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Badiger S, Hanumappa V, Jugati AV. A Study of Tpeak-Tend/QT Interval Ratio in Predicting Heart Failure in ST-Elevation Myocardial Infarction and Its Correlation With N-terminal Pro B-type Natriuretic Peptide (NT-proBNP). Cureus 2024; 16:e68495. [PMID: 39364490 PMCID: PMC11449083 DOI: 10.7759/cureus.68495] [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: 07/31/2024] [Accepted: 09/02/2024] [Indexed: 10/05/2024] Open
Abstract
Background Acute ST-elevation myocardial infarction (STEMI) is the most common cause of mortality across the world. The electrocardiogram (ECG) Tpeak-Tend/QT interval appears to be a measure of the left ventricle's transmural dispersion of repolarization (TDR). Prolongation of this time could indicate adverse cardiac events like heart failure, arrhythmias, etc. Heart failure is a clinical syndrome that includes signs and symptoms such as peripheral edema and high jugular vein pressure. N-terminal pro B-type natriuretic peptide (NT-proBNP) is an effective predictor of left ventricular function and also helps in predicting the disease prognosis. Elevated levels of NT-proBNP are seen in many cases of left ventricular dysfunction. This study aims to evaluate the predictive utility of the Tpeak-Tend/QT interval ratio in predicting major adverse cardiac events (MACEs), such as heart failure, by examining the Tend/QT interval ratio values with NT-proBNP in STEMI. Methodology This cross-sectional study was conducted at a tertiary hospital between April 2024 and June 2024. It included STEMI patients, excluding those with non-STEMI (NSTEMI), valvular heart diseases, bundle branch block, or pacemakers. The patients with a Tpeak-Tend/QT ratio < 0.3 were included in group A, and the Tpeak-Tend/QT ratio > 0.3 in group B. They were monitored for MACE-like heart failure during hospitalization and were compared with a study of the Tpeak-Tend/QT interval ratio in predicting heart failure in STEMI and its correlation with NT-proBNP levels. Results In this study, out of 45 patients, male predominance was observed, with 35 (78%) being men and 10 (22%) being women. In group A, the most common age group was 60-70 years, with 16 (51%) patients; in Group B, it was 50-60 years, with six (42.8%) patients. Out of 31 patients in group A, 25 were male, and six were female. In group B, out of 14 patients, 10 were male, and four were female. In this study, out of the 45 patients included, 12 (85%) among 14 patients who had MACEs like heart failure had a Tpeak-Tend/QT interval ratio of more than 0.3, and their measured NT-proBNP levels were also more than 900 pg/mL, thus showing a statistically significant association between Tpeak-Tend/QT interval ratio and NT-proBNP. Conclusion The present study showed an increased Tpeak-Tend/QT interval ratio and NT-proBNP in patients who developed heart failure in STEMI. As ECG is a readily available and affordable tool, the Tpeak-Tend/QT interval ratio can be used along with conventional markers like NT-proBNP to predict MACE in patients with STEMI.
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Affiliation(s)
- Sharan Badiger
- General Medicine, Shri B. M. Patil Medical College Hospital and Research Centre, Bijapur Lingayat District Education (Deemed to be University), Vijayapura, IND
| | - Venugopal Hanumappa
- General Medicine, Shri B. M. Patil Medical College Hospital and Research Centre, Bijapur Lingayat District Education (Deemed to be University), Vijayapura, IND
| | - Avinash V Jugati
- General Medicine, Shri B. M. Patil Medical College Hospital and Research Centre, Bijapur Lingayat District Education (Deemed to be University), Vijayapura, IND
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Gür V, Yapici F, Küçük U, Subaşi İÖ, Gökgöz MB, Karaköse R, Koçkara N. Patients with Achilles Tendon Rupture Are Prone to Develop Ventricular Arrhythmia. J Clin Med 2023; 12:jcm12103583. [PMID: 37240689 DOI: 10.3390/jcm12103583] [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: 04/08/2023] [Revised: 05/14/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES This study aimed to examine the ventricular repolarization (VR) disturbances of patients operated on for acute spontaneous Achilles tendon ruptures (ATRs), by comparing them with a healthy individual control group. MATERIALS AND METHODS Between June 2014 and July 2020, a total of 29 patients (28 males, 1 female; mean age: 40 ± 9.78 years; range, 21-66 years) who presented to the emergency department within the first three weeks of injury, and were diagnosed with acute spontaneous ATRs and treated with an open Krackow suture technique, were retrospectively analyzed. Fifty-two healthy individuals (47 males, 5 females; mean age: 39 ± 11.45 years; range, 21-66 years) were recruited as a control group from the cardiology outpatient clinic. Clinical data (demographic features and laboratory parameters (serum glucose, creatinine, hemoglobin, white blood cell count, and lipid profile)) and electrocardiograms (ECGs) were collected from medical records. ECGs were evaluated for heart rate and VR parameters of QRS width, QTc interval, cQTd interval, Tp-e interval, and Tp-e/QT ratio. The clinical data and these ECG parameters were compared between groups. RESULTS There was no statistically significant difference between groups, regarding clinical data (all p < 0.05). Among ECG parameters, heart rate, QRS width, QTc interval, and cQTd interval were similar between groups (all p < 0.05). There were two important statistically significant findings of this research: The mean Tp-e interval was longer (ATR group: 72.4 ± 24.7, control group: 58.8 ± 14.5, p: 0.01), and the Tp-e/QT ratio was higher (ATR group: 0.2 ± 0.1, control group: 0.16 ± 0.4, p: 0.027) in the ATR group. CONCLUSIONS According to the ventricular repolarization disturbances found in this study, patients with ATR may be at a higher risk of ventricular arrhythmia than healthy people. As a result, ATR patients should be assessed for ventricular arrhythmia risk by an expert cardiologist.
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Affiliation(s)
- Volkan Gür
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erzincan University, 24180 Erzincan, Turkey
| | - Furkan Yapici
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erzincan University, 24180 Erzincan, Turkey
| | - Uğur Küçük
- Department of Cardiology, Faculty of Medicine, 18 Mart University, 17020 Çanakkale, Turkey
| | - İzzet Özay Subaşi
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erzincan University, 24180 Erzincan, Turkey
| | - Mehmet Burak Gökgöz
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erzincan University, 24180 Erzincan, Turkey
| | - Reşit Karaköse
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erzincan University, 24180 Erzincan, Turkey
| | - Nizamettin Koçkara
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erzincan University, 24180 Erzincan, Turkey
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Li D, Weng Y, Zhen G, Jiang L. Tp-Te Interval and Tp-Te/QT Ratio Are Valuable Tools in Predicting Poor Outcome in Sepsis Patients. Front Cardiovasc Med 2022; 9:879085. [PMID: 35677695 PMCID: PMC9167962 DOI: 10.3389/fcvm.2022.879085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Objective About 50% of patients with sepsis have different degrees of myocardial inhibition, known as sepsis-induced myocardial dysfunction (SMD), which increases the mortality rate of sepsis. Tp-Te interval and Tp-Te/QT ratio reflect ventricular transmural dispersion repolarization (TDR), and have good predictive value for death in patients with heart disease. This study aimed to investigate the prognostic value of Tp-Te and Tp-Te/QT in patients with sepsis. Methods The current study included a total of 625 participants: 201 patients with sepsis, 213 patients with heart failure, and 211 healthy participants. According to the severity and outcome, the patients with sepsis were divided into the sepsis group and the septic shock group, and the death group and the survival group to explore the differences of indicators among subgroups of sepsis. The ROC curve was used to analyze the predictive value of the indicators for deaths of patients with sepsis and calculate the cutoff point. Then, we investigated the incidence of arrhythmia in patients with sepsis with different TDR. The correlation between Tp-Te/QT and the commonly used predictive indicators in ICU was also discussed. Results (1) Tp-Te and Tp-Te/QT in patients with sepsis and heart failure (HF) were significantly higher than the control group (p < 0.01). (2) Compared with patients with sepsis, the increase of Tp-Te and Tp-Te/QT is more prominent in patients with HF. Especially, the increase of the Tp-Te/QT was statistically significant (p < 0.001). (3) compared with patients with sepsis (no shock), the Tp-Te, Tp-Te/QT, and SOFA were increased in patients with septic shock (p < 0.05). (4) In the death group, Tp-Te /QT, SOFA, and Apache-II were higher; LVEF was lower than the survival group (p < 0.05). (5) ROC curves showed that Tp-Te/QT, SOFA, and LVEF have predictive values for death (p < 0.05; AUC = 0.808, 0.716, 0.412). The cutoff point of Tp-Te/QT was 0.32. (6) The incidence of arrhythmia is different in patients with sepsis with different TDR. (7) There is a significant correlation between Tp-Te/QT and SOFA (p < 0.001, r = 0.79). Conclusion TDR in patients with sepsis is significantly increased, which was between healthy population and patients with HF. Tp-Te and Tp-Te/QT are effective indicators to reflect the severity and poor outcome of patients with sepsis.
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Affiliation(s)
- Duo Li
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
- Department of Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yibing Weng
- Department of Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Genshen Zhen
- Department of Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Li Jiang
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Li Jiang
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Tran CT, Atanasovska T, Graff C, Melgaard J, Kanters JK, Smith R, Petersen AC, Kjeldsen KP, McKenna MJ. Plasma potassium concentration and cardiac repolarisation markers, Tpeak–Tend and Tpeak–Tend/QT, during and after exercise in healthy participants and in end-stage renal disease. Eur J Appl Physiol 2022; 122:691-702. [DOI: 10.1007/s00421-021-04870-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 12/07/2021] [Indexed: 11/29/2022]
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Terminal T-wave inversion predicts reperfusion tachyarrhythmias in STEMI. J Electrocardiol 2022; 71:28-31. [PMID: 35026678 DOI: 10.1016/j.jelectrocard.2021.12.008] [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: 09/29/2021] [Revised: 11/15/2021] [Accepted: 12/23/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION A reliable electrocardiographic predictor of ventricular fibrillation (VF) in patients with ST elevation myocardial infarction (STEMI) is lacking so far. Previous experimental/simulation study suggested a terminal T-wave inversion (TTWI) in ischemia-related ECG leads corresponding to anterior infarct localization as an independent predictor of reperfusion VF (rVF). This T-wave characteristic has never been tested as a rVF predictor in clinical settings. The aim of this study was to test if terminal T-wave inversion (TTWI) at admission ECG (before reperfusion) can serve as a predictor of ventricular fibrillation during reperfusion (rVF) in patients with anterior STEMI undergoing primary PCI. METHODS AND RESULTS Study population included consecutive patients with anterior infarct localization admitted for primary PCI (n = 181, age 65 [57; 76] years, 66% male). Of those, 14 patients had rVF (rVF group, age 59 [47; 76] years, 64% male) and patients without rVF comprised the No-rVF group (n = 167, age 65 [57; 76] years, 66% male). Association of TTWI with rVF was analyzed using logistic regression analysis adjusted for relevant clinical and electrocardiographic covariates. The prevalence of TTWI in rVF group was 62% comparing to 23% in the No-rVF group, p = 0.005. TTWI was associated with increased risk of rVF (OR 5.51; 95% CI 1.70-17.89; p = 0.004) and remained a significant predictor after adjustment for age, gender, history of MI prior to index admission, VF before reperfusion, Tpeak-Tend, maximal ST elevation, and QRS duration (OR 23.49; 95% CI 3.14-175.91; p = 0.002). CONCLUSIONS The terminal T-wave inversion in anterior leads before PCI independently predicted rVF in patients with anterior MI thus confirming the previous experimental/simulation findings.
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Prognostic value of infarct-related-lead Tpeak-Tend/QT ratio in patients with ST-segment elevation myocardial infarction. Heart Vessels 2021; 37:539-548. [PMID: 34599658 DOI: 10.1007/s00380-021-01950-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
Tpeak-Tend/QT ratio (Tp-e/QT) in patients with ST-segment elevation myocardial infarction (STEMI) is reportedly associated with major adverse cardiac events (MACEs). However, Tp-e/QT measurement methods are controversial, and few studies have clarified the effect of different Tp-e/QT measures on prognosis. Our study is the first to investigate the advantages of the Tp-e/QT measured by infarct-related-lead method in predicting MACEs during hospitalization and long-term mortality in patients with STEMI. A total of 427 STEMI patients undergoing primary percutaneous coronary intervention (PCI) were included in this study. The Tp-e/QT before PCI was measured by traditional 12-lead method and infarct-related-lead method. Outcomes were tested using comparative statistics, logistic regression, receiver operating characteristic (ROC) curve and Kaplan-Meier survival analysis. There were 62 (14.5%) patients who had MACEs in-hospital. Logistic regression showed that the Tp-e/QT in infarct-related-lead was an independent predictor (p < 0.001). The area under the ROC curve (AUC) of the Tp-e/QT in infarct-related-lead was larger than that in the Tp-e/QT in traditional 12-lead (0.889 vs 0.741), and the optimal cutoff value was 0.32. The three-year survival rate of patients in the infarct-related-lead Tp-e/QT < 0.32 group was better than Tp-e/QT ≥ 0.32 group in Kaplan-Meier survival analysis (93.9 vs 87.0%). When stratified according to infarct-related arteries, the results showed that the common odds ratio of patients in Tp-e/QT ≥ 0.32 group occurred MACEs was 1.562, P = 0.038. The infarct-related-lead Tp-e/QT performed better than the traditional 12-lead Tp-e/QT in predicting poor prognosis.
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Hayıroğlu Mİ, Lakhani I, Tse G, Çınar T, Çinier G, Tekkeşin Aİ. In-Hospital Prognostic Value of Electrocardiographic Parameters Other Than ST-Segment Changes in Acute Myocardial Infarction: Literature Review and Future Perspectives. Heart Lung Circ 2020; 29:1603-1612. [PMID: 32624331 DOI: 10.1016/j.hlc.2020.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/11/2020] [Accepted: 04/26/2020] [Indexed: 01/25/2023]
Abstract
Electrocardiography (ECG) remains an irreplaceable tool in the management of the patients with myocardial infarction, with evaluation of the QRS and ST segment being the present major focus. Several ECG parameters have already been proposed to have prognostic value with regard to both in-hospital and long-term follow-up of patients. In this review, we discuss various ECG parameters other than ST segment changes, particularly with regard to their in-hospital prognostic importance. Our review not only evaluates the prognostic segments and parts of ECG, but also highlights the need for an integrative approach in big data to re-assess the parameters reported to predict in-hospital prognosis. The evolving importance of artificial intelligence in evaluation of ECG, particularly with regard to predicting prognosis, and the potential integration with other patient characteristics to predict prognosis, are discussed.
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Affiliation(s)
- Mert İlker Hayıroğlu
- Department of Cardiology, Haydarpasa Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey.
| | - Ishan Lakhani
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, China
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, China; Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, China
| | - Tufan Çınar
- Department of Cardiology, Haydarpasa Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Göksel Çinier
- Department of Cardiology, Kaçkar State Hospital, Rize, Turkey
| | - Ahmet İlker Tekkeşin
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Bazoukis G, Yeung C, Wui Hang Ho R, Varrias D, Papadatos S, Lee S, Ho Christien Li K, Sakellaropoulou A, Saplaouras A, Kitsoulis P, Vlachos K, Lampropoulos K, Thomopoulos C, Letsas KP, Liu T, Tse G. Association of QT dispersion with mortality and arrhythmic events-A meta-analysis of observational studies. J Arrhythm 2020; 36:105-115. [PMID: 32071628 PMCID: PMC7011802 DOI: 10.1002/joa3.12253] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/02/2019] [Accepted: 10/13/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The risk stratification of coronary heart disease (CHD) and/or heart failure (HF) patients with easily measured electrocardiographic markers is of clinical importance. The aim of this meta-analysis is to indicate whether increased QT dispersion (QTd) is associated with fatal and nonfatal outcomes in patients with CHD and/or HF. METHODS We systematically searched MEDLINE and Cochrane databases without restrictions until August 15, 2018 using the keyword "QT dispersion". Studies including data on the association between QTd and all-cause mortality, sudden cardiac death (SCD) or arrhythmic events in patients with HF and/or CHD were classified as eligible. RESULTS In the analysis including patients with CHD and/or HF, we found that QTd did not differ significantly in patients with SCD compared to no SCD patients while QTd was significantly greater in the group of all-cause mortality patients and in patients who experienced a sustained ventricular arrhythmia. Subgroup analysis showed that in myocardial infarction studies, QTd was significantly higher in patients with an arrhythmic event compared to arrhythmic event-free patients while a nonsignificant difference was found in QTd in patients who died from any cause compared to survivors. Similarly, in HF patients, the QTd was significantly greater in patients with an arrhythmic event while a nonsignificant difference was found regarding all-cause mortality and SCD outcomes. CONCLUSIONS QTd has a prognostic role for stratifying myocardial infarction or HF patients who are at higher risk of arrhythmic events. However, no prognostic role was found regarding all-cause mortality or SCD in this patient population.
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Affiliation(s)
- George Bazoukis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Cynthia Yeung
- Department of MedicineQueen's UniversityKingstonONCanada
| | - Ryan Wui Hang Ho
- Li Ka Shing Faculty of MedicineUniversity of Hong KongHong KongP.R. China
| | | | - Stamatis Papadatos
- 3rd Department of Internal MedicineSotiria General HospitalNational and Kapodistrian University of Athens Medical SchoolAthensGreece
| | - Sharen Lee
- Laboratory of Cardiovascular PhysiologyLi Ka Shing Institute of Health SciencesHong Kong S.A.R.P.R. China
| | | | - Antigoni Sakellaropoulou
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Athanasios Saplaouras
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Panagiotis Kitsoulis
- Laboratory of Anatomy‐Histology‐Embryology School of MedicineUniversity of IoanninaIoanninaGreece
| | - Konstantinos Vlachos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Konstantinos Lampropoulos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | | | - Konstantinos P. Letsas
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular diseaseDepartment of CardiologyTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Gary Tse
- Laboratory of Cardiovascular PhysiologyLi Ka Shing Institute of Health SciencesHong Kong S.A.R.P.R. China
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Kazemi B, Hajizadeh R, Ranjbar A, Sohrabi B, Vaezi H. Evaluation of T peak to end/QT and T peak to end/QTc ratios in patients with STEMI undergoing percutaneous intervention vs. thrombolytic therapy. J Electrocardiol 2020; 58:160-164. [PMID: 31895992 DOI: 10.1016/j.jelectrocard.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/15/2019] [Accepted: 12/03/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The patients with ST-segment Elevation Myocardial Infarction (STEMI) are significantly at increased risk of arrhythmia. Repolarization of myocardium has been evaluated by a series of electrical parameters including T wave peak to T wave end (Tp-Te) and Tp-Te/QT ratio. Which were compared with survival outcomes between two groups of STEMI patients treated with Primary Percutaneous Coronary Intervention (PPCI) and recombinant Tissue Plasminogen Activator (r-TPA). METHODS In this prospective study, 188 patients with STEMI were included in the study. 12‑Lead ECGs were obtained from all patients on time of admission and after 24 h after treatment. After dividing the patients into two groups based on their type of treatment (PPCI or r-TPA), The Tp-Te/QT and Tp-Te/QTc ratios were calculated using ECG records. The survival outcomes were compared between two groups. RESULTS 95 patients (50.5%) underwent PPCI and 93 patients (49.5%) received r-TPA. Tp-Te/QT and Tp-Te/QTc ratios after administration of the treatments were significantly decreased in both groups (P-value = .001) with lower Tp-Te/QT and Tp-Te/QTc ratios in PPCI group (P-value = .001). 7 patients in PPCI group (7.3%) and 16 patients in r-TPA group (17.2%) were died during their hospitalization period (P-value = .04). The best combination of sensitivity and specificity of post treatment Tp-Te/QT ratio was at cutoff points of 29.4 with 82% sensitivity and 83% specificity. CONCLUSION Our study demonstrated that Tp-Te/QT and Tp-Te/QTc ratios decrease significantly after both PPCI and r-TPA therapies, but with PPCI these indexes decrease more than r-TPA, resulting a better survival outcome in patients with STEMI.
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Affiliation(s)
- Babak Kazemi
- Department of Cardiology, Faculty of Medicine, Tabriz University of Medical Science, Tabriz, Iran
| | - Reza Hajizadeh
- Department of Cardiology, Faculty of Medicine, Urmia University of Medical Science, Urmia, Iran
| | - Abdolmohammad Ranjbar
- Department of Cardiology, Faculty of Medicine, Tabriz University of Medical Science, Tabriz, Iran.
| | - Bahram Sohrabi
- Department of Cardiology, Faculty of Medicine, Tabriz University of Medical Science, Tabriz, Iran
| | - Hasanali Vaezi
- Department of Cardiology, Faculty of Medicine, Tabriz University of Medical Science, Tabriz, Iran
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Vehmeijer JT, Koyak Z, Vink AS, Budts W, Harris L, Silversides CK, Oechslin EN, Zwinderman AH, Mulder BJM, de Groot JR. Prolonged T peak -T end interval is a risk factor for sudden cardiac death in adults with congenital heart disease. CONGENIT HEART DIS 2019; 14:952-957. [PMID: 31573144 PMCID: PMC7003836 DOI: 10.1111/chd.12847] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 09/05/2019] [Accepted: 09/11/2019] [Indexed: 11/29/2022]
Abstract
Objective Adult congenital heart disease (ACHD) patients are at risk of sudden cardiac death (SCD). However, methods for risk stratification are not yet well‐defined. The Tpeak‐Tend (TpTe) interval, a measure of dispersion of ventricular repolarization, is a risk factor for SCD in non‐ACHD patients. We aim to evaluate whether TpTe can be used in risk stratification for SCD in ACHD patients. Design From an international multicenter cohort of 25 790 ACHD patients, we identified all SCD cases. Cases were matched to controls by age, gender, congenital defect, and (surgical) intervention. Outcome Measures TpTe was measured on a standard 12‐lead ECG. The maximum TpTe of all ECG leads (TpTe‐max), mean (TpTe‐mean), and TpTe dispersion (maximum minus minimum) were obtained. Odds ratios (OR) for SCD cases vs controls were calculated using conditional logistic regression analysis. Results ECGs were available for 147 cases (median age at death 33.5 years (quartiles 26.2, 48.7), 66% male) and 267 controls. The mean TpTe‐max was 97 ± 24 ms in cases vs 84 ± 17 ms in controls (P < .001); TpTe‐mean was 70 ± 16 vs 63 ± 10 ms (P < .001); and dispersion was 51 ± 22 ms vs 41 ± 16 ms (P = .02), respectively. Assessing each ECG lead separately, TpTe in lead aVR predicted SCD most accurately. TpTe in lead aVR was 71 ± 23 ms in cases vs 61 ± 13 ms in controls (P < .001). After adjusting for impaired ventricular function, heart failure symptoms, and prolonged QRS duration, the OR of SCD of TpTe in lead aVR at an optimal cutoff of 80 ms was 5.8 (95% CI 2.7‐12.4, P < .001). Conclusions The TpTe interval is associated with SCD in ACHD patients. Particularly, TpTe in lead aVR can be used as an independent risk factor for SCD in ACHD patients and may, therefore, add precision to current risk prediction models.
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Affiliation(s)
- Jim T Vehmeijer
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Zeliha Koyak
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - A Suzanne Vink
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Werner Budts
- Department of Cardiology, Universitair Ziekenhuis Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Louise Harris
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto Congenital Cardiac Centre for Adults, University of Toronto, Toronto, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto Congenital Cardiac Centre for Adults, University of Toronto, Toronto, Ontario, Canada
| | - Erwin N Oechslin
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto Congenital Cardiac Centre for Adults, University of Toronto, Toronto, Ontario, Canada
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Barbara J M Mulder
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.,Netherlands Heart Institute, Utrecht, the Netherlands
| | - Joris R de Groot
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
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Prolonged Tpeak-Tend interval is associated with ventricular fibrillation during reperfusion in ST-elevation myocardial infarction. Int J Cardiol 2019; 280:80-83. [DOI: 10.1016/j.ijcard.2019.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 12/04/2018] [Accepted: 01/02/2019] [Indexed: 11/22/2022]
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12
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Noninvasive assessment of left-ventricular diastolic electromechanical coupling in hypertensive heart disease. J Echocardiogr 2019; 17:206-212. [PMID: 30756346 DOI: 10.1007/s12574-019-00421-4] [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: 12/26/2018] [Revised: 01/29/2019] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND There is a need to stratify patients who may develop heart failure because of the current "heart failure pandemic". We hypothesized that noninvasive assessment of diastolic electromechanical coupling by electrocardiography and Doppler echocardiography may be clinically useful for risk stratification of hypertensive patients who may develop heart failure. METHODS We measured the time from the peak to end of the T wave (TpTe) as an electrophysiological parameter, and peak early diastolic mitral flow (E) and lateral annular (e') velocities as mechanical parameters in 109 patients with hypertension. Relationships between these parameters and their association with the prognosis were evaluated. RESULTS The e' was inversely correlated with TpTe (p < 0.001) and QTc (p < 0.014), whereas E/e' was positively correlated with TpTe (p < 0.001) and QTc (p < 0.001). The TpTe predicted patients with E/e' > 12. There were 24 cardiovascular events during follow-up (57 ± 20 months), and Kaplan-Meier analysis showed that outcome was worse (p = 0.003) in patients with higher E/e' than lower E/e'; however, there was no difference between patients with longer TpTe (≧72 ms) and shorter TpTe (< 72 ms). CONCLUSION The correlation of TpTe with e' and E/e' in hypertensive patients suggests that these parameters reflect diastolic ventricular electromechanical coupling. The E/e' predicted outcome, and an elevated E/e' should be suspected when TpTe is prolonged (> 72 ms). Noninvasive evaluation of diastolic electromechanical coupling is clinically useful in patients with hypertension for predicting their outcome.
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Poręba M, Gać P, Usnarska-Zubkiewicz L, Pilecki W, Kuliczkowski K, Mazur G, Gonerska M, Sobieszczańska M, Poręba R. Evaluation of the impact of treatment with hematopoietic stem cells transplantation (HSCT) on biochemical markers of heart function and novel electrocardiographic markers of repolarization in patients with hematological malignancies. Med Oncol 2018; 35:162. [PMID: 30382530 PMCID: PMC6208856 DOI: 10.1007/s12032-018-1221-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 10/25/2018] [Indexed: 11/28/2022]
Abstract
High-dose chemotherapy (HDC) followed by stem cell transplantation (HSCT) is a well-established method in patients with hematological malignancies, and for last few years, many efforts have been made to estimate short- and long-term efficacy of this method, as well as early and late complications. The present study concentrates on cardiotoxic effects, mainly early changes using biochemical markers such as N-terminal natriuretic peptide type B (NT-proBNP) and cardiac troponins (cTn). Simultaneously, the analysis of 12-lead ECG was done before and after the procedure in which the novel repolarization markers: Tp-e and Tp-e/QT ratio were measured, together with standard markers: QT, QTc. It was found that NT-pro BNP was significantly increased after HSCT in comparison to results before it, and no significant changes were present in Troponin levels. Simultaneously, Tp-e interval and Tp-e/QT ratio were significantly higher after HSCT. The use of cyclophosphamide, advanced age, and higher level of blood cholesterol concentration were risk factors for the increase in NT-proBNP and treatment with cyclophosphamide as well as fludarabine and higher creatinine levels were risk factors for the increase in Tp-e/QT ratio. In conclusion, in the early term evaluation after HSCT in patients with no previously diagnosed heart disease, the mild changes in markers of heart overload and repolarization were noted. The observations suggest that in all patients undergoing HSCT, even the ones without pre-existing cardiovascular disease, the evaluation, and monitoring of heart function should be considered.
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Affiliation(s)
- Małgorzata Poręba
- Department of Pathophysiology, Wroclaw Medical University, Marcinkowskiego 1, 50-368, Wroclaw, Poland
| | - Paweł Gać
- Department of Hygiene, Wroclaw Medical University, Mikulicza-Radeckiego 7, 50-368, Wroclaw, Poland.
| | - Lidia Usnarska-Zubkiewicz
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Pasteur 4, 50-367, Wroclaw, Poland
| | - Witold Pilecki
- Department of Pathophysiology, Wroclaw Medical University, Marcinkowskiego 1, 50-368, Wroclaw, Poland
| | - Kazimierz Kuliczkowski
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Pasteur 4, 50-367, Wroclaw, Poland
| | - Grzegorz Mazur
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
| | - Marzena Gonerska
- Department of Pathophysiology, Wroclaw Medical University, Marcinkowskiego 1, 50-368, Wroclaw, Poland
| | - Małgorzata Sobieszczańska
- Department of Pathophysiology, Wroclaw Medical University, Marcinkowskiego 1, 50-368, Wroclaw, Poland
| | - Rafał Poręba
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
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Wang X, Zhang L, Gao C, Zhu J, Yang X. Tpeak-Tend/QT interval predicts ST-segment resolution and major adverse cardiac events in acute ST-segment elevation myocardial infarction patients undergoing percutaneous coronary intervention. Medicine (Baltimore) 2018; 97:e12943. [PMID: 30412109 PMCID: PMC6221564 DOI: 10.1097/md.0000000000012943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Elevated ST-segment and increased Tpeak-Tend interval (Tp-e) were prognostic predictors in major adverse cardiac events (MACEs) in ST-segment elevation myocardial infarction (STEMI). The electrophysiologic relationship between them during percutaneous coronary intervention (PCI) needs to elucidate.Patients with STEMI admitted to hospital were prospectively evaluated. ST-segment resolution (STR) (defined as ≥50% reduction as the complete-STR [CSTR] group, <50% as incomplete-STR [ISTR] group), Tp-e interval, and ratio of Tp-e to QT interval (Tp-e/QT) were measured, calculated and analyzed with MACEs.Tp-ec interval (corrected Tp-e interval, P < .001) and Tp-e/QT ratio (P < .001) were significantly increased by myocardial infarction and partly recovered post-PCI. Patients with ISTR showed more increased Tp-ec interval (P < .001) and Tp-e/QT ratio (P < .001) than those in CSTR groups post-PCI. In multivariate analysis and receiver operating characteristic curves analysis, Tp-e/QT was an independent and strongest predictor for STR. STR and electrocardiogram parameters with a cutoff value for predicting STR showed prognostic value for MACE in STEMI in Kaplan-Meier survival analysis.Both STR and change of Tp-e parameters were not only predictors of arrhythmia, but also prognostic factors of MACE in patients with STEMI after PCI.
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15
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Tse G, Bazoukis G, Roever L, Liu T, Wu WKK, Wong MCS, Baranchuk A, Korantzopoulos P, Asvestas D, Letsas KP. T-Wave Indices and Atherosclerosis. Curr Atheroscler Rep 2018; 20:55. [PMID: 30225618 DOI: 10.1007/s11883-018-0756-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Tpeak-Tend interval, the time difference between the peak and the end of the T-wave, reflects the degree of dispersion of repolarization. Its prolongation has been associated with higher risks of developing ventricular arrhythmias and sudden cardiac death in different pro-arrhythmic conditions such as Brugada and long QT syndromes. In this review, we will provide a comprehensive overview on how Tpeak-Tend is altered in different atherosclerotic conditions such as hypertension, stable coronary artery disease, acute coronary obstruction, and coronary slow flow as well as inflammatory diseases affecting the arterial tree. We will explore its relationship with arterial function and dysfunction, ventricular remodeling, and arrhythmic and mortality outcomes. The published literature shows that patients with coronary atherosclerosis, whether in the form of stable coronary artery disease, chronic total occlusion, slow flow, or acute coronary obstruction, have prolonged Tpeak-Tend intervals and Tpeak-Tend/QT ratios. These can be used to predict the occurrence of ventricular arrhythmias and sudden cardiac death. They also correlate with the extent and severity of arterial stenosis and structural remodeling of the ventricles as well as arterial function and dysfunction. Finally, they can be normalized following revascularization and may therefore be used as a surrogate measure of treatment success.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China. .,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.
| | - George Bazoukis
- Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Leonardo Roever
- Department of Clinical Research, Federal University of Uberlândia, Uberlândia, MG, Brazil
| | - 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, 300211, People's Republic of China
| | - William K K Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Martin C S Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | | | - Dimitrios Asvestas
- Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Konstantinos P Letsas
- Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece. .,Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, 10676, Athens, Greece.
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16
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Kollu K, Altintepe L, Duran C, Topal M, Ecirli S. The assessment of P-wave dispersion and myocardial repolarization parameters in patients with chronic kidney disease. Ren Fail 2018; 40:1-7. [PMID: 29285964 PMCID: PMC6014377 DOI: 10.1080/0886022x.2017.1419962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: The risks of sudden death and cardiac arrhythmia are increased in patients with chronic kidney disease (CKD). Here, we aimed to evaluate the indicators of arrhythmias, such as p-wave dispersion (P-WD), QTc dispersion, Tp-e and Tp-e/QT ratio in patients with CKD stages 3–5 on no renal replacement therapy (RRT). Material and methods: One-hundred and thirty three patients with CKD stages 3–5 and 32 healthy controls were enrolled into the study. No patients received RRT. QTc dispersion, P-WD and Tp-e interval were measured using electrocardiogram and Tp-e/QT ratio was also calculated. Results: Mean age rates were found similar in patients and controls (60.8 ± 14.2 and 61 ± 12.9 y, p = .937, respectively). Compared patients with controls, P-WD (45.85 ± 12.42 vs. 21.17 ± 6.6 msec, p < .001), QTc-min (366.99 ± 42.31 vs. 387.15 ± 20.5 msec, p < .001), QTc dispersion (71.13 ± 27.95 vs. 41.25 ± 14.55 msec, p < .001), Tp-e maximum (81.04 ± 10.34 vs. 75.49 ± 10.9 msec, p < .001), Tp-e minimum (62.25 ± 7.58 vs. 54.8 ± 6.72 msec, p < .001) and Tp-e/QTc ratio (0.19 ± 0.02 vs. 0.18 ± 0.01, p = .001) were found to be different. QTc-max and Tp-e interval were found to be similar in both groups. Conclusion: P-WD and QTc dispersion, Tp-e interval and Tp-e/QTc ratio were found to be increased in with CKD stages 3–5 on no RRT.
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Affiliation(s)
- Korhan Kollu
- a The Department of Internal Medicine , Konya Health Application and Research Center, University of Health Sciences , Konya , Turkey
| | - Lutfullah Altintepe
- b The Division of Nephrology and Internal Medicine , Konya Health Application and Research Center, University of Health Sciences , Konya , Turkey
| | - Cevdet Duran
- c The Deparment of Internal Medicine, The Division of Endocrinology and Metabolism , Usak University, The School of Medicine , Usak , Turkey
| | - Mustafa Topal
- b The Division of Nephrology and Internal Medicine , Konya Health Application and Research Center, University of Health Sciences , Konya , Turkey
| | - Samil Ecirli
- d The Division of Internal Medicine , Konya Health Application and Research Center, University of Health Sciences , Konya , Turkey
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Xianpei W, Sha W, Chuanyu G, Juanjuan Y, Chong C, Yongen S, Yu F, Zhenhao L. Tpeak-Tend dispersion as a predictor for malignant arrhythmia events in patients with vasospastic angina. Int J Cardiol 2018; 249:61-65. [PMID: 29121758 DOI: 10.1016/j.ijcard.2017.07.093] [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: 03/27/2017] [Revised: 07/02/2017] [Accepted: 07/24/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tpeak-Tend interval (Tp-e interval) in electrocardiogram (ECG) has been reported to predict malignant arrhythmia events (MAE) in ST-segment elevation myocardial infarction and ion channelopathy. Tp-e interval and other ECG parameters as predictors for MAE was evaluated in patients with vasospastic angina (VA). METHODS AND RESULTS Sixty-two patients with VA (Non-MAE group) and 20 patients with VA complicated by MAE (MAE group) were enrolled in our Division of Cardiology between January 2010 and December 2015. Continuous variables were analyzed by t-test and categorical variables by Chi-square analysis. Patients with MAE showed greater QTc (corrected QT interval) dispersion (P=0.005), Tp-ec (corrected Tp-e) interval (P=0.001), Tp-ec dispersion (P<0.001) and Tp-e/QT ratio (P<0.001) than those in non-MAE groups when ST-segment elevated. After elevated ST-segment returned, there were no significant differences in these ECG parameters between two groups (All P>0.05). At univariate binary logistic regression analysis QTc dispersion (odds ratio(OR)=1.133; P=0.013), Tp-ec (OR=1.058; P=0.003), Tp-e/QT (OR=1.403; P=0.001), and Tp-ec dispersion (OR=1.497; P=0.004) were significantly associated with MAE. At multivariable logistic regression analysis, Tp-ec dispersion remained a predictor of MAE. Receiver operating characteristic (ROC) curve analysis showed that only AUC (Area under curve) of Tp-ec dispersion had significant difference with those in QTc dispersion (P<0.001), Tp-ec (P=0.003), and Tp-e/QT ratio (P=0.012), respectively. CONCLUSIONS QTc dispersion, Tp-ec, Tp-e/QT and Tp-ec dispersion were significantly increased in VA patients with MAE than those without MAE when coronary spasm was onset. Prolonged Tp-ec dispersion was the best discriminators and a strong independent predictor of MAE in VA patients.
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Affiliation(s)
- Wang Xianpei
- Department of Cardiology, People's Hospital of Zhengzhou University, Institute of Cardiovascular Epidemiology of Henan Province, Zhengzhou, Henan Province, China
| | - Wu Sha
- Department of Cardiology, People's Hospital of Zhengzhou University, Institute of Cardiovascular Epidemiology of Henan Province, Zhengzhou, Henan Province, China
| | - Gao Chuanyu
- Department of Cardiology, People's Hospital of Zhengzhou University, Institute of Cardiovascular Epidemiology of Henan Province, Zhengzhou, Henan Province, China.
| | - Yan Juanjuan
- Department of Cardiology, People's Hospital of Zhengzhou University, Institute of Cardiovascular Epidemiology of Henan Province, Zhengzhou, Henan Province, China.
| | - Chen Chong
- Department of Cardiology, People's Hospital of Zhengzhou University, Institute of Cardiovascular Epidemiology of Henan Province, Zhengzhou, Henan Province, China.
| | - Shi Yongen
- Department of Cardiology, People's Hospital of Zhengzhou University, Institute of Cardiovascular Epidemiology of Henan Province, Zhengzhou, Henan Province, China
| | - Feng Yu
- Department of Cardiology, People's Hospital of Zhengzhou University, Institute of Cardiovascular Epidemiology of Henan Province, Zhengzhou, Henan Province, China.
| | - Lin Zhenhao
- Department of Cardiology, People's Hospital of Zhengzhou University, Institute of Cardiovascular Epidemiology of Henan Province, Zhengzhou, Henan Province, China.
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The T peak − T end interval as an electrocardiographic risk marker of arrhythmic and mortality outcomes: A systematic review and meta-analysis. Heart Rhythm 2017; 14:1131-1137. [PMID: 28552749 DOI: 10.1016/j.hrthm.2017.05.031] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Indexed: 11/21/2022]
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