Prevalence, characteristics, and prognosis role of type 1 ST elevation in the peripheral ECG leads in patients with Brugada syndrome.
Rollin A,Sacher F,Gourraud J B,Pasquié J L,Raczka F,Duparc A,Mondoly P,Cardin C,Delay M,Chatel S,Derval N,Denis A,Sadron M,Davy J M,Hocini M,Jaïs P,Jesel L,Haïssaguerre M,Probst V,Maury P
BACKGROUND:Despite isolated reports of Brugada syndrome (BrS) in the inferior or lateral leads, the prevalence and prognostic value of ST elevation in the peripheral electrocardiographic (ECG) leads in patients with BrS remain poorly known. OBJECTIVE:To study the prevalence, characteristics, and prognostic value of type 1 ST elevation and ST depression in the peripheral ECG leads in a large cohort of patients with BrS. METHODS:ECGs from 323 patients with BrS (age 47 ± 13 years; 257 men) with spontaneous (n = 141) or drug-induced (n = 182) type 1 ECG were retrospectively reviewed. Two hundred twenty-five (70%) patients were asymptomatic, 72 (22%) patients presented with unexplained syncope, and 26 (8%) patients presented with sudden death (12 patients) or appropriated implantable cardioverter-defibrillator therapies (14 patients) at diagnosis or over a mean follow-up of 48 ± 34 months. RESULTS:Thirty (9%) patients presented with type 1 ST elevation in at least 1 peripheral lead (22 patients in the aVR leads, 2 in the inferior leads, 5 in both aVR and inferior leads, and 1 in the aVR and VL leads). Patients with type 1 ST elevation in the peripheral leads more often had mutations in the SCN5A gene, were more often inducible, had slower heart rate, and higher J-wave amplitude in the right precordial leads. Twenty-seven percent (8 of 30) of the patients with type 1 ST elevation in the peripheral leads experimented sudden death/appropriate implantable cardioverter-defibrillator therapy, whereas it occurred in only 6% (18 of 293) of other patients (P < .0001). In multivariate analysis, type 1 ECG in the peripheral leads was independently associated with malignant arrhythmic events (odds ratio 4.58; 95% confidence interval 1.7-12.32; P = .0025). CONCLUSIONS:Type 1 ST elevation in the peripheral ECG leads can be seen in 10% of the patients with BrS and is an independent predictor for a malignant arrhythmic event.
Association of QRS-T angle and heart rate variability with major cardiac events and mortality in hemodialysis patients.
Poulikakos Dimitrios,Hnatkova Katerina,Banerjee Debasish,Malik Marek
Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc
INTRODUCTION:Mortality in hemodialysis (HD) patients is high with significant proportion attributed to fatal arrhythmias. In a pilot study, we showed that intradialytic electrocardiographic (ECG) monitoring can yield stable profiles of selected repolarisation descriptors and heart rate variability (HRV) parameters. This study investigated the relationship of these ECG markers with major adverse cardiac events (MACE) and mortality. METHODS:Continuous ECGs were obtained during HD and repeated five times at 2-week intervals. The QRS-T angle calculated as Total Cosine R to T (TCRT) and T-wave morphology dispersion (TMD) were calculated in overlapping 10 s ECG segments. High- (HF) and low (LF)-frequency components and the LF/HF ratio of HRV were calculated every 5 min. These indices were averaged during the first hour of dialysis and subsequently overall recordings in each subject. RESULTS:All ECG parameters were available in 72 patients aged 61 ± 15, 23 (31.9%) females and 26 (36.1%) diabetics. After a median follow up of 54.8 months, 16 patients died, 20 were transplanted, and 9 suffered MACE. TCRT (in degrees) was higher and LF/HF was lower in patients who died compared to survivors (112 ± 30 vs. 73 ± 35, p = 0.000 and 0.222 ± 0.418 vs. 0.401 ± 0.274, p = 0.000, respectively) and in MACE positive compared to negative (117 ± 40 vs. 77 ± 34, p = 0.017 and 0.125 ± 0.333 vs.0.401 ± 0.274, p = 0.007 respectively). In multivariate Cox regression analysis of mortality risk adjusted for age, diabetes mellitus, and coronary artery disease, TCRT and LF/HF remained significant predictors (p < 0.05). CONCLUSION:QRS-T angle and HRV may serve risk assessment in future prospective studies in HD patients.
Electrocardiographic left ventricular hypertrophy in GUSTO IV ACS: an important risk marker of mortality in women.
Westerhout Cynthia M,Lauer Michael S,James Stefan,Fu Yuling,Wallentin Lars,Armstrong Paul W,
European heart journal
AIM:To examine the association of left ventricular hypertrophy (LVH) on admission electrocardiography with adverse outcomes in acute coronary syndrome (ACS) patients. METHODS AND RESULTS:A total of 7443 non-ST-elevation ACS patients in Global Utilization of STrategies to Open occluded arteries (GUSTO) IV ACS trial had admission electrocardiograms analysed at a core laboratory. LVH [>or=20 mm Cornell voltage (LV voltage) (women) or >or=28 mm (men) plus strain patterns] was observed in 586 (7.9%) patients, and women accounted for 74%. LVH patients were also older and had more co-morbidities, ST-depression >or= 0.5 mm, elevated C-reactive protein and N-terminal pro-brain naturetic peptide (NT-proBNP), and lower troponin T. Invasive procedures occurred less often in LVH patients (cardiac catheterization: 31 vs. 38%, P = 0.001; percutaneous coronary intervention: 12 vs. 20%, P < 0.001). Mortality was significantly higher in patients with LVH (30 day: 5 vs. 3%, P = 0.046; 1 year: 14 vs. 7%, P < 0.001), whereas 30 day myocardial infarction (MI) and death/MI did not differ. After baseline adjustment including NT-proBNP, LVH remained associated with increased hazard of 1 year mortality in women, but not in men [P-interaction = 0.033; women: adjusted hazard ratio (LVH vs. no LVH): 1.42 (1.04-1.94), P = 0.029]. CONCLUSION:Electrocardiographic-LVH identifies an important subset of ACS patients with a higher risk of long-term mortality, particularly among women. These novel findings highlight opportunities to improve treatment and outcome among similar ACS patients.
Association of electrocardiographic morphology of exercise-induced ventricular arrhythmia with mortality.
Eckart Robert E,Field Michael E,Hruczkowski Tomasz W,Forman Daniel E,Dorbala Sharmila,Di Carli Marcelo F,Albert Christine E,Maisel William H,Epstein Laurence M,Stevenson William G
Annals of internal medicine
BACKGROUND:The prognostic importance of exercise-induced ventricular arrhythmia (EIVA) may be confounded by the presence of lower-risk idiopathic right ventricular outflow tract arrhythmias with left bundle-branch block (LBBB) morphology. OBJECTIVE:To determine whether right bundle-branch block (RBBB)-morphology EIVA was associated with increased mortality. DESIGN:Retrospective cohort. SETTING:Academic medical center. PATIENTS:585 unique patients with EIVA and 2340 patients without EIVA, matched by age, sex, and risk factor, who were referred for exercise testing in an academic medical center. MEASUREMENTS:Deaths and ischemia and infarction found on perfusion scan. RESULTS:During a mean follow-up of 24 months (SD, 13), 31 deaths occurred in the EIVA group compared with 43 deaths in the group without EIVA (5.3% vs. 1.8%; P < 0.001). Worse survival in patients with RBBB-morphology or multiple-morphology EIVA (6.9%) than in patients without EIVA caused this difference. Patients with LBBB-morphology EIVAs had a mortality rate (2.5%) similar to that of patients without EIVA (P = 0.93, log-rank test). Among patients without known atherosclerotic coronary artery disease, any RBBB-morphology EIVA was associated with death (hazard ratio, 2.73 [95% CI, 1.78 to 4.13]; P < 0.001), but LBBB-morphology EIVA was not (hazard ratio, 0.82 [CI, 0.18 to 2.04]; P = 0.72). LIMITATIONS:Not all LBBB-morphology EIVA can be dismissed, and not all RBBB-morphology EIVA is high risk. Further evaluation of patients for structural heart disease was clinically driven, not protocol-driven. CONCLUSION:Right bundle-branch block- or multiple-morphology EIVA is associated with increased mortality. Inclusion of patients with isolated LBBB-morphology EIVA, which often is idiopathic, may contribute to differences in the prognostic importance of EIVA in previous studies.
Electrocardiographic left ventricular hypertrophy with strain pattern: prevalence, mechanisms and prognostic implications.
Ogah O S,Oladapo O O,Adebiyi A A,Adebayo A K,Aje A,Ojji D B,Salako B L,Falase A O
Cardiovascular journal of Africa
BACKGROUND:Electrocardiographic left ventricular hypertrophy with strain pattern has been documented as a marker for left ventricular hypertrophy. Its presence on the ECG of hypertensive patients is associated with a poor prognosis. This review was undertaken to report the prevalence, mechanism and prognostic implications of this ECG abnormality. MATERIALS AND METHODS:We conducted a comprehensive search of electronic databases to identify studies relating to the title of this review. The search criteria were related to the title. Two of the reviewers independently screened the searches. RESULTS:Results were described qualitatively. The data were not pooled because there were no randomised studies on the topic. The prevalence of ECG strain pattern ranged from 2.1 to 36%. The highest prevalence was reported before the era of good antihypertensive therapy. The sensitivity as a measure of left ventricular hypertrophy ranged from 3.8 to 50%, while the specificity was in the range of 89.8 to 100%. Strain pattern was associated with adverse cardiovascular risk factors as well as increased all-cause and CV morbidity and mortality. ST-segment depression and T-wave inversion on the ECG was recognised as the strongest marker of morbidity and mortality when ECG-LVH criteria were utilised for risk stratification in hypertensive subjects. CONCLUSION:Electrocardiographic strain pattern identifies cardiac patients at higher risk of cardiovascular-related as well as all-cause morbidity and mortality.
Idiopathic dilated cardiomyopathy: prognostic significance of electrocardiographic and electrophysiologic findings in the nineties.
Morgera Tullio,Di Lenarda Andrea,Sabbadini Gastone,Rakar Serena,Carniel Elisa,Driussi Mauro,Sinagra Gianfranco
Italian heart journal : official journal of the Italian Federation of Cardiology
BACKGROUND:With the exception of a few cases such as aborted sudden cardiac death, sustained ventricular tachycardia, and syncope of unexplained origin, there is no consensus on the clinical findings identifying patients with idiopathic dilated cardiomyopathy with an increased risk of sudden cardiac death or malignant ventricular arrhythmias. METHODS:To verify whether electrocardiographic and arrhythmologic features could be useful for prognostic stratification, 78 consecutive patients with an invasive diagnosis of idiopathic dilated cardiomyopathy, but without symptomatic ventricular arrhythmias, were enrolled in a prospective study. Signal-averaged ECG, 24 to 48 hour ECG monitoring and electrophysiologic study were performed at the time of diagnosis to identify arrhythmogenic predictors of outcome. Transplant-free and arrhythmic event-free survival was evaluated on the basis of initial parameters. RESULTS:During a mean follow-up of 85 months, 9 patients died (6 of sudden cardiac death and 3 of congestive heart failure), 10 patients underwent cardiac transplantation for refractory heart failure, and 3 presented with sustained ventricular tachycardia. The independent predictors for death and cardiac transplantation were an HV interval > 55 ms and the combination of frequent repetitive ventricular ectopics with a poor left ventricular function. A strong index of arrhythmic events proved to be the association of a prolonged HV interval with a wide (> 110 ms) QRS complex (odds ratio 4.53, 95% confidence interval 1.57-13.04, p < 0.005). CONCLUSIONS:An accurate measurement of the HV interval and QRS duration at baseline evaluation may add prognostic information in patients with idiopathic dilated cardiomyopathy. In our experience, abnormal values of both parameters identified a group of patients with a very high risk of late occurring arrhythmic events.
Meta-analysis of ventricular premature complexes and their relation to cardiac mortality in general populations.
Ataklte Feven,Erqou Sebhat,Laukkanen Jari,Kaptoge Stephen
The American journal of cardiology
Although previous studies have shown that frequent ventricular premature complexes (VPCs) in patients with established heart disease are associated with increased risk of cardiac mortality, the significance of VPCs in general populations is unclear. The aim of this study was to assess the association between VPCs and risk of sudden cardiac death or total cardiac death in general populations by conducting a meta-analysis of published research. The electronic databases MEDLINE and Embase were searched for relevant studies. Data were abstracted using standardized forms. Study-specific relative risk estimates were pooled using a random-effects meta-analysis model. Eleven studies comprising a total of 106,195 participants sampled from general populations were included. Studies generally defined frequent VPCs as occurring ≥1 time during a standard electrocardiographic recording or ≥30 times over a 1-hour recording. The prevalence of frequent VPCs in the studies ranged from 1.2% to 10.7%. The overall adjusted relative risk for sudden cardiac death comparing participants with frequent VPCs versus those without frequent VPCs was 2.64 (95% confidence interval 1.93 to 3.63). The corresponding value for total cardiac death was 2.07 (95% confidence interval 1.71 to 2.50). Although most studies made attempts to exclude high-risk subjects, such as those with histories of cardiovascular disease, they did not test participants for underlying structural heart disease. In conclusion, findings from observational studies in general populations indicate that frequent VPCs are associated with a substantial increase in the risk for sudden cardiac death and total cardiac death. Further study is needed to determine the role of confounding and underlying structural heart disease in the observed association and its utility in cardiovascular risk prediction.
Electrocardiographic and cardiac magnetic resonance imaging parameters as predictors of a worse outcome in patients with idiopathic dilated cardiomyopathy.
Hombach Vinzenz,Merkle Nico,Torzewski Jan,Kraus Johann M,Kunze Markus,Zimmermann Oliver,Kestler Hans A,Wöhrle Jochen
European heart journal
AIMS:Clinical parameters are weak predictors of outcome in patients with idiopathic dilated cardiomyopathy (IDC). We assessed the prognostic value of cardiac magnetic resonance (CMR) parameters in addition to conventional clinical and electrocardiographic characteristics. METHODS AND RESULTS:One hundred and forty-one IDC patients were studied. QRS and QTc intervals were measured in 12-lead surface electrocardiogram. Patients were followed for median 1339 days, including 483 patient-years. The primary endpoint-cardiac death or sudden death-occurred in 25 (18%) patients, including 16 patients with cardiac death, 3 patients with sudden cardiac death (SCD), and 6 patients with ICD shock. Late gadolinium enhancement (LGE) was detected in 36 patients (26%). Kaplan-Meier survival analysis displayed QRS >110 ms (P = 0.010), the presence of LGE (P = 0.037), and diabetes mellitus (P < 0.001) as significant parameters for a worse outcome. Multivariable analysis revealed cardiac index (P < 0.001), right ventricular end-diastolic volume index (RVEDVI) (P = 0.006) derived from CMR imaging, the presence of diabetes mellitus (P = 0.006), and QRS >110 ms (P = 0.045) as significant predictors for the primary endpoint. CONCLUSION:Cardiac index and RVEDVI derived from CMR imaging in addition to QRS duration >110 ms from conventional surface ECG and diabetes mellitus provide prognostic impact for cardiac death and SCD in patients with IDC.
High-risk electrocardiographic parameters are ubiquitous in patients with ischemic cardiomyopathy.
Carey Mary G,Al-Zaiti Salah S,Canty John M,Fallavollita James A
Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc
BACKGROUND:The electrocardiogram (ECG) can be used to predict cardiovascular risk; however, like all risk factors with imperfect specificity, studies in low risk populations have been plagued by poor predictive accuracy. Although predictive accuracy might be improved among cohorts with a higher likelihood of cardiovascular events, this would also affect the prevalence of abnormal parameters and their exclusions. METHOD:To determine the magnitude of these changes in a cohort with ischemic cardiomyopathy we analyzed 15 previously validated high-risk parameters from the resting and ambulatory ECG in subjects enrolled in the Prediction of Arrhythmic Events with Positron Emission Tomography (PAREPET) study (n = 198). RESULTS:Using the published exclusion criteria from the validation studies (i.e., atrial fibrillation, persistent pacing, prolonged QRS), only 4 high-risk ECG parameters (27%) could be evaluated in all subjects and only 42% of subjects could have all 15 ECG parameters assessed. Nevertheless, almost every subject (97%) had at least one abnormal parameter. On average, there were 3.4 ± 1.8 (range, 0-8) high-risk ECG parameters per subject among the 11.7 ± 4.5 (range, 4-15) parameters that could be assessed. CONCLUSIONS:Thus, 34% of all assessable parameters were abnormal. In conclusion, a significant proportion of ECG parameters cannot be assessed in patients with ischemic cardiomyopathy, but high-risk results are ubiquitous. The influence of these issues will be clarified when the results of the PAREPET study are available to actually determine the predictive value of these parameters on cause-specific mortality in a high-risk cohort.
Early repolarization: electrocardiographic phenotypes associated with favorable long-term outcome.
Tikkanen Jani T,Junttila M Juhani,Anttonen Olli,Aro Aapo L,Luttinen Samuli,Kerola Tuomas,Sager Solomon J,Rissanen Harri A,Myerburg Robert J,Reunanen Antti,Huikuri Heikki V
BACKGROUND:Early repolarization (ER) in inferior/lateral leads of standard ECGs increases the risk of arrhythmic death. We tested the hypothesis that variations in the ST-segment characteristics after the ER waveforms may have prognostic importance. METHODS AND RESULTS:ST segments after ER were classified as horizontal/descending or rapidly ascending/upsloping on the basis of observations from 2 independent samples of young healthy athletes from Finland (n=62) and the United States (n=503), where ascending type was the dominant and common form of ER. Early repolarization was present in 27/62 (44%) of the Finnish athletes and 151/503 (30%) of the US athletes, and all but 1 of the Finnish (96%) and 91/107 (85%) of US athletes had an ascending/upsloping ST variant after ER. Subsequently, ECGs from a general population of 10 864 middle-aged subjects were analyzed to assess the prognostic modulation of ER-associated risk by ST-segment variations. Subjects with ER ≥0.1 mV and horizontal/descending ST variant (n=412) had an increased hazard ratio of arrhythmic death (relative risk 1.43; 95% confidence interval 1.05 to 1.94). When modeled for higher amplitude ER (>0.2 mV) in inferior leads and horizontal/descending ST-segment variant, the hazard ratio of arrhythmic death increased to 3.14 (95% confidence interval 1.56 to 6.30). However, in subjects with ascending ST variant, the relative risk for arrhythmic death was not increased (0.89; 95% confidence interval 0.52 to 1.55). CONCLUSIONS:ST-segment morphology variants associated with ER separates subjects with and without an increased risk of arrhythmic death in middle-aged subjects. Rapidly ascending ST segments after the J-point, the dominant ST pattern in healthy athletes, seems to be a benign variant of ER.
Estimating Myocardial Infarction Size With a Simple Electrocardiographic Marker Score.
Lee Daniel C,Albert Christine M,Narula Dhiraj,Kadish Alan H,Panicker Gopi Krishna,Wu Edwin,Schaechter Andi,Pester Julie,Chatterjee Neal A,Cook Nancy R,Goldberger Jeffrey J
Journal of the American Heart Association
Background Myocardial infarction (MI) size is a key predictor of prognosis in post-MI patients. Cardiovascular magnetic resonance (CMR) is the gold standard test for MI quantification, but the ECG is less expensive and more widely available. We sought to quantify the relationship between ECG markers and cardiovascular magnetic resonance infarct size. Methods and Results Patients with prior MI enrolled in the DETERMINE (Defibrillators to Reduce Risk by Magnetic Resonance Imaging Evaluation) and PRE-DETERMINE Trial and Registry were included. ECG leads were analyzed for markers of MI: Q waves, fragmented QRS, and T wave inversion. DETERMINE Score=number of leads with [Q waves×2]+[fragmented QRS]+[T wave inversion]. Left ventricular ejection fraction (LVEF) and infarct size as a percentage of left ventricular mass (MI%) were quantified by cardiovascular magnetic resonance. The Modified Selvester Score estimates MI size from 37 ECG criteria. In 551 patients (aged 62.1±10.9 years, 79% men, and LVEF=40.3±11.0%), MI% increased as the number of ECG markers increased (<0.001). By univariable linear regression, the DETERMINE Score (range 0-26) estimated MI% (=0.18, <0.001) with an accuracy approaching that of LVEF (=0.22, <0.001) and higher than the Modified Selvester Score (=0.09, <0.001). By multivariable linear regression, addition of the DETERMINE Score improved estimation of MI% over LVEF alone (<0.001) and over Modified Selvester Score alone (<0.001). Conclusions In patients with prior MI, a simple ECG score estimates infarct size and improves infarct size estimation over LVEF alone. Because infarct size is a powerful prognostic indicator, the DETERMINE Score holds promise as a simple and inexpensive risk assessment tool.
J-Wave Syndromes: Electrocardiographic and Clinical Aspects.
Priori Silvia G,Napolitano Carlo
Cardiac electrophysiology clinics
Early repolarization, Brugada syndrome, and pathologic J waves have been described for decades, but only recently experimental and clinical data have allowed reconciliation of Brugada and Early Repolarization under the common definition of J-wave syndromes. The concept was derived from studies showing, in both conditions, the presence of transmural dispersion of repolarization, localized conduction abnormalities, and abnormal transition between QRS and ST segment on electrocardiogram. Although several clinical studies have addressed the clinical presentation and epidemiology of J-wave syndromes, relevant knowledge gaps exist. Incomplete pathophysiologic understanding and uncertain electrocardiographic definitions limit effective risk stratification. Here, we review the current knowledge and recommendations for diagnosis and clinical management of these arrhythmogenic disorders.
Electrocardiographic parameters and fatal arrhythmic events in patients with Brugada syndrome: combination of depolarization and repolarization abnormalities.
Tokioka Koji,Kusano Kengo F,Morita Hiroshi,Miura Daiji,Nishii Nobuhiro,Nagase Satoshi,Nakamura Kazufumi,Kohno Kunihisa,Ito Hiroshi,Ohe Tohru
Journal of the American College of Cardiology
OBJECTIVES:This study aimed to determine the usefulness of the combination of several electrocardiographic markers on risk assessment of ventricular fibrillation (VF) in patients with Brugada syndrome (BrS). BACKGROUND:Detection of high-/low-risk BrS patients using a noninvasive method is an important issue in the clinical setting. Several electrocardiographic markers related to depolarization and repolarization abnormalities have been reported, but the relationship and usefulness of these parameters in VF events are unclear. METHODS:Baseline characteristics of 246 consecutive patients (236 men; mean age, 47.6 ± 13.6 years) with a Brugada-type electrocardiogram, including 13 patients with a history of VF and 40 patients with a history of syncope episodes, were retrospectively analyzed. During the mean follow-up period of 45.1 months, VF in 23 patients and sudden cardiac death (SCD) in 1 patient were observed. Clinical/genetic and electrocardiographic parameters were compared with VF/SCD events. RESULTS:On univariate analysis, a history of VF and syncope episodes, paroxysmal atrial fibrillation, spontaneous type 1 pattern in the precordial leads, and electrocardiographic markers of depolarization abnormalities (QRS duration ≥120 ms, and fragmented QRS [f-QRS]) and those of repolarization abnormalities (inferolateral early repolarization [ER] pattern and QT prolongation) were associated with later cardiac events. On multivariable analysis, a history of VF and syncope episodes, inferolateral ER pattern, and f-QRS were independent predictors of documented VF and SCD (odds ratios: 19.61, 28.57, 2.87, and 5.21, respectively; p < 0.05). Kaplan-Meier curves showed that the presence/absence of inferolateral ER and f-QRS predicted a worse/better prognosis (log-rank test, p < 0.01). CONCLUSIONS:The combination of depolarization and repolarization abnormalities in BrS is associated with later VF events. The combination of these abnormalities is useful for detecting high- and low-risk BrS patients.
Usefulness of electrocardiographic parameters for risk prediction in arrhythmogenic right ventricular dysplasia.
Saguner Ardan M,Ganahl Sabrina,Baldinger Samuel H,Kraus Andrea,Medeiros-Domingo Argelia,Nordbeck Sebastian,Saguner Arhan R,Mueller-Burri Andreas S,Haegeli Laurent M,Wolber Thomas,Steffel Jan,Krasniqi Nazmi,Delacrétaz Etienne,Lüscher Thomas F,Held Leonhard,Brunckhorst Corinna B,Duru Firat
The American journal of cardiology
The value of electrocardiographic findings predicting adverse outcome in patients with arrhythmogenic right ventricular dysplasia (ARVD) is not well known. We hypothesized that ventricular depolarization and repolarization abnormalities on the 12-lead surface electrocardiogram (ECG) predict adverse outcome in patients with ARVD. ECGs of 111 patients screened for the 2010 ARVD Task Force Criteria from 3 Swiss tertiary care centers were digitized and analyzed with a digital caliper by 2 independent observers blinded to the outcome. ECGs were compared in 2 patient groups: (1) patients with major adverse cardiovascular events (MACE: a composite of cardiac death, heart transplantation, survived sudden cardiac death, ventricular fibrillation, sustained ventricular tachycardia, or arrhythmic syncope) and (2) all remaining patients. A total of 51 patients (46%) experienced MACE during a follow-up period with median of 4.6 years (interquartile range 1.8 to 10.0). Kaplan-Meier analysis revealed reduced times to MACE for patients with repolarization abnormalities according to Task Force Criteria (p = 0.009), a precordial QRS amplitude ratio (∑QRS mV V1 to V3/∑QRS mV V1 to V6) of ≤ 0.48 (p = 0.019), and QRS fragmentation (p = 0.045). In multivariable Cox regression, a precordial QRS amplitude ratio of ≤ 0.48 (hazard ratio [HR] 2.92, 95% confidence interval [CI] 1.39 to 6.15, p = 0.005), inferior leads T-wave inversions (HR 2.44, 95% CI 1.15 to 5.18, p = 0.020), and QRS fragmentation (HR 2.65, 95% CI 1.1 to 6.34, p = 0.029) remained as independent predictors of MACE. In conclusion, in this multicenter, observational, long-term study, electrocardiographic findings were useful for risk stratification in patients with ARVD, with repolarization criteria, inferior leads TWI, a precordial QRS amplitude ratio of ≤ 0.48, and QRS fragmentation constituting valuable variables to predict adverse outcome.
Dispersion of repolarization and beta-thalassemia major: the prognostic role of QT and JT dispersion for identifying the high-risk patients for sudden death.
Russo Vincenzo,Rago Anna,Pannone Bruno,Papa Andrea A,Di Meo Federica,Mayer Maria C,Spasiano Anna,Russo Maria G,Golino Paolo,Calabrò Raffaele,Nigro Gerardo
European journal of haematology
BACKGROUND:Patients with beta-thalassemia major (β-TM) are at increased risk for sudden cardiac death (SCD). Heterogeneity of ventricular repolarization is considered to provide an electrophysiological substrate for malignant arrhythmias. QT dispersion (QTc-D) and JT dispersion (JTc-D) are electrocardiographic parameters indicative of heterogeneity of ventricular repolarization. The aim of our study was to evaluate the heterogeneity of ventricular repolarization in patients with beta-thalassemia and to test the hypothesis that an abnormal QTc and JTc dispersion may predict SCD in this population. MATERIALS AND METHODS: The study involved 51 patients with β-TM (age 33.9±8.4; 33M) and 51 healthy subjects used as controls, matched for age, gender, and body mass index (BMI). Among the β-TM group, 14 patients with β-TM (age 27±6.64; 11M) died from SCD during follow-up. For each patient, QTD and JTD intervals were calculated. RESULTS:Compared to the healthy control group, β-TM group presented increased values of the QTc-D (65.36±33.95 vs. 37, 62±17.65; P<0.003) and JTc-D (74.64±33.27 vs. 40.32±12.45; P<0.001). In the β-TM sudden death group, QTc-D and JTc-D were significantly greater than in survived β-TM group (92.70±44.24 vs. 56.14±23.80, P=0.0001; 101.54±47.93 vs. 64.47±17.90, P=0.0001). A cutoff value of 70ms for QTc-D had a sensitivity and specificity of 77% in identifying patients at risk for SCD. A cutoff value of 100ms for JTc-D had a sensitivity of 65% and a specificity of 94% in identifying this category of patients. CONCLUSION:β-TM is associated with significant changes in heterogeneity of ventricular repolarization. QTc and JTc dispersion are useful markers of risk of SCD in patients with β-TM.
Determinants of sudden cardiac death in individuals with the electrocardiographic pattern of Brugada syndrome and no previous cardiac arrest.
Brugada Josep,Brugada Ramon,Brugada Pedro
BACKGROUND:Patients with Brugada syndrome who were resuscitated from an episode of ventricular fibrillation are at high risk for recurrent sudden death. There is general agreement about the therapeutic strategy for these patients. Conversely, the prognosis and approach in patients with a diagnostic ECG but without a previous history of sudden cardiac death is controversial. We analyzed a large cohort of patients with Brugada syndrome without previous cardiac arrest to understand the determinants of prognosis. METHODS AND RESULTS:A total of 547 patients with an ECG diagnostic of Brugada syndrome and no previous cardiac arrest were studied. The mean age was 41+/-15 years, and 408 were male. The diagnostic ECG was present spontaneously in 391 patients. In the remaining 156 individuals, the abnormal ECG was noted only after the administration of an antiarrhythmic drug. One hundred twenty-four patients had suffered from at least 1 episode of syncope. During programmed ventricular stimulation, a sustained ventricular arrhythmia was induced in 163 of 408 patients. During a mean follow-up of 24+/-32 months, 45 patients (8%) suffered sudden death or documented ventricular fibrillation. Multivariate analysis identified the inducibility of a sustained ventricular arrhythmia (P<0.0001) and a history of syncope (P<0.01) as predictors of events. Logistic regression analysis showed that a patient with a spontaneously abnormal ECG, a previous history of syncope, and inducible sustained ventricular arrhythmias had a probability of 27.2% of suffering an event during follow-up. CONCLUSIONS:Individuals with Brugada syndrome and no previous cardiac arrest have a high risk of sudden death. Inducibility of ventricular arrhythmias and a previous history of syncope are markers of a poor prognosis.
Average T-wave alternans activity in ambulatory ECG records predicts sudden cardiac death in patients with chronic heart failure.
Monasterio Violeta,Laguna Pablo,Cygankiewicz Iwona,Vázquez Rafael,Bayés-Genís Antoni,de Luna Antoni Bayés,Martínez Juan Pablo
BACKGROUND:T-wave alternans (TWA) is a well-documented noninvasive electrocardiographic (ECG) method useful for identifying patients at risk for sudden cardiac death (SCD). OBJECTIVE:The purpose of this study was to evaluate whether the long-term average TWA activity on Holter monitoring provides prognostic information in patients with chronic heart failure. METHODS:Twenty-four-hour Holter ECGs from 650 ambulatory patients with mild-to-moderate chronic heart failure were analyzed in the study. Average TWA activity was measured by using a fully automated multilead technique, and 2 indices were proposed to quantify TWA: an index quantifying the average TWA activity in the whole recording (IAA), which was used to define a positive/negative TWA test, and an index quantifying the average TWA activity at heart rates between 80 and 90 beats/min (IAA(90)). RESULTS:Patients were divided into TWA positive (TWA+) and TWA negative (TWA-) groups by setting a cut point of 3.7 μV for IAA, corresponding to the 75th percentile of the distribution of IAA in the population. After a median follow-up of 48 months, the survival rate was significantly higher in the TWA- group for cardiac death and SCD (p = .017 and p = .001, respectively). Multivariate Cox proportional hazards analysis revealed that both TWA+ and IAA(90) were associated with SCD with hazard rates of 2.29 (p = .004) and 1.07 per μV (p = .046), respectively. CONCLUSION:The average TWA activity measured automatically from Holter ECGs predicted SCD in patients with mild-to-moderate chronic heart failure.
Sleep-disordered breathing and electrocardiographic QRS-T angle: The MESA study.
Kwon Younghoon,Misialek Jeffrey R,Duprez Daniel,Jacobs David R,Alonso Alvaro,Heckbert Susan R,Zhao Ying Y,Redline Susan,Soliman Elsayed Z
Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc
INTRODUCTION:Sleep-disordered breathing (SDB) has been linked to sudden cardiac death (SCD) but the mechanism is unclear. Abnormal QRS-T angle, a novel electrocardiographic (ECG) marker of ventricular repolarization, has been linked to adverse cardiovascular outcomes including SCD. We hypothesized that individuals with SDB have more pronounced abnormality in QRS-T angle. METHODS:We performed a cross-sectional analysis from the Multi-Ethnic Study of Atherosclerosis (MESA) Exam Sleep ancillary study. We calculated the odds ratio (OR) of abnormal frontal and spatial QRS-T angle (defined as >sex-specific 95th percentile thresholds) related to the apnea-hypopnea index (AHI) using logistic regression, adjusting for demographics, body habitus, cardiovascular risks, and prevalent cardiovascular disease. Linear associations between AHI and frontal and spatial QRS-T angle, separately, were also examined using multiple regression models. RESULTS:A total of 1,804 participants (mean age 67.9 (±9.0) years, 55.3% women and 64.1% non-whites) were included in the study. Sleep-disordered breathing was common among participants (median AHI 8.6 events/hr IQR [3.2-19.5/hr]). Higher AHI was associated with the odds of abnormal frontal (≥81° in men and ≥79° in women) and spatial QRS-T angle (≥129.7° in men and ≥115.9° in women; OR [95%CI]: 1.25 [1.02-1.51], p = 0.03; 1.23 [1.01-1.50], p = 0.04 respectively per 1 SD [16.8 events/hr] increase in AHI). Similarly, linear associations were observed (frontal QRS-T angle: beta coefficient: 2.30° [0.92, 3.66], p = 0.001; spatial QRS-T angle: beta coefficient: 2.16° [0.67, 3.64], p = 0.005). CONCLUSION:In a racially/ethnically diverse community cohort, severity of SDB is associated with abnormal ventricular repolarization as measured by QRS-T angle.
Asymptomatic ST-segment depression during exercise testing and the risk of sudden cardiac death in middle-aged men: a population-based follow-up study.
Laukkanen Jari A,Mäkikallio Timo H,Rauramaa Rainer,Kurl Sudhir
European heart journal
AIMS:Silent electrocardiographic ST change predicts future coronary events in patients with coronary heart disease (CHD), but the prognostic significance of asymptomatic ST-segment depression with respect to sudden cardiac death in subjects without apparent CHD is not well known. METHODS AND RESULTS:We investigated the association between silent ST-segment depression during and after maximal symptom-limited exercise test and the risk of sudden cardiac death in a population-based sample of 1769 men without evident CHD. A total of 72 sudden cardiac death occurred during the median follow-up of 18 years. The risk of sudden cardiac death was increased among men with asymptomatic ST-segment depression during exercise [hazard ratio (HR) 2.1, 95% confidence interval (CI) 1.2-3.9] as well as among those with asymptomatic ST-segment depression during recovery period (HR 3.2, 95% CI 1.7-6.0). Asymptomatic ST-depression during exercise testing was a stronger predictor for the risk of sudden cardiac death especially among smokers as well as in hypercholesterolaemic and hypertensive men than in men without these risk factors. CONCLUSION:Asymptomatic ST-segment depression was a very strong predictor of sudden cardiac death in men with any conventional risk factor but no previously diagnosed CHD, emphasizing the value of exercise testing to identify asymptomatic high-risk men who could benefit from preventive measures.
Sudden cardiac death in non-ischemic dilated cardiomyopathy: a critical appraisal of existing and potential risk stratification tools.
Koutalas Emmanuel,Kanoupakis Emmanuel,Vardas Panos
International journal of cardiology
Non ischemic dilated cardiomyopathy poses a significant risk of malignant ventricular arrhythmias and subsequent sudden cardiac death. The pathologic and electrophysiological substrate implicated to arrhythmogenesis has been quite adequately defined over the last decades and multiple forms of myocardial fibrosis - diffuse, patchy or gross scarring - are being studied regarding their arrhythmogenic potential. Moreover, the recent demonstration and continuous expansion of knowledge regarding causative genes in dilated cardiomyopathy open a new chapter in the field of diagnosis and prognosis of these patients. Numerous noninvasive and invasive methods have been used to stratify patients according to sudden cardiac death level of risk. Severely reduced left ventricular systolic myocardial function, expressed mostly by left ventricular ejection function, NYHA functional class, syncope and invasive electrophysiological study with programmed electrical stimulation have been incorporated into international guidelines, though leaving significant proportions of primary prevention patients out of stratification schemes. Electrocardiographic markers, signal-averaged ECG, heart rate variability, heart rate turbulence, baroreflex sensitivity, heart rate recovery and T-wave alternans have given conflicting results in non ischemic dilated cardiomyopathy. During the last decade, cardiac magnetic resonance, especially with gadolinium enhancement, has made a step forward in defining the fibrotic substrate of such patients. Prospective studies have given promising results, demonstrating correlation between late gadolinium enhancement and ventricular arrhythmogenesis. Identification of patients with genetically caused dilated cardiomyopathy prone to sudden cardiac death and large prospective trials investigating cardiac magnetic resonance and its prognostic potential may be able to establish a new era in stratification schemes.
Usefulness of Electrocardiographic Patterns at Presentation to Predict Long-term Risk of Cardiac Death in Patients With Hypertrophic Cardiomyopathy.
Biagini Elena,Pazzi Chiara,Olivotto Iacopo,Musumeci Beatrice,Limongelli Giuseppe,Boriani Giuseppe,Pacileo Giuseppe,Mastromarino Vittoria,Bacchi Reggiani Maria Letizia,Lorenzini Massimiliano,Lai Francesco,Berardini Alessandra,Mingardi Francesca,Rosmini Stefania,Resciniti Elvira,Borghi Claudia,Autore Camillo,Cecchi Franco,Rapezzi Claudio
The American journal of cardiology
The objective of this study was to investigate the prognostic significance of 12-lead electrocardiogram (ECG) patterns in a large multicenter cohort of patients with hypertrophic cardiomyopathy; 1,004 consecutive patients with hypertrophic cardiomyopathy and a recorded standard ECG (64% men, mean age 50 ± 16 years) were evaluated at 4 Italian centers. The study end points were sudden cardiac death (SCD) or surrogates, including appropriate implanted cardiac defibrillator discharge and resuscitated cardiac arrest and major cardiovascular events (including SCD or surrogates and death due to heart failure, cardioembolic stroke, or heart transplantation). Prevalence of baseline electrocardiographic characteristics was: normal ECG 4%, ST-segment depression 56%, pseudonecrosis waves 33%, "pseudo-ST-segment elevation myocardial infarction (STEMI)" pattern 17%, QRS duration ≥120 ms 17%, giant inverted T waves 6%, and low QRS voltages 3%. During a mean follow-up of 7.4 ± 6.8 years, 77 patients experienced SCD or surrogates and 154 patients experienced major cardiovascular events. Independent predictors of SCD or surrogates were unexplained syncope (hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.4 to 4.5, p = 0.003), left ventricular ejection fraction <50% (HR 3.5, 95% CI 1.9 to 6.7, p = 0.0001), nonsustained ventricular tachycardia (HR 1.7, 95% CI 1.1 to 2.6, p = 0.027), pseudo-STEMI pattern (HR 2.3, 95% CI 1.4 to 3.8, p = 0.001), QRS duration ≥120 ms (HR 1.8, 95% CI 1.1 to 3.0, p = 0.033), and low QRS voltages (HR 2.3, 95% CI 1.01 to 5.1, p = 0.048). Independent predictors of major cardiovascular events were age (HR 1.02, 95% CI 1.01 to 1.03, p = 0.0001), LV ejection fraction <50% (HR 3.73, 95% CI 2.39 to 5.83, p = 0.0001), pseudo-STEMI pattern (HR 1.66, 95% CI 1.13 to 2.45, p = 0.010), QRS duration ≥120 ms (HR 1.69, 95% CI 1.16 to 2.47, p = 0.007), and prolonged QTc interval (HR 1.68, 95% CI 1.21 to 2.34, p = 0.002). In conclusion, a detailed qualitative and quantitative electrocardiographic analyses provide independent predictors of prognosis that could be integrated with the available score systems to improve the power of the current model.
Prediction of sudden cardiac death with automated high-throughput analysis of heterogeneity in standard resting 12-lead electrocardiograms.
Kenttä Tuomas V,Nearing Bruce D,Porthan Kimmo,Tikkanen Jani T,Viitasalo Matti,Nieminen Markku S,Salomaa Veikko,Oikarinen Lasse,Jula Antti,Kontula Kimmo,Newton-Cheh Chris,Huikuri Heikki V,Verrier Richard L
BACKGROUND:Heterogeneity of depolarization and repolarization underlies the development of lethal arrhythmias. OBJECTIVE:We investigated whether quantification of spatial depolarization and repolarization heterogeneity identifies individuals at risk for sudden cardiac death (SCD). METHODS:Spatial R-, J-, and T-wave heterogeneity (RWH, JWH, and TWH, respectively) was analyzed using automated second central moment analysis of standard digital 12-lead electrocardiograms in 5618 adults (2588, 46% men; mean ± SEM age 50.9 ± 0.2 years), who took part in the epidemiological Health 2000 Survey as representative of the entire Finnish adult population. RESULTS:During the follow-up period of 7.7 ± 0.2 years, a total of 72 SCDs occurred (1.3%), with an average yearly incidence rate of 0.17% per year. Increased RWH, JWH, and TWH in left precordial leads (V4-V6) were univariately associated with SCD (P < .001 for each). When adjusted with standard clinical risk markers, JWH and TWH remained independent predictors of SCD. Increased TWH (≥102 µV) was associated with a 1.7-fold adjusted relative risk for SCD (95% confidence interval [CI] 1.0-2.9; P = .048) and increased JWH (≥123 µV) with a 2.0-fold adjusted relative risk for SCD (95% CI 1.2-3.3; P = .006). When both TWH and JWH were above the threshold, the adjusted relative risk for SCD was 2.9-fold (95% CI 1.5-5.7; P = .002). When RWH (≥470 µV), JWH, and TWH were all above the threshold, the adjusted relative risk for SCD was 3.2-fold (95% CI 1.4-7.1; P = .009). CONCLUSION:Second central moment analysis of standard resting 12-lead electrocardiographic morphology provides an ultrarapid means for the automated measurement of spatial RWH, JWH, and TWH, enabling analysis of high subject volumes and screening for SCD risk in the general population.
Traditional and novel electrocardiographic conduction and repolarization markers of sudden cardiac death.
Tse Gary,Yan Bryan P
Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology
Sudden cardiac death, frequently due to ventricular arrhythmias, is a significant problem globally. Most affected individuals do not arrive at hospital in time for medical treatment. Therefore, there is an urgent need to identify the most-at-risk patients for insertion of prophylactic implantable cardioverter defibrillators. Clinical risk markers derived from electrocardiography are important for this purpose. They can be based on repolarization, including corrected QT (QTc) interval, QT dispersion (QTD), interval from the peak to the end of the T-wave (Tpeak - Tend), (Tpeak - Tend)/QT, T-wave alternans (TWA), and microvolt TWA. Abnormal repolarization properties can increase the risk of triggered activity and re-entrant arrhythmias. Other risk markers are based solely on conduction, such as QRS duration (QRSd), which is a surrogate marker of conduction velocity (CV) and QRS dispersion (QRSD) reflecting CV dispersion. Conduction abnormalities in the form of reduced CV, unidirectional block, together with a functional or a structural obstacle, are conditions required for circus-type or spiral wave re-entry. Conduction and repolarization can be represented by a single parameter, excitation wavelength (λ = CV × effective refractory period). λ is an important determinant of arrhythmogenesis in different settings. Novel conduction-repolarization markers incorporating λ include Lu et al.' index of cardiac electrophysiological balance (iCEB: QT/QRSd), [QRSD× (Tpeak - Tend)/QRSd] and [QRSD × (Tpeak - Tend)/(QRSd × QT)] recently proposed by Tse and Yan. The aim of this review is to provide up to date information on traditional and novel markers and discuss their utility and downfalls for risk stratification.
Sudden death prediction by C-reactive protein, electrocardiographic findings, and myocardial fatty acid uptake in haemodialysis patients: analysis of a multicentre prospective cohort sub-study.
Nakata Tomoaki,Hashimoto Akiyoshi,Moroi Masao,Tamaki Nagara,Nishimura Tsunehiko,Hasebe Naoyuki,Kikuchi Kenjiro,Nakatani Eiji
European heart journal cardiovascular Imaging
AIMS:The purpose of this study was to identify determinants of sudden death among clinical information in combination with cardiac fatty acid metabolism for better risk-stratification of haemodialysis patients. METHODS AND RESULTS:Clinical and imaging data from 677 haemodialysis patients enrolled in the beta-methyl-p-iodophenyl pentadecanoic acid (BMIPP) SPECT Analysis for Decreasing Cardiac Events in Hemodialysis Patients (B-SAFE) study were analysed in this study. During a 3-year prospective follow-up interval, 20 sudden deaths were observed. Compared with non-sudden death patients, sudden death patients more frequently had an increased C-reactive protein level (>2.38 mg/dL), electrocardiographic abnormal Q-wave and increased BMIPP abnormality score (>16). Patients with BMIPP score >16 and at least one of the other predictors had significantly lower event-free rates than did those without the BMIPP abnormality (P < 0.001). Univariate and multivariate Cox regression analyses revealed increased C-reactive protein level, abnormal Q-wave, and greater BMIPP abnormality as significant sudden death predictors with hazards ratios of 6.83 (95% CI: 1.76-26.47, P = 0.005), 17.73 (95% CI: 4.91-63.98, P < 0.001), and 10.58 (95% CI; 3.84-29.14, P < 0.001), respectively. The addition of BMIPP score >16 to the other clinical predictors increased the hazard ratio and receiver-operating characteristic analysis-area under the curve up to 145.22 (95% CI; 0.34-695.09) and to 0.677-0.690, respectively. CONCLUSIONS:Increased C-reactive protein, electrocardiographic Q-wave, and impaired myocardial fatty acid metabolism are independently and synergistically related to sudden death risk in haemodialysis patients. The non-invasive strategy presented here might contribute to the identification of haemodialysis patients who can most benefit from a prophylactic treatment against sudden death.
Electrocardiographic predictors of coronary heart disease and sudden cardiac deaths in men and women free from cardiovascular disease in the Atherosclerosis Risk in Communities study.
Rautaharju Pentti M,Zhang Zhu-Ming,Warren James,Gregg Richard E,Haisty Wesley K,Kucharska-Newton Anna M,Rosamond Wayne D,Soliman Elsayed Z
Journal of the American Heart Association
BACKGROUND:We evaluated predictors of coronary heart disease (CHD) death and sudden cardiac death (SCD) in the Atherosclerosis Risk in Communities (ARIC) study. METHODS AND RESULTS:The study population included 13 621 men and women 45 to 65 years of age free from manifest cardiovascular disease at entry. Hazard ratios from Cox regression with 95% confidence intervals were computed for 18 dichotomized repolarization-related ECG variables. The average follow-up was 14 years. Independent predictors of CHD death in men were TaVR- and rate-adjusted QTend (QTea), with a 2-fold increased risk for both, and spatial angles between mean QRS and T vectors and between Tpeak (Tp) and normal R reference vectors [θ(Rm|Tm) and θ(Tp|Tref), respectively], with a >1.5-fold increased risk for both. In women, independent predictors of the risk of CHD death were θ(Rm|Tm), with a 2-fold increased risk for θ(Rm|Tm), and θ(Tp|Tref), with a 1.7-fold increased risk. Independent predictors of SCD in men were θ(Tp|Tref) and QTea, with a 2-fold increased risk, and θ(Tinit|Tterm), with a 1.6-fold increased risk. In women, θ(Tinit|Tterm) was an independent predictor of SCD, with a >3-fold increased risk, and θ(Rm|Tm) and TV1 were >2-fold for both. CONCLUSIONS:θ(Rm|Tm) and θ(Tp|Tref), reflecting different aspects of ventricular repolarization, were independent predictors of CHD death and SCD, and TaVR and TV1 were also independent predictors. The risk levels for independent predictors for both CHD death and SCD were stronger in women than in men, and QTea was a significant predictor in men but not in women.
Acute inferior myocardial infarction with right ventricular involvement and several clinical-electrocardiographic markers of poor prognosis.
García-Niebla Javier,Pérez-Riera Andrés Ricardo,Barbosa-Barros Raimundo,Díaz-Muñoz Jorge,Daminello-Raimundo Rodrigo,de Abreu Luiz Carlos,Nikus Kjell
Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc
Right ventricular involvement in inferior myocardial infarction is a marker of poor prognosis. We present a case of a 62-year-old man with very recent onset of acute chest pain and cardiac shock with the triad of elevated jugular venous pressure, distension of the jugular veins on inspiration, and clear lung fields. In addition, the admission electrocardiogram showed a slurring J wave or lambda-like wave and conspicuous ST segment depression in several leads, predominantly in the lateral precordial (V4-V6), all clinical-electrocardiographic features of ominous prognosis.
Wide QRS-T Angle on the 12-Lead ECG as a Predictor of Sudden Death Beyond the LV Ejection Fraction.
Chua Kelvin C M,Teodorescu Carmen,Reinier Kyndaron,Uy-Evanado Audrey,Aro Aapo L,Nair Sandeep G,Chugh Harpriya,Jui Jonathan,Chugh Sumeet S
Journal of cardiovascular electrophysiology
INTRODUCTION:Improvements in risk stratification for sudden cardiac arrest (SCA) will require discovery of markers that extend beyond the LV ejection fraction (LVEF). The frontal QRS-T angle has been shown to predict risk of SCA but the value of this marker independent of the LVEF has not been investigated. METHODS AND RESULTS:Cases of adult SCA with an archived electrocardiogram (12-lead ECG) available before the event, with a computable frontal QRS-T angle, were identified from the Oregon Sudden Unexpected Death Study (Oregon SUDS) ongoing in the Portland, Oregon metro area. A total of 666 SCA cases (mean age 67.2 years; 95% CI, 52.3-82.1 years; 68.6% males) were compared to 863 controls (mean age 66.6 years, 55.2-78.0 years; 68.1% males; 75.0% had CAD) from the same geographical region. The mean frontal QRS-T angle was wider in cases (74(o) ; 95% CI, 17(o) -131(o) ) compared to controls (51(o) ; 95% CI, 5(o) -97(o;) P< 0.0001). A frontal QRS-T angle of more than 90(o) remained associated with increased risk of SCD after adjusting for age, gender, heart rate, prolonged intraventricular conduction, electrocardiographic left ventricular hypertrophy (ECG LVH), baseline comorbidities, and left ventricular ejection fraction (LVEF) (OR 2.2; 95% CI, 1.60-3.09; P< 0.0001). CONCLUSION:A wide QRS-T angle greater than 90(o) is associated with an increased risk of SCA independent of the left ventricular ejection fraction.
QT spatial dispersion and sudden cardiac death in hypertrophic cardiomyopathy: Time for reappraisal.
Magrì Damiano,Santolamazza Caterina,Limite Luca,Mastromarino Vittoria,Casenghi Matteo,Orlando Paola,Pagannone Erika,Musumeci Maria Beatrice,Maruotti Antonello,Ricotta Agnese,Oliviero Giada,Piccirillo Gianfranco,Volpe Massimo,Autore Camillo
Journal of cardiology
BACKGROUND:The 12-lead surface electrocardiographic (ECG) analysis is able to provide independent predictors of prognosis in several cardiovascular settings, including hypertrophic cardiomyopathy (HCM). The present single-center study investigated the possible ability of several ECG-derived variables in stratifying sudden cardiac death (SCD) risk and, possibly, in improving the accuracy of the 2014 European Society of Cardiology guidelines. METHODS:A total of 221 consecutive HCM outpatients were recruited and prospectively followed. All of them underwent a full clinical and instrumental examination, including a 12-lead surface ECG to calculate the dispersion for the following intervals: QRS, Q-Tend (QT), Q-Tpeak (QTp), Tpeak-Tend (TpTe), J-Tpeak (JTp), and J-Tend (JT). The study composite end-point was SCD, aborted SCD, and appropriate implantable cardioverter defibrillator (ICD) interventions. RESULTS:During a median follow-up of 4.4 years (25th-75th interquartile range: 2.4-9.4 years), 23 patients reached the end-point at 5-years (3 SCD, 3 aborted SCD, 17 appropriate ICD interventions). At multivariate analysis, the spatial QT dispersion corrected according to Bazett's formula (QTcd) remains independently associated to the study endpoint over the HCM Risk-SCD score (C-index 0.737). A QTcd cut-off value of 93ms showed the best accuracy in predicting the SCD endpoint within the entire HCM study cohort (sensitivity 56%, specificity 75%, positive predictive value 22%, negative predictive value 97%). CONCLUSION:Our data suggest that the QTcd might be helpful in SCD risk stratification, particularly in those HCM categories classified at low-intermediate SCD risk according to the contemporary guidelines.
Electrocardiographic and clinical predictors separating atherosclerotic sudden cardiac death from incident coronary heart disease.
Soliman Elsayed Z,Prineas Ronald J,Case L Douglas,Russell Gregory,Rosamond Wayne,Rea Thomas,Sotoodehnia Nona,Post Wendy S,Siscovick David,Psaty Bruce M,Burke Gregory L
Heart (British Cardiac Society)
OBJECTIVE:To identify specific ECG and clinical predictors that separate atherosclerotic sudden cardiac death (SCD) from incident coronary heart disease (CHD) (non-fatal events and non-sudden death) in the combined cohorts of the Atherosclerosis Risk in Communities study and the Cardiovascular Health Study. METHODS:This analysis included 18,497 participants (58% females, 24% black individuals, mean age 58 years) who were initially free of clinical CHD. A competing risk analysis was conducted to examine the prognostic significance of baseline clinical characteristics and an extensive electronic database of ECG measurements for prediction of 229 cases of SCD as a first event versus 2297 incident CHD cases (2122 non-fatal events and 175 non-sudden death) that occurred during a median follow-up time of 13 years in the Cardiovascular Health Study and 14 years in the Atherosclerosis Risk in Communities study. RESULTS:After adjusting for common CHD risk factors, a number of clinical characteristics and ECG measurements were independently predictive of SCD and CHD. However, the risk of SCD versus incident CHD was significantly different for race/ethnicity, hypertension, body mass index (BMI), heart rate, QTc, abnormally inverted T wave in any ECG lead group and level of ST elevation in V2. Black race/ethnicity (compared to non-black) was predictive of high SCD risk but less risk of incident CHD (p value for differences in the risk (HR) for SCD versus CHD <0.0001). Hypertension, increased heart rate, prolongation of QTc and abnormally inverted T wave were stronger predictors of high SCD risk compared to CHD (p value=0.0460, 0.0398, 0.0158 and 0.0265, respectively). BMI was not predictive of incident CHD but was predictive of high SCD risk in a quadratic fashion (p value=0.0220). On the other hand, elevated ST height as measured at the J point and that measured at 60 ms after the J point in V2 were not predictive of SCD but were predictive of high incident CHD risk (p value=0.0251 and 0.0155, respectively). CONCLUSIONS:SCD and CHD have many risk factors in common. Hypertension, race/ethnicity, BMI, heart rate, QTc, abnormally inverted T wave in any ECG lead group and level of ST elevation in V2 have the potential to separate between the risks of SCD and CHD. These results need to be validated in another cohort.
Electrocardiographic repolarization-related predictors of coronary heart disease and sudden cardiac deaths in men and women with cardiovascular disease in the Atherosclerosis Risk in Communities (ARIC) study.
Rautaharju Pentti M,Zhang Zhu-Ming,Haisty Wesley K,Kucharska-Newton Anna M,Rosamond Wayne D,Soliman Elsayed Z
Journal of electrocardiology
INTRODUCTION:We evaluated repolarization-related predictors of coronary heart disease (CHD) death and sudden cardiac death (SCD) in men and women with cardiovascular disease (CVD) in the Atherosclerosis Risk in Communities (ARIC) study. METHODS AND RESULTS:Hazard ratios (HR) from Cox regression were computed for 11 ECG measures of repolarization in 1384 subjects (50% women) 45 to 65years of age. The average follow-up was 14years. Based on electrophysiological considerations the spatial angle between Tpeak and normal repolarization reference vector [Ѳ(Tp|Tref)], STJV6 amplitude, QRS duration and Tonset and Tpeak vector magnitude ratio (ToV/TpV) were considered as primary candidates for independent mortality predictors, and as an alternative set TaVR and TV1 amplitudes and the spatial angle between the initial and terminal T vectors [Ѳ(Tinit|Tterm)]. From the primary set [Ѳ(Tp|Tref)] was a strong independent predictor for CHD death (nearly 4-fold increased risk in men and 2-fold increased risk in women) and for SCD [Ѳ(Tinit|Tterm)] in men (3.4-fold increased risk) and (ToV/TpV) in women (7.76-fold increased risk). From the alternative set of independent predictors TaVR amplitude negativity reduced to less than 150μV (1.5mm) was a strong mortality predictor with an approximately 3-fold increased risk for CHD death and SCD in men and women. CONCLUSIONS:The strongest independent predictors of CHD death were [Ѳ(Tp|Tref)] in men and TaVR in women and of SCD were [Ѳ(Tp|Tref)] in men and ToV/TpV in women. Overall, TaVR amplitude negativity reduced to less than 150μV (1.5mm) was the most consistent mortality predictor in all subgroups. These ECG variables may warrant consideration for identification of high risk men and women for more intense preventive intervention.
Predictive value of electrocardiographic T-wave morphology parameters and T-wave peak to T-wave end interval for sudden cardiac death in the general population.
Porthan Kimmo,Viitasalo Matti,Toivonen Lauri,Havulinna Aki S,Jula Antti,Tikkanen Jani T,Väänänen Heikki,Nieminen Markku S,Huikuri Heikki V,Newton-Cheh Christopher,Salomaa Veikko,Oikarinen Lasse
Circulation. Arrhythmia and electrophysiology
BACKGROUND:Previous population studies have found an association between electrocardiographic T-wave morphology parameters and cardiovascular mortality, but their relationship to sudden cardiac death (SCD) is not clear. To our knowledge, there are no follow-up studies assessing the association between electrocardiographic T-wave peak to T-wave end interval (TPE) and SCD. We assessed the predictive value of electrocardiographic T-wave morphology parameters and TPE for SCD in an adult general population sample. METHODS AND RESULTS:A total of 4 T-wave morphology parameters (principal component analysis ratio, T-wave morphology dispersion, total cosine R-to-T, T-wave residuum) as well as TPE were measured from digital standard 12-lead ECGs in 5618 adults (46% men; mean age 50.9±12.5 years) participating in the Finnish population-based Health 2000 Study. After a mean follow-up time of 7.7±1.4 years, 72 SCDs had occurred. In univariable analyses, all T-wave morphology parameters were associated with an increased SCD risk. In multivariable Cox models, T-wave morphology dispersion and total cosine R-to-T remained as predictors of SCD, with T-wave morphology dispersion showing the highest SCD risk (hazard ratio of 1.4 [95% confidence interval 1.1-1.7, P=0.001] per 1 SD increase in the loge T-wave morphology dispersion). In contrast, TPE was not associated with SCD in univariable or multivariable analyses. CONCLUSIONS:Electrocardiographic T-wave morphology parameters describing the 3-dimensional shape of the T-wave stratify SCD risk in the general population, but we did not find an association between TPE and SCD.
T-wave inversion, QRS duration, and QRS/T angle as electrocardiographic predictors of the risk for sudden cardiac death.
Laukkanen Jari Antero,Di Angelantonio Emanuele,Khan Hassan,Kurl Sudhir,Ronkainen Kimmo,Rautaharju Pentti
The American journal of cardiology
The aim of this study was to investigate the prognostic utility of isolated T-wave inversion (TWI), QRS duration, and QRS/T angle on electrocardiogram at rest as predictors for sudden cardiac death (SCD) and death from all causes. The assessment of electrocardiographic findings was based on a population-based cohort of 1,951 men (age 42 to 61 years) with a follow-up period of 20 years. Isolated TWI in the absence of ST depression, bundle branch block or major arrhythmias, prolonged QRS duration from 110 to 119 ms, and a wide QRS/T angle of >67° were identified from the 12-lead electrocardiograms. SCD was observed in 171 men (8.3%) during the follow-up. As a single electrocardiographic parameter, TWI (prevalence 2.4%) was associated with an increased risk of SCD (hazard ratio [HR] 3.30, 95% confidence interval [CI] 1.91 to 5.71, p<0.001) after adjustment for age and clinical factors. Similarly, prolonged QRS duration and wide QRS/T angle were significantly related to the risk of SCD, with HR 1.50 (95% CI 1.08 to 2.19, p=0.017) for QRS duration and HR 3.03 (95% CI 2.23 to 4.14, p<0.001) for QRS/T angle. The integrated discrimination improvement was significant when TWI (0.014, p=0.036) or QRS/T angle (0.015, p=0.002) was added to the model with age and clinical factors. In conclusion, TWI, QRS duration, and QRS/T angle are significantly associated with the risk of SCD and death from all causes beyond conventional cardiovascular risk predictors in the general population.