1
|
Gomez N, Ramirez J, Martinez JP, Laguna P. Time-Warping Analysis of the T-Wave Peak-to-End Interval to Quantify Ventricular Repolarization Dispersion During Ischemia. IEEE J Biomed Health Inform 2023; 27:5314-5325. [PMID: 37651478 DOI: 10.1109/jbhi.2023.3310878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Variations in the dispersion of ventricular repolarization can be quantified by T-wave time-warping based index, dw. However, the early phase of the T-wave can be affected by ST-segment changes during ischemia. We hypothesized that restricting dw to the T-wave peak-to-end ( Tpe) would circumvent this limitation while still quantifying variations in repolarization dispersion. A total of 101 ECG recordings from patients undergoing coronary occlusion, together with their control recordings, were analyzed. A series of dw values was calculated by quantifying the Tpe morphological variations between the T-waves at different occlusion stages and a baseline T-wave. We introduced a normalized version of dw, Rd, reflecting variations of dw during occlusion relative to control recordings ( Rd = 1 corresponds to the same level of variation). The dw series followed a gradually increasing trend with occlusion time, reaching median [range] Rd values of 9.44 [1.01, 80.74] at the occlusion end. Rd at occlusion end was significantly higher than threshold values of 1, 2, 5, and 10 in 94.1%, 85.11%, 64.4% and 48.5% of patients, respectively. The spatial lead-wise analysis of dw showed distinct distributions depending on the occluded artery, suggesting a relation with the ischemia location. The relative variation R with ischemia of index dw (9.4) is greater than that of the T-wave amplitude (7.7), Tpe interval (2.7) and T-wave width (3.0). In conclusion, dw tracks ischemic-induced variations in repolarization dispersion in a more robust manner than classical indexes, avoiding the impact of ST segment elevation/depression or early T-wave distortions, thus warranting further clinical studies.
Collapse
|
2
|
Hekkanen JJ, Kenttä TV, Holmström L, Tulppo MP, Ukkola OH, Pakanen L, Junttila MJ, Huikuri HV, Perkiömäki JS. Association of electrocardiographic spatial heterogeneity of repolarization and spatial heterogeneity of atrial depolarization with left ventricular fibrosis. Europace 2023; 25:820-827. [PMID: 36635858 PMCID: PMC10062366 DOI: 10.1093/europace/euac273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/14/2022] [Indexed: 01/14/2023] Open
Abstract
AIMS To evaluate the relationship between spatial heterogeneity of electrocardiographic repolarization and spatial heterogeneity of atrial depolarization with arrhythmic substrate represented by left ventricular fibrosis. METHODS AND RESULTS We assessed the associations of T- and P-wave morphology parameters analysed from the standard 12-lead electrocardiograms with left ventricular fibrosis in 378 victims of unexpected sudden cardiac death (SCD) who underwent medico-legal autopsy. Based on autopsy findings, the SCD victims were categorized into four different groups according to different stages of severity of left ventricular fibrosis (substantial fibrosis, moderate patchy fibrosis, scattered mild fibrosis, no fibrosis). T-wave and P-wave area dispersion (TWAd: 0.0841 ± 0.496, 0.170 ± 0.492, 0.302 ± 404, 0.296 ± 0.476, P = 0.008; PWAd: 0.574 ± 0.384, 0.561 ± 0.367, 0.654 ± 0.281, 0.717 ± 0.257, P = 0.011, respectively; low values abnormal), non-dipolar components of T-wave and P-wave morphology (T_NonDipolarABS: 0.0496 ± 0.0377, 0.0571 ± 0.0487, 0.0432 ± 0.0476, 0.0380 ± 0.0377, P = 0.027; P_NonDipolarABS: 0.0132 ± 0.0164, 0.0130 ± 0.0135, 0.0092 ± 0.0117, 0.0069 ± 0.00472, P = 0.005, respectively, high values abnormal), T-wave morphology dispersion (TMD: 45.9 ± 28.3, 40.5 ± 25.8, 35.5 ± 24.9, 33.0 ± 24.6, P = 0.030, respectively, high values abnormal), and P-wave heterogeneity (PWH: 20.0 ± 9.44, 19.7 ± 8.87, 17.9 ± 9.78, 15.4 ± 4.60, P = 0.019, respectively, high values abnormal) differed significantly between the groups with different stages of left ventricular fibrosis. After adjustment with heart weight, T_NonDipolarABS [standardized β (sβ) = 0.131, P = 0.014], PWAd (sβ = -0.161, P = 0.003), P_NonDipolarABS (sβ = 0.174, P = 0.001), and PWH (sβ = 0.128, P = 0.015) retained independent association, and TWAd (sβ = -0.091, P = 0.074) and TMD (sβ = 0.097, P = 0.063) tended to retain their association with the degree of myocardial fibrosis. CONCLUSION Our findings suggest that abnormal values of T- and P-wave morphology are associated with arrhythmic substrate represented by ventricular fibrosis partly explaining the mechanism behind their prognostic significance.
Collapse
Affiliation(s)
- Jenni J Hekkanen
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Lauri Holmström
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Mikko P Tulppo
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Lasse Pakanen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Hoitajanrinne 1, P.O. Box 310, FI-90101 Oulu, Finland
- Department of Forensic Medicine, Medical Research Center Oulu, Research Unit of Internal Medicine, University of Oulu, Aapistie 5B, P.O. Box 5000, FI-90014 Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| |
Collapse
|
3
|
Bortolan G, Christov I, Simova I. Modifications in Electrocardiographic and Vectordardiographic Morphological Parameters in Elderly Males as Result of Cardiovascular Diseases and Diabetes Mellitus. Diagnostics (Basel) 2022; 12:diagnostics12122911. [PMID: 36552917 PMCID: PMC9776814 DOI: 10.3390/diagnostics12122911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/09/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Morphological electrocardiographic and vectorcardiographic features have been used in the detection of cardiovascular diseases and prediction of the risk of cardiac death for a long time. The objective of the current study was to investigate the morphological electrocardiographic modifications in the presence of cardiovascular diseases and diabetes mellitus in an elderly male population, most of them with multiple comorbidities. METHODS A database of ECG recordings from the Italian Longitudinal Study on Aging (ILSA-CNR), created to evaluate physiological and pathological modifications related to aging, was considered. The study examined a group of 1109 males with full clinical documentation aged 65-84 years. A healthy control group (219 individuals) was compared to the groups of diabetes mellitus (130), angina pectoris (99), hypertension (607), myocardial infarction (160), arrhythmia (386), congestive heart failure (73), and peripheral artery disease (95). Twenty-one electrocardiographic features were explored, and the effects of cardiovascular diseases and diabetes on these parameters were analyzed. The three-years mortality index was derived and analyzed. RESULTS AND CONCLUSIONS Myocardial infarction and arrhythmia were the diagnostic groups that showed a significant deviation of 11 electrocardiographic parameters compared to the healthy group, followed by hypertension and congestive heart failure (10), angina pectoris (9), and diabetes mellitus and peripheral artery disease (8). In particular, a set of three parameters (QRS and T roundness and principal component analysis of T wave) increased significantly, whereas four parameters (T amplitude, T maximal vector, T vector ratio, and T wave area dispersion) decreased significantly in all cardiovascular diseases and diabetes mellitus with respect to healthy group. The QRS parameters show a more specific discrimination with a single disease or a group of diseases, whereas the T-wave features seems to be influenced by all the pathological conditions. The present investigation of disease-related electrocardiographic parameters changes can be used in assessing the risk analysis of cardiac death, and gender medicine.
Collapse
Affiliation(s)
- Giovanni Bortolan
- Institute of Neuroscience-National Research Council, IN-CNR, 35127 Padova, Italy
- Correspondence:
| | - Ivaylo Christov
- Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria
| | - Iana Simova
- Heart and Brain Center of Excellence, University Hospital Pleven, 5804 Pleven, Bulgaria
| |
Collapse
|
4
|
Ramírez J, Kiviniemi A, van Duijvenboden S, Tinker A, Lambiase PD, Junttila J, Perkiömäki JS, Huikuri HV, Orini M, Munroe PB. ECG T-Wave Morphologic Variations Predict Ventricular Arrhythmic Risk in Low- and Moderate-Risk Populations. J Am Heart Assoc 2022; 11:e025897. [PMID: 36036209 PMCID: PMC9496440 DOI: 10.1161/jaha.121.025897] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Early identification of individuals at risk of sudden cardiac death (SCD) remains a major challenge. The ECG is a simple, common test, with potential for large-scale application. We developed and tested the predictive value of a novel index quantifying T-wave morphologic variations with respect to a normal reference (TMV), which only requires one beat and a single-lead ECG. Methods and Results We obtained reference T-wave morphologies from 23 962 participants in the UK Biobank study. With Cox models, we determined the association between TMV and life-threatening ventricular arrhythmia in an independent data set from UK Biobank study without a history of cardiovascular events (N=51 794; median follow-up of 122 months) and SCD in patients with coronary artery disease from ARTEMIS (N=1872; median follow-up of 60 months). In UK Biobank study, 220 (0.4%) individuals developed life-threatening ventricular arrhythmias. TMV was significantly associated with life-threatening ventricular arrhythmias (hazard ratio [HR] of 1.13 per SD increase [95% CI, 1.03-1.24]; P=0.009). In ARTEMIS, 34 (1.8%) individuals reached the primary end point. Patients with TMV ≥5 had an HR for SCD of 2.86 (95% CI, 1.40-5.84; P=0.004) with respect to those with TMV <5, independently from QRS duration, corrected QT interval, and left ventricular ejection fraction. TMV was not significantly associated with death from a cause other than SCD. Conclusions TMV identifies individuals at life-threatening ventricular arrhythmia and SCD risk using a single-beat single-lead ECG, enabling inexpensive, quick, and safe risk assessment in large populations.
Collapse
Affiliation(s)
- Julia Ramírez
- Clinical Pharmacology and Precision Medicine William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom.,Aragon Institute of Engineering Research University of Zaragoza Zaragoza Spain.,Centro de Investigación Biomédica en Red - Bioingeniería, Biomateriales y Nanomedicina Zaragoza Spain
| | - Antti Kiviniemi
- Research Unit of Internal Medicine Medical Research Center Oulu, University of Oulu and Oulu University Hospital Oulu Finland
| | - Stefan van Duijvenboden
- Clinical Pharmacology and Precision Medicine William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom.,Institute of Cardiovascular Science University College London London United Kingdom
| | - Andrew Tinker
- Clinical Pharmacology and Precision Medicine William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom.,National Institute for Health and Care Research Barts Cardiovascular Biomedical Research Centre Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom
| | - Pier D Lambiase
- Institute of Cardiovascular Science University College London London United Kingdom.,Barts Heart Centre St Bartholomew's Hospital London United Kingdom
| | - Juhani Junttila
- Research Unit of Internal Medicine Medical Research Center Oulu, University of Oulu and Oulu University Hospital Oulu Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine Medical Research Center Oulu, University of Oulu and Oulu University Hospital Oulu Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine Medical Research Center Oulu, University of Oulu and Oulu University Hospital Oulu Finland
| | - Michele Orini
- Institute of Cardiovascular Science University College London London United Kingdom.,Barts Heart Centre St Bartholomew's Hospital London United Kingdom
| | - Patricia B Munroe
- Clinical Pharmacology and Precision Medicine William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom.,National Institute for Health and Care Research Barts Cardiovascular Biomedical Research Centre Barts and The London School of Medicine and Dentistry, Queen Mary University of London London United Kingdom
| |
Collapse
|
5
|
van der Waal J, Bear L, Meijborg V, Dubois R, Cluitmans M, Coronel R. Steep repolarization time gradients in pig hearts cause distinct changes in composite electrocardiographic T‐wave parameters. Ann Noninvasive Electrocardiol 2022; 27:e12994. [DOI: 10.1111/anec.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/09/2022] [Accepted: 06/20/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jeanne van der Waal
- Department of Experimental and Clinical Cardiology Amsterdam UMC, Location AMC Amsterdam The Netherlands
| | - Laura Bear
- IHU Liryc, Electrophysiology and Heart Modeling Institute Fondation Bordeaux Université Pessac France
- Université de Bordeaux Pessac France
- Inserm, Cardio‐Thoracix Research Centre of Bordeaux Pessac France
| | - Veronique Meijborg
- Department of Experimental and Clinical Cardiology Amsterdam UMC, Location AMC Amsterdam The Netherlands
| | - Rémi Dubois
- IHU Liryc, Electrophysiology and Heart Modeling Institute Fondation Bordeaux Université Pessac France
- Université de Bordeaux Pessac France
- Inserm, Cardio‐Thoracix Research Centre of Bordeaux Pessac France
| | - Matthijs Cluitmans
- CARIM School for Cardiovascular Diseases Maastricht University Medical Centre Maastricht The Netherlands
| | - Ruben Coronel
- Department of Experimental and Clinical Cardiology Amsterdam UMC, Location AMC Amsterdam The Netherlands
- Université de Bordeaux Pessac France
- Inserm, Cardio‐Thoracix Research Centre of Bordeaux Pessac France
| |
Collapse
|
6
|
Using QRS loop descriptors to characterize the risk of sudden cardiac death in patients with structurally normal hearts. PLoS One 2022; 17:e0263894. [PMID: 35171953 PMCID: PMC8849494 DOI: 10.1371/journal.pone.0263894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022] Open
Abstract
The predictive value of non-invasive electrocardiographic examination findings for the risk of sudden cardiac death (SCD) in populations with structurally normal hearts remains unclear. This study aimed to investigate the characteristics of the QRS vectorcardiography of surface electrocardiography in patients with structurally normal hearts who experienced SCD. We consecutively enrolled patients who underwent vectorcardiography between March 2017 and December 2018 in a tertiary referral medical center. These patients didn’t have structural heart diseases, histories of congestive heart failure, or reduced ejection fraction, and they were classified into SCD (with aborted SCD history and cerebral performance category score of 1) and control groups (with an intervention for atrioventricular node reentrant tachycardia and without SCD history). A total of 162 patients (mean age, 54.3±18.1 years; men, 75.9%), including 59 in the SCD group and 103 in the control group, underwent propensity analysis. The baseline demographic variables, underlying diseases, QRS loop descriptors (the percentage of the loop area, loop dispersion, and inter-lead QRS dispersion), and other electrocardiographic parameters were compared between the two groups. In the univariate and multivariate analyses, a smaller percentage of the loop area (odds ratio, 0.0003; 95% confidence interval, 0.00–0.02; p<0.001), more significant V4-5 dispersion (odds ratio, 1.04; 95% confidence interval, 1.02–1.07; p = 0.002), and longer QRS duration (odds ratio, 1.05; 95% confidence interval, 1.00–1.10; p = 0.04) were associated with SCD. In conclusion, the QRS loop descriptors of surface electrocardiography could be used as non-invasive markers to identify patients experiencing aborted SCD from a healthy population. A decreased percentage of loop area and elevated V4-5 QRS dispersion values assessed using vectorcardiography were associated with an increased risk of SCD in patients with structurally normal hearts.
Collapse
|
7
|
Holkeri A, Eranti A, Haukilahti MAE, Kerola T, Kenttä TV, Noponen K, Seppänen T, Rissanen H, Heliövaara M, Knekt P, Junttila MJ, Huikuri HV, Aro AL. Prognostic significance of flat T-waves in the lateral leads in general population. J Electrocardiol 2021; 69:105-110. [PMID: 34656915 DOI: 10.1016/j.jelectrocard.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Negative T-waves are associated with sudden cardiac death (SCD) risk in the general population. Whether flat T-waves also predict SCD is not known. The aim of the study was to examine the clinical characteristics and risk of SCD in general population subjects with flat T-waves. METHODS We examined the electrocardiograms of 6750 Finnish general population adults aged ≥30 years and classified the subjects into 3 groups: 1) negative T-waves with an amplitude ≥0.1 mV in ≥2 of the leads I, II, aVL, V4-V6, 2) negative or positive low amplitude T-waves with an amplitude <0.1 mV and the ratio of T-wave and R-wave <10% in ≥2 of the leads I, II, aVL, V4-V6, and 3) normal positive T-waves (not meeting the aforesaid criteria). The association between T-wave classification and SCD was assessed during a 10-year follow-up. RESULTS A total of 215 (3.2%) subjects had negative T-waves, 856 (12.7%) flat T-waves, and 5679 (84.1%) normal T-waves. Flat T-wave subjects were older and had more often cardiovascular morbidities compared to normal T-wave subjects, while negative T-wave subjects were the oldest and had most often cardiovascular morbidities. After adjusting for multiple factors, both flat T-waves (hazard ratio [HR] 1.81; 95% confidence interval [CI] 1.13-2.91) and negative T-waves (HR 3.27; 95% CI 1.85-5.78) associated with SCD. CONCLUSIONS Cardiovascular risk factors and disease are common among subjects with flat T-waves, but these minor T-wave abnormalities are also independently associated with increased SCD risk.
Collapse
Affiliation(s)
- Arttu Holkeri
- Department of Internal Medicine, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850 Lahti, Finland.
| | - Antti Eranti
- Heart Center, Central Hospital of North Karelia, Tikkamäentie 16, 80210 Joensuu, Finland
| | - M Anette E Haukilahti
- Research Unit of Internal Medicine, Medical Research Center, Oulu University Hospital and University of Oulu, Faculty of Medicine, PO Box 5000, FI-90014 Oulu, Finland
| | - Tuomas Kerola
- Department of Internal Medicine, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850 Lahti, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center, Oulu University Hospital and University of Oulu, Faculty of Medicine, PO Box 5000, FI-90014 Oulu, Finland
| | - Kai Noponen
- Center for Machine Vision and Signal Analysis, University of Oulu, PO Box 4500, Oulu FI-90014, Finland
| | - Tapio Seppänen
- Center for Machine Vision and Signal Analysis, University of Oulu, PO Box 4500, Oulu FI-90014, Finland
| | - Harri Rissanen
- Finnish Institute for Health and Welfare, PO Box 30, FI-00271 Helsinki, Finland
| | - Markku Heliövaara
- Finnish Institute for Health and Welfare, PO Box 30, FI-00271 Helsinki, Finland
| | - Paul Knekt
- Finnish Institute for Health and Welfare, PO Box 30, FI-00271 Helsinki, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center, Oulu University Hospital and University of Oulu, Faculty of Medicine, PO Box 5000, FI-90014 Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center, Oulu University Hospital and University of Oulu, Faculty of Medicine, PO Box 5000, FI-90014 Oulu, Finland
| | - Aapo L Aro
- Division of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Meilahti Tower Hospital, PL 340, 00029 HUS Helsinki, Finland
| |
Collapse
|
8
|
Rahola JT, Kiviniemi AM, Ukkola OH, Tulppo MP, Junttila MJ, Huikuri HV, Kenttä TV, Perkiömäki JS. Temporal variability of T-wave morphology and risk of sudden cardiac death in patients with coronary artery disease. Ann Noninvasive Electrocardiol 2021; 26:e12830. [PMID: 33486851 PMCID: PMC8164143 DOI: 10.1111/anec.12830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 12/16/2022] Open
Abstract
Background The possible relationship between temporal variability of electrocardiographic spatial heterogeneity of repolarization and the risk of sudden cardiac death (SCD) in patients with coronary artery disease (CAD) is not completely understood. Methods The standard deviation of T‐wave morphology dispersion (TMD‐SD), of QRST angle (QRSTA‐SD), and of T‐wave area dispersion (TW‐Ad‐SD) were analyzed on beat‐to‐beat basis from 10 min period of the baseline electrocardiographic recording in ARTEMIS study patients with angiographically verified CAD. Results After on average of 8.6 ± 2.3 years of follow‐up, a total of 66 of the 1,678 present study subjects (3.9%) had experienced SCD or were resuscitated from sudden cardiac arrest (SCA). TMD‐SD was most closely associated with the risk for SCD and was significantly higher in patients who had experienced SCD/SCA compared with those who remained alive (3.61 ± 2.83 vs. 2.64 ± 2.52, p = .008, respectively), but did not differ significantly between the patients who had experienced non‐SCD (n = 71, 4.2%) and those who remained alive (3.20 ± 2.73 vs. 2.65 ± 2.53, p = .077, respectively) or between the patients who succumbed to non‐cardiac death (n = 164, 9.8%) and those who stayed alive (2.64 ± 2.17 vs. 2.68 ± 2.58, p = .853). After adjustments with relevant clinical risk indicators of SCD/SCA, TMD‐SD still predicted SCD/SCA (HR 1.107, 95% CIs 1.035–1.185, p = .003). Conclusions Temporal variability of electrocardiographic spatial heterogeneity of repolarization represented by TMD‐SD independently predicts long‐term risk of SCD/SCA in patients with CAD.
Collapse
Affiliation(s)
- Janne T Rahola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mikko P Tulppo
- Department of Physiology, Research Unit of Biomedicine, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| |
Collapse
|
9
|
Isaksen JL, Ghouse J, Graff C, Olesen MS, Holst AG, Pietersen A, Nielsen JB, Skov MW, Kanters JK. Electrocardiographic T-wave morphology and risk of mortality. Int J Cardiol 2020; 328:199-205. [PMID: 33321127 DOI: 10.1016/j.ijcard.2020.12.016] [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: 10/23/2020] [Revised: 11/10/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Electrocardiographic T-wave morphology is used in drug safety studies as an adjunct to the QTc interval, but few measurements of T-wave morphology can be interpreted in clinical practice. Morphology combination score (MCS) is a combination of T-wave flatness/peakedness, asymmetry, and notching, enabling easy visual assessment of T-wave morphology. We aimed to test the association between T-wave morphology, quantified by MCS, and mortality. METHODS We included electrocardiograms recorded in 2001-2011 from 342,294 primary care patients. Using Cox regression, we evaluated the association between MCS, cardiovascular death, and all-cause mortality, adjusting for heart rate, QTc, QT-prolonging drugs, diabetes, ischemic heart disease, hypertension, and congestive heart failure. RESULTS 270,039 individuals (44% men, median age 55 [inter-quartile range: 42-67 years]) were included and followed for a median of 9.3 years, during which time 13,489 (5.0%) died from cardiovascular causes and 50,481 (18.7%) from any cause. High values of MCS (i.e. asymmetric, flattened, and/or notched T waves) were associated with an adjusted mortality Hazard Ratio of 1.75 (95% CI 1.62-1.89) and 1.61 (1.43-1.92) for women and men, respectively. Low values of MCS (i.e. peaked and symmetric T waves) were associated with a Hazard Ratio of 1.18 (1.08-1.28) and 1.71 (1.48-1.98) for women and men, respectively. CONCLUSIONS In a large primary care population, we found that T-wave asymmetry, flatness, and notching provided prognostic information on mortality independent of heart rate, QTc, and baseline comorbidities.
Collapse
Affiliation(s)
- Jonas L Isaksen
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas Ghouse
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Morten S Olesen
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Anders G Holst
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Adrian Pietersen
- Copenhagen General Practitioners' Laboratory, Copenhagen, Denmark
| | - Jonas B Nielsen
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark; Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Morten W Skov
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.
| |
Collapse
|
10
|
Sánez Tähtisalo H, Hiltunen TP, Kenttä T, Junttila J, Oikarinen L, Virolainen J, Kontula KK, Porthan K. Effect of four classes of antihypertensive drugs on cardiac repolarization heterogeneity: A double-blind rotational study. PLoS One 2020; 15:e0230655. [PMID: 32208439 PMCID: PMC7092984 DOI: 10.1371/journal.pone.0230655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/04/2020] [Indexed: 11/21/2022] Open
Abstract
Background T-wave area dispersion (TW-Ad) is a novel electrocardiographic (ECG) repolarization marker associated with sudden cardiac death. However, limited data is available on the clinical correlates of TW-Ad. In addition, there are no previous studies on cardiovascular drug effects on TW-Ad. In this study, we examined the relation between TW-Ad and left ventricular mass. We also studied the effects of four commonly used antihypertensive drugs on TW-Ad. Methods A total of 242 moderately hypertensive males (age, 51±6 years; office systolic/diastolic blood pressure during placebo, 153±14/100±8 mmHg), participating in the GENRES study, were included. Left ventricular mass index was determined by transthoracic echocardiography. Antihypertensive four-week monotherapies (a diuretic, a beta-blocker, a calcium channel blocker, and an angiotensin receptor antagonist) were administered in a randomized rotational fashion. Four-week placebo periods preceded all monotherapies. The average value of measurements (over 1700 ECGs in total) from all available placebo periods served as a reference to which measurements during each drug period were compared. Results Lower, i.e. risk-associated TW-Ad values correlated with a higher left ventricular mass index (r = −0.14, p = 0.03). Bisoprolol, a beta-blocker, elicited a positive change in TW-Ad (p = 1.9×10−5), but the three other drugs had no significant effect on TW-Ad. Conclusions Our results show that TW-Ad is correlated with left ventricular mass and can be modified favorably by the use of bisoprolol, although demonstration of any effects on clinical endpoints requires long-term prospective studies. Altogether, our results suggest that TW-Ad is an ECG repolarization measure of left ventricular arrhythmogenic substrate.
Collapse
Affiliation(s)
- Heini Sánez Tähtisalo
- Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Timo P. Hiltunen
- Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- * E-mail:
| | - Tuomas Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Lasse Oikarinen
- Division of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Juha Virolainen
- Division of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Kimmo K. Kontula
- Department of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Kimmo Porthan
- Division of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Department of Medicine, University of Helsinki and Minerva Foundation Institute for Medical Research, Helsinki, Finland
| |
Collapse
|
11
|
Reynard JT, Oshodi OM, Lai JC, Lai RW, Bazoukis G, Fragakis N, Letsas KP, Korantzopoulos P, Liu FZ, Liu T, Xia Y, Tse G, Li CK. Electrocardiographic conduction and repolarization markers associated with sudden cardiac death: moving along the electrocardiography waveform. Minerva Cardioangiol 2019; 67:131-144. [PMID: 30260143 DOI: 10.23736/s0026-4725.18.04775-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
The QT interval along with its heart rate corrected form (QTc) are well-established ECG markers that have been found to be associated with malignant ventricular arrhythmogenesis. However, extensive preclinical and clinical investigations over the years have allowed for novel clinical ECG markers to be generated as predictors of arrhythmogenesis and sudden cardiac death. Repolarization markers include the older QTc, QT dispersion and newer Tpeak - Tend intervals, (Tpeak - Tend) / QT ratios, T-wave alternans (TWA), microvolt TWA and T-wave area dispersion. Meanwhile, conduction markers dissecting the QRS complex, such as QRS dispersion (QRSD) and fragmented QRS, were also found to correlate conduction velocity and unidirectional block with re-entrant substrates in various cardiac conditions. Both repolarization and conduction parameters can be combined into the excitation wavelength (λ). A surrogate marker for λ is the index of Cardiac Electrophysiological Balance (iCEB: QT / QRSd). Other markers based on conduction-repolarization are [QRSD x (Tpeak-Tend) / QRSd] and [QRSD x (Tpeak-Tend) / (QRSd x QT)]. Advancement in technology permitted sophisticated electrophysiological analyses such as principal component analysis and periodic repolarization dynamics to further improve risk stratification. This was closely followed by other novel indices including ventricular ectopic QRS interval, the f99 index and EntropyXQT, which integrates mathematical and physical calculations for determining the risk markers. Though proven to be effective in limited patient cohorts, more clinical studies across different cardiac pathologies are required to confirm their validity. As such, this review seeks to encapsulate the development of old and new ECG markers along with their associated utility and shortcomings in clinical practice.
Collapse
Affiliation(s)
- Jack T Reynard
- Faculty of Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | | | - Jenny C Lai
- Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Rachel W Lai
- Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - George Bazoukis
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Nikolaos Fragakis
- Third Department of Cardiology, Hippokration Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- First Department of Cardiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Konstantinos P Letsas
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Panagiotis Korantzopoulos
- Third Department of Cardiology, Hippokration Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- First Department of Cardiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Fang-Zhou Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital affiliated to South China University of Technology, Guangzhou, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gary Tse
- Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Christien K Li
- Faculty of Medicine, Newcastle University, Newcastle Upon Tyne, UK -
- Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| |
Collapse
|
12
|
Narayan SM, Wang PJ, Daubert JP. New Concepts in Sudden Cardiac Arrest to Address an Intractable Epidemic: JACC State-of-the-Art Review. J Am Coll Cardiol 2019; 73:70-88. [PMID: 30621954 PMCID: PMC6398445 DOI: 10.1016/j.jacc.2018.09.083] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/28/2018] [Accepted: 09/22/2018] [Indexed: 12/11/2022]
Abstract
Sudden cardiac arrest (SCA) is one of the largest causes of mortality globally, with an out-of-hospital survival below 10% despite intense research. This document outlines challenges in addressing the epidemic of SCA, along the framework of respond, understand and predict, and prevent. Response could be improved by technology-assisted orchestration of community responder systems, access to automated external defibrillators, and innovations to match resuscitation resources to victims in place and time. Efforts to understand and predict SCA may be enhanced by refining taxonomy along phenotypical and pathophysiological "axes of risk," extending beyond cardiovascular pathology to identify less heterogeneous cohorts, facilitated by open-data platforms and analytics including machine learning to integrate discoveries across disciplines. Prevention of SCA must integrate these concepts, recognizing that all members of society are stakeholders. Ultimately, solutions to the public health challenge of SCA will require greater awareness, societal debate and focused public policy.
Collapse
Affiliation(s)
- Sanjiv M Narayan
- Department of Medicine, Division of Cardiology, Stanford University, Stanford, California.
| | - Paul J Wang
- Department of Medicine, Division of Cardiology, Stanford University, Stanford, California
| | - James P Daubert
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina
| |
Collapse
|
13
|
Simov D, Christov I, Simova I. T-wave Area Dispersion in Coronary Artery Bypass Grafting is Indicative for Increased Risk of Adverse Events in Diabetics. Curr Diabetes Rev 2019; 15:347-348. [PMID: 30648513 DOI: 10.2174/1573399815666190115150321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/16/2018] [Accepted: 01/08/2019] [Indexed: 11/22/2022]
Abstract
Problems in measuring the QT-dispersion are associated mostly with the inaccurate location of the T-wave end. The complications are: (i) In methodology due to various definition for Tend, (ii) In automatic measurements, due to low amplitude of T-wave, presence of U-wave and noise, and (iii) In manual measurements, due to lack of repeatability in the results, and involuntary subjectivism, when the QT-dispersion is measured by a person familiar with the ultimate goal of the study. New ECG repolarization parameter, 'T-Wave Area Dispersion' (TWAD), has been defined by Kenttä et al. 2018. Clustering ability of TWAD for prediction of risk for Sudden Cardiac Death (SCD) has been proven by the authors, working with a large database. We have measured TWAD in peri-, and postoperative ECG recordings of patients, undergoing coronary artery bypass grafting. Analysis of perioperative TWAD has shown an increased risk of adverse events in diabetics. Postoperative TWAD parameters have deteriorated proportionally in both diabetics/ non-diabetics groups indicating increased cardiac risk within the first ten postoperative days. The ability for diabetics/non-diabetics clustering of TWAD has been proven even in case of inaccurate location of the Tend. So far this is a reasonable advantage of TWAD vs. QT-dispersion in the study of ECG repolarization.
Collapse
Affiliation(s)
- Dimitar Simov
- Cardiac Surgery Department, St Anna Hospital, Sofia, Bulgaria
| | - Ivaylo Christov
- Institute of Biophysics and Biomedical Engineering - Bulgarian Academy of Sciences, Sofia, Bulgaria
| | - Iana Simova
- Acibadem City Clinic Cardiovascular Center - University Hospital, Sofia, Bulgaria
| |
Collapse
|