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Hnatkova K, Andršová I, Novotný T, Britton A, Shipley M, Vandenberk B, Sprenkeler DJ, Junttila J, Reichlin T, Schlögl S, Vos MA, Friede T, Bauer A, Huikuri HV, Willems R, Schmidt G, Franz MR, Sticherling C, Zabel M, Malik M. QRS micro-fragmentation as a mortality predictor. Eur Heart J 2022; 43:4177-4191. [PMID: 35187560 PMCID: PMC9584751 DOI: 10.1093/eurheartj/ehac085] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 01/05/2022] [Accepted: 02/08/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS Fragmented QRS complex with visible notching on standard 12-lead electrocardiogram (ECG) is understood to represent depolarization abnormalities and to signify risk of cardiac events. Depolarization abnormalities with similar prognostic implications likely exist beyond visual recognition but no technology is presently suitable for quantification of such invisible ECG abnormalities. We present such a technology. METHODS AND RESULTS A signal processing method projects all ECG leads of the QRS complex into optimized three perpendicular dimensions, reconstructs the ECG back from this three-dimensional projection, and quantifies the difference (QRS 'micro'-fragmentation, QRS-μf) between the original and reconstructed signals. QRS 'micro'-fragmentation was assessed in three different populations: cardiac patients with automatic implantable cardioverter-defibrillators, cardiac patients with severe abnormalities, and general public. The predictive value of QRS-μf for mortality was investigated both univariably and in multivariable comparisons with other risk factors including visible QRS 'macro'-fragmentation, QRS-Mf. The analysis was made in a total of 7779 subjects of whom 504 have not survived the first 5 years of follow-up. In all three populations, QRS-μf was strongly predictive of survival (P < 0.001 univariably, and P < 0.001 to P = 0.024 in multivariable regression analyses). A similar strong association with outcome was found when dichotomizing QRS-μf prospectively at 3.5%. When QRS-μf was used in multivariable analyses, QRS-Mf and QRS duration lost their predictive value. CONCLUSION In three populations with different clinical characteristics, QRS-μf was a powerful mortality risk factor independent of several previously established risk indices. Electrophysiologic abnormalities that contribute to increased QRS-μf values are likely responsible for the predictive power of visible QRS-Mf.
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Affiliation(s)
- Katerina Hnatkova
- National Heart and Lung Institute, Imperial College, ICTEM, Hammersmith Campus, 72 Du Cane Road, Shepherd's Bush, London W12 0NN, UK
| | - Irena Andršová
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic.,Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic
| | - Tomáš Novotný
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic.,Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic
| | - Annie Britton
- Research Department of Epidemiology and Public Health, University College London, UK
| | - Martin Shipley
- Research Department of Epidemiology and Public Health, University College London, UK
| | - Bert Vandenberk
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - David J Sprenkeler
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Juhani Junttila
- Medical Research Center Oulu, University Central Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Simon Schlögl
- Department of Cardiology and Pneumology, University Medical Center, Göttingen, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Marc A Vos
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tim Friede
- German Center of Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.,Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Axel Bauer
- University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Heikki V Huikuri
- Medical Research Center Oulu, University Central Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Rik Willems
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Georg Schmidt
- Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael R Franz
- Veteran Affairs and Georgetown University Medical Centers, Washington, DC, USA
| | | | - Markus Zabel
- Department of Cardiology and Pneumology, University Medical Center, Göttingen, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College, ICTEM, Hammersmith Campus, 72 Du Cane Road, Shepherd's Bush, London W12 0NN, UK.,Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic
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6
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Roudijk RW, Bosman LP, van der Heijden JF, de Bakker JMT, Hauer RNW, van Tintelen JP, Asselbergs FW, te Riele ASJM, Loh P. Quantitative Approach to Fragmented QRS in Arrhythmogenic Cardiomyopathy: From Disease towards Asymptomatic Carriers of Pathogenic Variants. J Clin Med 2020; 9:E545. [PMID: 32079223 PMCID: PMC7073517 DOI: 10.3390/jcm9020545] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/09/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022] Open
Abstract
Fragmented QRS complexes (fQRS) are common in patients with arrhythmogenic cardiomyopathy (ACM). A new method of fQRS quantification may aid early disease detection in pathogenic variant carriers and assessment of prognosis in patients with early stage ACM. Patients with definite ACM (n = 221, 66%), carriers of a pathogenic ACM-associated variant without a definite ACM diagnosis (n = 57, 17%) and control subjects (n = 58, 17%) were included. Quantitative fQRS (Q-fQRS) was defined as the total amount of deflections in the QRS complex in all 12 electrocardiography (ECG) leads. Q-fQRS was scored by a single observer and reproducibility was determined by three independent observers. Q-fQRS count was feasible with acceptable intra- and inter-observer agreement. Q-fQRS count is significantly higher in patients with definite ACM (54 ± 15) and pathogenic variant carriers (55 ± 10) compared to controls (35 ± 5) (p < 0.001). In patients with ACM, Q-fQRS was not associated with sustained ventricular arrhythmia (p = 0.701) at baseline or during follow-up (p = 0.335). Both definite ACM patients and pathogenic variant carriers not fulfilling ACM diagnosis have a higher Q-fQRS than controls. This may indicate that increased Q-fQRS is an early sign of disease penetrance. In concealed and early stages of ACM the role of Q-fQRS for risk stratification is limited.
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Affiliation(s)
- Rob W. Roudijk
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
| | - Laurens P. Bosman
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
| | - Jeroen F. van der Heijden
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
| | - Jacques M. T. de Bakker
- Department of Clinical and Experimental Cardiology, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
| | - Richard N. W. Hauer
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
| | - J. Peter van Tintelen
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
- Department of Genetics, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands
| | - Folkert W. Asselbergs
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London WC1E, UK
- Health Data Research UK and Institute of Health Informatics, University College London, London WC1E, UK
| | - Anneline S. J. M. te Riele
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
| | - Peter Loh
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
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8
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Das M, Suszko AM, Nayyar S, Viswanathan K, Spears DA, Tomlinson G, Pinter A, Crystal E, Dalvi R, Krishnan S, Chauhan VS. Automated Quantification of Low-Amplitude Abnormal QRS Peaks From High-Resolution ECG Recordings Predicts Arrhythmic Events in Patients With Cardiomyopathy. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.116.004874. [PMID: 28705874 DOI: 10.1161/circep.116.004874] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 06/08/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiomyopathy patients are at risk of sudden death, typically from scar-related abnormalities of electrical activation that promote ventricular tachyarrhythmias. Abnormal intra-QRS peaks may provide a measure of altered activation. We hypothesized that quantification of such QRS peaks (QRSp) in high-resolution ECGs would predict arrhythmic events in implantable cardioverter-defibrillator (ICD)-eligible cardiomyopathy patients. METHODS AND RESULTS Ninety-nine patients with ischemic or non-ischemic dilated cardiomyopathy undergoing prophylactic ICD implantation were prospectively enrolled (age 62±11 years, left ventricular ejection fraction 27±7%). High-resolution (1024 Hz) digital 12-lead ECGs were recorded during intrinsic rhythm. QRSp was quantified for each precordial lead as the total number of low-amplitude deflections that deviated from their respective naive QRS template. The primary end point of arrhythmic events was defined as appropriate ICD therapy or sustained ventricular tachyarrhythmias. After a median follow-up of 24 (15-43) months, 20 (20%) patients had arrhythmic events. Both QRSp and QRS duration were greater in those with arrhythmic events (both P<0.001) and this was consistent for QRSp for both cardiomyopathy types. In a multivariable Cox regression model that included age, left ventricular ejection fraction, QRS duration, and QRSp, only QRSp was an independent predictor of arrhythmic events (hazard ratio, 2.1; P<0.001). Receiver operating characteristic analysis revealed that a QRSp ≥2.25 identified arrhythmic events with greater sensitivity (100% versus 70%, P<0.05) and negative predictive value (100% versus 89%, P<0.05) than QRS duration ≥120 ms. CONCLUSIONS QRSp measured from high-resolution digital 12-lead ECGs independently predicts ventricular tachyarrhythmias in ICD-eligible cardiomyopathy patients. This novel QRS morphology index has the potential to improve sudden death risk stratification and patient selection for prophylactic ICD therapy.
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Affiliation(s)
- Moloy Das
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - Adrian M Suszko
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - Sachin Nayyar
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - Karthik Viswanathan
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - Danna A Spears
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - George Tomlinson
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - Arnold Pinter
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - Eugene Crystal
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - Rupin Dalvi
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - Sridhar Krishnan
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.)
| | - Vijay S Chauhan
- From the Peter Munk Cardiac Center, Division of Cardiology, University Health Network, Toronto, Ontario, Canada (M.D., A.M.S., S.N., K.V., D.A.S., G.T., R.D., V.S.C.); Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom (M.D.); Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada (A.P.); Division of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (E.C.); and Department of Electrical and Computer Engineering, Ryerson University, Toronto, Ontario, Canada (S.K.).
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