstanbulTurkey
| | - Barış Şimşek
- Department of CardiologyDr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research HospitalHealth Science UniversityIstanbulTurkey
| | - Barış Güngör
- Department of CardiologyDr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research HospitalHealth Science UniversityIstanbulTurkey
| | - İlker Avcı
- Department of CardiologyDr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research HospitalHealth Science UniversityIstanbulTurkey
| | | | - Can Yücel Karabay
- Department of CardiologyDr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research HospitalHealth Science UniversityIstanbulTurkey
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12
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Xu S, Yang L, Hong D, Chen L, Wang X. Predictive value of fragmented QRS for ventricular tachyarrhythmias in patients with acute myocardial infarction: A meta-analysis. Eur J Clin Invest 2020; 50:e13182. [PMID: 31675435 DOI: 10.1111/eci.13182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 10/17/2019] [Accepted: 10/31/2019] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Shangbo Xu
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, Shantou, China
- Shantou University Medical College, Shantou, China
| | - Lihua Yang
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Danhua Hong
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Lan Chen
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Xin Wang
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, Shantou, China
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13
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Fragmented QRS complex in patients with systemic lupus erythematosus at the time of diagnosis and its relationship with disease activity. PLoS One 2020; 15:e0227022. [PMID: 31895922 PMCID: PMC6939939 DOI: 10.1371/journal.pone.0227022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/10/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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14
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Aquino NJ, Centurión OA, Torales JM, Miño LM, Scavenius KE, Alderete JF, Candia JC, García LB, Cáceres C, Martínez JE, Lovera OA. Association of QRS Complex Fragmentation with QT Interval Prolongation in Patients with Ischemic Heart Disease. CURRENT HEALTH SCIENCES JOURNAL 2019; 45:398-404. [PMID: 32110442 PMCID: PMC7014980 DOI: 10.12865/chsj.45.04.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/26/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND The fragmented QRS complex (FQRS) was found to be associated to malignant ventricular arrhythmias and sudden death in patients with hypertrophic cardiomyopathy and other entities. There is scant data available correlating the presence of FQRS with QT interval prolongation in patients with ischemic heart disease (IHD). METHODS A descriptive, retrospective, cross-sectional study was performed in 123 patients with IHD to analyze and correlate the presence of FQRS with QT interval prolongation in the conventional 12-leads electrocardiogram in patients with documented chronic IHD. RESULTS There were 62% male patients. The mean age was 63.8±12.6 years. Thirty six (44%) patients had fragmented QRS (64% men and 36% women). The duration of QT and QTc, the mean values were 413±59ms, and 463±67ms, respectively. Of the 36 patients with FQRS, 23 patients have prolongation of the QTc interval, and 13 patients did not present it. Of the 45 patients without FQRS, 21 of them have prolongation of the QTc interval, and 24 patients did not have it. These data resulted in a sensitivity of 52% with a moderate SnNout, a specificity of 65% with moderate SpPin, a positive predictive accuracy of 64%, a negative predictive accuracy of 53%. These data resulted in a prevalence of 54%. CONCLUSION the presence of FQRS in the ECG has a moderate sensitivity and specificity, as well as, moderate negative and positive predictive value of the existence of QT interval prolongation in patients with ischemic heart disease.
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Affiliation(s)
- N J Aquino
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
| | - O A Centurión
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
- Departament of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay
| | - J M Torales
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
- Departament of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay
| | - L M Miño
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
- Departament of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay
| | - K E Scavenius
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
- Departament of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay
| | - J F Alderete
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
- Departament of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay
| | - J C Candia
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
| | - L B García
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
- Departament of Health Sciences Investigation, Sanatorio Metropolitano, Fernando de la Mora, Paraguay
| | - C Cáceres
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
| | - J E Martínez
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
| | - O A Lovera
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences, Asunción National University (UNA), San Lorenzo, Paraguay
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15
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Cho HJ, Yoon JY, Kim N, Jang SY, Bae MH, Lee JH, Yang DH, Park HS, Cho Y, Chae SC. Predictive value of a fragmented QRS complex in diagnosing patients with myocardial ischemia. Clin Cardiol 2019; 42:379-384. [PMID: 30597592 PMCID: PMC6712309 DOI: 10.1002/clc.23148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 12/27/2018] [Indexed: 11/26/2022] Open
Abstract
Background A fragmented QRS complex (fQRS) is caused by conduction abnormalities of the ventricle secondary to myocardial ischemia and/or scar in patients with myocardial infarction. However, the implications of the fQRS in the development of coronary artery disease with myocardial ischemia in those without a scar remain unknown. Methods We studied electrocardiograms (ECGs) obtained from 150 patients (60.5 ± 8.5 years, 102 men) with myocardial ischemia, which was confirmed by performing both, a nuclear exercise stress test and coronary angiography. We also studied ECGs obtained from 601 patients (58.5 ± 10.0 years, 315 men) who showed a negative nuclear exercise stress test (control group). Patients in whom the nuclear exercise stress test showed a myocardial scar were excluded. Results An fQRS was more commonly observed in patients with myocardial ischemia (n = 48, 32.0%) than in the control group (n = 133, 22.1%) (P = 0.011). The sensitivity, specificity, positive, and negative predictive values of fQRS in diagnosing myocardial ischemia were 32.0, 77.9, 26.5, and 82.1%, respectively. The fQRS (odds ratio 1.580, 95% confidence interval 1.020‐2.446, P = 0.040) was an independent predictor of myocardial ischemia after adjusting for age, sex, current smoking habits, ST‐T changes on ECG, as well as histories of hypertension, diabetes, and dyslipidemia. Moreover, the fQRS showed an incremental prognostic value over conventional risk factors (χ2 = 5, P = 0.032) and over a combination of conventional factors and ST‐T changes (χ2 = 9, P = 0.014). Conclusions The fQRS is a moderately sensitive and independent predictor of myocardial ischemia.
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Affiliation(s)
- H J Cho
- Department of Cardiology, Daegu Fatima Hospital, Daegu, Republic of Korea
| | - J Y Yoon
- Department of Cardiology, CHA Gumi Medical Center, CHA University, Gumi, Republic of Korea
| | - N Kim
- Department of Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - S Y Jang
- Department of Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - M H Bae
- Department of Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - J H Lee
- Department of Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - D H Yang
- Department of Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - H S Park
- Department of Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Y Cho
- Department of Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - S C Chae
- Department of Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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16
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Kanjanahattakij N, Rattanawong P, Riangwiwat T, Prasitlumkum N, Limpruttidham N, Chongsathidkiet P, Vutthikraivit W, Crossey E. Fragmented QRS and mortality in patients undergoing percutaneous intervention for ST-elevation myocardial infarction: Systematic review and meta-analysis. Ann Noninvasive Electrocardiol 2018; 23:e12567. [PMID: 29932268 DOI: 10.1111/anec.12567] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/20/2018] [Accepted: 05/11/2018] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
| | - Pattara Rattanawong
- University of Hawaii Internal Medicine Residency Program, Honolulu, Hawaii.,Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tanawan Riangwiwat
- University of Hawaii Internal Medicine Residency Program, Honolulu, Hawaii
| | - Narut Prasitlumkum
- University of Hawaii Internal Medicine Residency Program, Honolulu, Hawaii
| | - Nath Limpruttidham
- University of Hawaii Internal Medicine Residency Program, Honolulu, Hawaii
| | | | - Wasawat Vutthikraivit
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Erin Crossey
- University of Hawaii Internal Medicine Residency Program, Honolulu, Hawaii
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17
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Sheng QH, Hsu CC, Li JP, Hong T, Huo Y. Combining fragmented QRS and TIMI score for predicting in-hospital short-term prognosis after acute myocardial infarction. J Zhejiang Univ Sci B 2018; 19:349-353. [PMID: 29732745 DOI: 10.1631/jzus.b1700413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Acute myocardial infarction (AMI) has a high mortality rate and poor prognosis for patients. The primary causes of death are arrhythmia and heart failure. For patients admitted because of myocardial infarction, various risk evaluations are initiated to foresee possible complications. The thrombolysis in myocardial infarction (TIMI) risk score, which can be used to predict the prognosis and the need for revascularisation, is the most convenient and commonly used system, but is inadequate for AMI patients on admittance. Fragmented QRS (fQRS) has been shown to be a valuable electrocardiographic (ECG) index for predicting the prognosis of patients with coronary heart disease. Also, fQRS is considered to predict an increased likelihood of a poor outcome and mortality in patients with coronary artery disease (CAD), even for some successfully revascularized AMI patients. So what would happen if fQRS and the TIMI risk score were combined? This study focused on the investigation of the short-term prognostic value of fQRS combined with the TIMI risk score for patients with AMI.
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Affiliation(s)
- Qin-Hui Sheng
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - Chih Chi Hsu
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - Jian-Ping Li
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - Tao Hong
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
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18
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Miranda DF, Lobo AS, Walsh B, Sandoval Y, Smith SW. New Insights Into the Use of the 12-Lead Electrocardiogram for Diagnosing Acute Myocardial Infarction in the Emergency Department. Can J Cardiol 2017; 34:132-145. [PMID: 29407007 DOI: 10.1016/j.cjca.2017.11.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 11/22/2017] [Accepted: 11/22/2017] [Indexed: 01/05/2023] Open
Abstract
The 12-lead electrocardiogram (ECG) remains the most immediately accessible and widely used initial diagnostic tool for guiding management in patients with suspected myocardial infarction (MI). Although the development of high-sensitivity cardiac troponin assays has improved the rule-in and rule-out and risk stratification of acute MI without ST elevation, the immediate management of the subset of acute MI with acute coronary occlusion depends on integrating clinical presentation and ECG findings. Careful interpretation of the ECG might yield subtle features suggestive of ischemia that might facilitate more rapid triage of patients with subtle acute coronary occlusion or, conversely, in identification of ST-elevation MI mimics (pseudo ST-elevation MI patterns). Our goal in this review article is to consider recent advances in the use of the ECG to diagnose coronary occlusion MIs, including the application of rules that allow MI to be diagnosed on the basis of atypical ECG manifestations. Such rules include the modified Sgarbossa criteria allowing identification of acute MI in left bundle branch block or ventricular pacing, the 3- and 4-variable formula to differentiate normal ST elevation (formerly called early repolarization) from subtle ECG signs of left anterior descending coronary artery occlusion, the differentiation of ST elevation of left ventricular aneurysm from that of acute anterior MI, and the use of lead aVL in the recognition of inferior MI. Improved use of the ECG is essential to improving the diagnosis and appropriate early management of acute coronary occlusion MIs, which will lead to improved outcomes for patients who present with acute coronary syndrome.
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Affiliation(s)
- David F Miranda
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Angie S Lobo
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Brooks Walsh
- Department of Emergency Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Yader Sandoval
- Mayo Clinic, Department of Cardiovascular Medicine, Rochester, Minnesota, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA.
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19
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Tanriverdi Z, Dursun H, Colluoglu T, Kaya D. Single Derivation Fragmented QRS Can Predict Poor Prognosis in Successfully Revascularized Acute STEMI Patients. Arq Bras Cardiol 2017; 109:213-221. [PMID: 28746519 PMCID: PMC5586228 DOI: 10.5935/abc.20170099] [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: 01/24/2017] [Accepted: 03/23/2017] [Indexed: 12/31/2022] Open
Abstract
Background QRS fragmentation (fQRS) is classically defined as the presence of slurred
QRS morphology in at least two contiguous leads, and its prognostic
importance has been shown in ST elevation myocardial infarction (STEMI).
However, no study has investigated the significance of single lead fQRS
(sl-fQRS) in surface electrocardiography (ECG). Objectives To evaluate whether sl-fQRS is as valuable as classical fQRS in patients with
acute STEMI who had successful revascularization with primary percutaneous
coronary intervention (pPCI). Methods We included 330 patients with a first STEMI who had been successfully
revascularized with pPCI. The patient’s electrocardiography was obtained in
the first 48 hours, and the patients were divided into three groups
according to the absence of fQRS (no-fQRS); fQRS presence in a single lead
(sl-fQRS); and ≥2 leads with fQRS (classical fQRS). Results In-hospital mortality was significantly higher both in patients with sl-fQRS
and in patients with ≥ 2 leads with fQRS compared to patients with
no-fQRS. In ROC curve analysis, ≥ 1 leads with fQRS yielded a
sensitivity of 75% and specificity of 57.4% for the prediction of
in-hospital mortality. Multivariate analysis showed that sl-fQRS is an
independent predictor of in-hospital mortality (OR: 3.989, 95% CI:
1.237-12.869, p = 0.021). Conclusions Although the concept of at least two derivations is mentioned for the
classical definition of fQRS, our study showed that fQRS in only one lead is
also associated with poor outcomes. Therefore, ≥1 leads with fQRS can
be useful when describing the patients under high cardiac risk in acute
STEMI.
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Affiliation(s)
| | - Huseyin Dursun
- Dokuz Eylul University - Faculty of Medicine - Department of Cardiology, Turkey
| | - Tugce Colluoglu
- Dokuz Eylul University - Faculty of Medicine - Department of Cardiology, Turkey
| | - Dayimi Kaya
- Dokuz Eylul University - Faculty of Medicine - Department of Cardiology, Turkey
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20
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Tanriverdi Z, Colluoglu T, Dursun H, Kaya D. The Relationship between neutrophil-to-lymphocyte ratio and fragmented QRS in acute STEMI patients treated with primary PCI. J Electrocardiol 2017. [PMID: 28623016 DOI: 10.1016/j.jelectrocard.2017.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND No study so far investigated fragmented QRS (fQRS) and neutrophil-to-lymphocyte ratio (NLR) together in ST segment elevation myocardial infarction (STEMI). OBJECTIVE To investigate the relationship between NLR and fQRS, and determine the prognostic significance of the combined use of these two parameters in STEMI. METHODS We included 368 patients with first acute STEMI who successfully revascularized with primary percutaneous coronary intervention. RESULTS Patients with fQRS had significantly higher NLR, and in-hospital mortality rate compared to patients with no-fQRS. The best cut-off value of NLR to predict mortality was 5.47. Patients with NLR≥5.47 had a higher frequency of fQRS and in-hospital mortality rate. Multivariate analysis showed that NLR was an independent predictor of the presence of fQRS (OR: 1.095, 95% CI: 1.039-1.153, P=0.001). When patients were stratified by fQRS and cut-off value of NLR, in-hospital mortality gradually increased (P<0.001). CONCLUSION NLR is independently associated with the presence of fQRS in STEMI patients. Combined use of both parameters provides additional prognostic contribution for identifying patients at higher cardiac risk.
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Affiliation(s)
| | - Tugce Colluoglu
- Department of Cardiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Huseyin Dursun
- Department of Cardiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Dayimi Kaya
- Department of Cardiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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21
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Haukilahti MAE, Eranti A, Kenttä T, Huikuri HV. QRS Fragmentation Patterns Representing Myocardial Scar Need to Be Separated from Benign Normal Variants: Hypotheses and Proposal for Morphology based Classification. Front Physiol 2016; 7:653. [PMID: 28082919 PMCID: PMC5183580 DOI: 10.3389/fphys.2016.00653] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 12/12/2016] [Indexed: 12/12/2022] Open
Abstract
The presence of a fragmented QRS complex (fQRS) in two contiguous leads of a standard 12-lead electrocardiogram (ECG) has been shown to be an indicator of myocardial scar in multiple different populations of cardiac patients. QRS fragmentation is also a predictor of adverse prognosis in acute myocardial infarction, coronary artery disease, and ischemic cardiomyopathy and a prognostic tool in structural heart diseases. An increased risk of sudden cardiac death associated with fQRS has been documented in patients with ischemic cardiomyopathy and hypertrophic cardiomyopathy. However, fQRS is also frequently observed in apparently healthy subjects. Thus, a more detailed classification of different QRS fragmentations is needed to identify the pathological fragmentation patterns and refine the role of fQRS as a risk marker of adverse cardiac events and sudden cardiac death. In most studies fQRS has been defined by the presence of an additional R wave (R′), or notching in the nadir of the S wave, or the presence of >1 R′ in two contiguous leads corresponding to a major coronary territory. However, this approach does not discriminate between minor and major fragmentations and the location of the fQRS is also neglected. In addition to this, the method is susceptible to large interobserver variability. We suppose that some fQRS subtypes result from conduction delays in the His-Purkinje system, which is a benign finding and thus can weaken the prognostic values of fQRS. The classification of fQRSs to subtypes with unambiguous definitions is needed to overcome the interobserver variability related issues and to separate fQRSs caused by myocardial scarring from benign normal variants. In this paper, we review the anatomic correlates of fQRS and the current knowledge of prognostic significance of fQRS. We also propose a detailed fQRS classification for research purposes which can later be simplified after the truly pathological morphologies have been identified. The research material of our study consist of 15,245 ECGs from the random general population and approximately six thousands (n = 6,241) ECGs from subjects with a known cardiac disease.
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Affiliation(s)
- M Anette E Haukilahti
- Research Unit of Internal Medicine, Medical Research Center, University Hospital of Oulu Oulu, Finland
| | - Antti Eranti
- Department of Internal Medicine, Päijät-Häme Central Hospital Lahti, Finland
| | - Tuomas Kenttä
- Research Unit of Internal Medicine, Medical Research Center, University Hospital of Oulu Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center, University Hospital of Oulu Oulu, Finland
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22
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Güngör B, Özcan KS, Karataş MB, Şahin İ, Öztürk R, Bolca O. Response to letter to the editor: Prognostic value of QRS fragmentation in patients with acute myocardial infarction: a meta-analysis. Ann Noninvasive Electrocardiol 2016; 21:534. [PMID: 27527111 DOI: 10.1111/anec.12396] [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: 11/30/2022] Open
Affiliation(s)
- Barış Güngör
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - Kazım S Özcan
- Department of Cardiology, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Mehmet B Karataş
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - İrfan Şahin
- Department of Cardiology, Bagcılar Training and Research Hospital, Istanbul, Turkey
| | - Recep Öztürk
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - Osman Bolca
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
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23
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Tanriverdi Z, Dursun H, Colluoglu T, Kaya D. Do fQRS Onset Time and Number of Leads with fQRS Affect Prognosis of Acute Myocardial Infarction Patients? Ann Noninvasive Electrocardiol 2016; 21:532-3. [PMID: 27297051 DOI: 10.1111/anec.12382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
| | - Huseyin Dursun
- Department of Cardiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Tugce Colluoglu
- Department of Cardiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Dayimi Kaya
- Department of Cardiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Güngör B, Özcan KS, Karataş MB, Şahin İ, Öztürk R, Bolca O. Prognostic Value of QRS Fragmentation in Patients with Acute Myocardial Infarction: A Meta-Analysis. Ann Noninvasive Electrocardiol 2016; 21:604-612. [PMID: 27018003 DOI: 10.1111/anec.12357] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 01/23/2016] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Barış Güngör
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - Kazım Serhan Özcan
- Department of Cardiology, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Mehmet Baran Karataş
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey.
| | - İrfan Şahin
- Department of Cardiology, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Recep Öztürk
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
| | - Osman Bolca
- Department of Cardiology, Siyami Ersek Cardiovascular and Thoracic Surgery Center, Istanbul, Turkey
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