Relation of dispersion of QRS and QT in patients with advanced congestive heart failure to cardiac and sudden death mortality

doi:10.1016/S0002-9149(00)00730-X

The American Journal of Cardiology

Volume 85, Issue 10, 15 May 2000, Pages 1212-1217

https://doi.org/10.1016/S0002-9149(00)00730-X Get rights and content

Abstract

This study examined the usefulness of QT and QRS dispersion in the prognosis of patients with advanced congestive heart failure (CHF). One hundred four patients in New York Heart Association functional classes II to IV, with a left ventricular ejection fraction of <35%, and untreated with antiarrhythmic drugs, were followed prospectively. QRS and QT dispersion were defined as the maximum difference in QRS and QT interval duration, respectively, measured on all leads of standard 12-lead electrocardiograms. The end points of the study were nonsudden and sudden cardiac mortality. During an average follow-up of 20 months, there were 13 nonsudden and 10 sudden deaths. The average QRS duration was significantly longer in nonsurvivors than in survivors (125 ± 34 vs 113 ± 34 ms, respectively, p <0.04). Similar results were obtained with QT dispersion (95 ± 48 ms vs 78 ± 31 ms, respectively, p <0.03) and QRS dispersion (54 ± 17 ms vs 46 ± 16 ms, respectively, p <0.02). Furthermore, patients who died suddenly had significantly greater QRS dispersion than patients who survived (56 ± 13 vs 46 ± 16 ms, respectively, p <0.02). In a multivariate analysis, QT and QRS dispersion were both independent predictors of nonsudden cardiac death (p = 0.01 and p = 0.001, respectively), and QRS dispersion was also an independent predictor of sudden cardiac death (p = 0.04). Death rate in patients with QT dispersion >90 ms was 2.8-fold higher than those with QT dispersion ≤90 ms (95% confidence intervals [CI] 1.2 to 6.4). Similarly, the death rate in patients with QRS dispersion >46 ms was 3.9-fold higher than in those with QRS dispersion ≤46 ms (95% CI 1.6 to 9.5). These findings suggest that QT and QRS dispersion are useful predictors of mortality in patients with advanced CHF.

Section snippets

Methods

Candidates for inclusion in this study were all patients in New York Heart Association (NYHA) functional classes II to IV, and with a LV ejection fraction of <35%, admitted to our institution’s outpatient department for management of CHF.

Exclusion criteria included age ≥75 years, pregnancy, heart failure secondary to hypertrophic or restrictive cardiomyopathy, constrictive pericarditis, congenital heart disease, mitral and aortic stenosis, right-sided cardiac failure secondary to pulmonary

Results

The demographic and electrocardiographic characteristics of 104 patients who satisfied the criteria for entry into the study are presented in TABLE I, TABLE II. There were 87 men and 17 women, and mean age was 52.6 ± 12.9 years (range 18 to 74). All suffered from symptomatic LV systolic dysfunction secondary to ischemic heart disease (n = 45) or idiopathic dilated cardiomyopathy (n = 59). Mean LV ejection fraction determined by radionuclide ventriculography was 22 ± 10% and mean NYHA functional

Study summary and implications

The results of the present study10, 11 demonstrate a substantial mortality risk in patients with advanced CHF and pronounced dispersion of ventricular repolarization. In addition, this study, to our knowledge, is the first to describe a relation between interlead variability of QRS measured in the standard 12-lead electrocardiogram and subsequent mortality in patients with severe CHF. An increased interlead variability in intraventricular conduction (QRS dispersion) identified a group of

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QRS dispersion (QRS-D) is the maximum difference between QRS duration between the right and left precordial leads. QRS-D has been shown to predict mortality and sudden cardiac death in patients with advanced congestive heart failure.66 QRS-D has also been compared against Qt dispersion, syncope, and negative T waves beyond V1 in a population of patients with arrhythmogenic right ventricular cardiomyopathy and was found to be significantly superior in predicting sudden cardiac death.67,68
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This study sought to determine whether the sodium/glucose cotransporter 2 (SGLT2) inhibitor empagliflozin improved heart failure (HF) outcomes in nondiabetic mice. The EMPA-REG OUTCOME (Empagliflozin, Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) trial demonstrated that empagliflozin markedly prevented HF and cardiovascular death in subjects with diabetes. However, despite ongoing clinical trials in HF patients without type 2 diabetes, there are no objective and translational data to support an effect of SGLT2 inhibitors on cardiac structure and function, particularly in the absence of diabetes and in the setting of established HF. Male C57Bl/6 mice were subjected to either sham or transverse aortic constriction surgery to induce HF. Following surgery, mice that progressed to HF received either vehicle or empagliflozin for 2 weeks. Cardiac function was then assessed in vivo using echocardiography and ex vivo using isolated working hearts. Although vehicle-treated HF mice experienced a progressive worsening of cardiac function over the 2-week treatment period, this decline was blunted in empagliflozin-treated HF mice. Treatment allocation to empagliflozin resulted in an improvement in cardiac systolic function, with no significant changes in cardiac remodeling or diastolic dysfunction. Moreover, isolated hearts from HF mice treated with empagliflozin displayed significantly improved ex vivo cardiac function compared to those in vehicle-treated controls. Empagliflozin treatment of nondiabetic mice with established HF blunts the decline in cardiac function both in vivo and ex vivo, independent of diabetes. These data provide important basic and translational clues to support the evaluation of SGLT2 inhibitors as a treatment strategy in a broad range of patients with established HF.
Race and gender variation in the QT interval and its association with mortality in patients with coronary artery disease: Results from the Duke Databank for Cardiovascular Disease (DDCD)
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Although prior studies of the QT interval in chronic kidney disease have largely focused on the end-stage renal disease population,22-24 it appears that even milder forms of renal dysfunction confer adverse effects on the QT interval in a graded fashion, with decreasing GFR. In addition, although the negative prognostic implications of QT prolongation in heart failure have been established in prior investigations,25-27 that QTc interval prolongation was associated with worsening NYHA class and lower ejection fraction is a novel finding. To date, this is the largest population-based study, of which we are aware, of the prevalence, associated clinical factors, and outcomes of patients with QTc interval prolongation and CAD.
In several studies, prolongation of the corrected QT (QTc) interval has been associated with an increased risk of cardiac events. However, data on race and gender variation in the QTc and its associated risk of death are lacking.
We prospectively followed 19,252 subjects who underwent cardiac catheterization and had at least 1 native coronary artery stenosis ≥ 75%. Automated QTc measurements were obtained from a baseline electrocardiogram.
The mean age of the population was 62.4 years, with 35% being female and 20% being black. The QTc varied by gender and race (417.9 ± 34.4 ms in men and 433.4 ± 33.6 ms in women, 422.1 ± 34.3 ms in whites and 428.1 ± 36.9 ms in blacks; P < .0001 for both). Risk factors most strongly associated with a prolonged QTc were lower ejection fraction, higher diastolic blood pressure, history of myocardial infarction, and lower glomerular filtration rate. Black race and female gender were also independently associated with a prolonged QTc, after adjustment for cardiac risk factors. Moreover, there was an independent association between QTc and all-cause mortality (hazard ratio 1.037 per 10-ms increase, P < .0001). The increased mortality risk associated with a 10-ms increase in the QTc interval was significantly greater for men compared with women (4.6% vs 2.4%, P = .004) and slightly greater for blacks compared with other races (5.0% vs 3.3%, P = .057).
Among patients with coronary artery disease, QTc prolongation is independently associated with all-cause mortality. The increased mortality risk is higher for men than for women, with a trend toward higher mortality in blacks.
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Determinar la relación entre duración y dispersión del QRS con la aparición de arritmias ventriculares en las fases iniciales del infarto agudo de miocardio (IAM).
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Se detectaron arritmias en 46 pacientes (22%), en 25 (15,9%) estas fueron ventriculares; más frecuentes en el IAM anterior extenso, que fue responsable del 81,8% de las fibrilaciones ventriculares y más de la mitad (57,1%) de las taquicardias ventriculares. La duración del QRS (77,3 ± 13,3 vs. 71,5 ± 6,4 ms; p = 0,029) y su dispersión (24,1 ± 16,2 vs. 16,5 ± 4,8 ms; p = 0,019) fue superior en las derivaciones afectadas por la isquemia. Los mayores valores de todas las mediciones se presentaron, con diferencia significativa, en el IAM anterior extenso: QRS 92,3 ± 18,8 ms, dQRS 37,9 ± 23,9 ms, QTc 518,5 ± 72,2 ms y dQTc 94,9 ± 26,8 ms. Los pacientes con mayores valores de dispersión del QRS tuvieron más probabilidad de presentar arritmias ventriculares, con puntos de corte de 23,5 ms para la taquicardia y de 24,5 ms para la fibrilación ventricular.
El incremento de la duración y dispersión del QRS mostró mayor probabilidad de aparición de arritmias ventriculares en las fases iniciales del IAM que los incrementos del intervalo QTc y su dispersión.
To determine the relationship between QRS duration and dispersion and the occurrence of ventricular arrhythmias in early stages of acute myocardial infarction (AMI).
A retrospective, longitudinal descriptive study was carried out.
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The duration and dispersion of the QT interval, corrected QT interval, and QRS complex were measured in the first electrocardiogram performed at the hospital. The presence of ventricular tachycardia/fibrillation was assessed during follow-up (length of hospital stay).
Arrhythmias were found in 46 patients (22%); in 25 of them (15.9%), arrhythmias originated in ventricles, and were more common in those subjects with extensive anterior wall AMI, which was responsible for 81.8% of the ventricular fibrillations and more than half (57.1%) of the ventricular tachycardias. The widest QRS complexes (77.3 ± 13.3 vs. 71.5 ± 6.4 ms; P = .029) and their greatest dispersion (24.1 ± 16.2 vs. 16.5 ± 4.8 ms; P = .019) were found on those leads that explore the regions affected by ischemia. The highest values of all measurements were found in extensive anterior wall AMI, with significant differences: QRS 92.3 ± 18.8 ms, QRS dispersion 37.9 ± 23.9 ms, corrected QT 518.5 ± 72.2 ms, and corrected QT interval dispersion 94.9 ± 26.8 ms. Patients with higher QRS dispersion values were more likely to have ventricular arrhythmias, with cutoff points at 23.5 ms and 24.5 ms for tachycardia and ventricular fibrillation, respectively.
Increased QRS duration and dispersion implied a greater likelihood of ventricular arrhythmias in early stages of AMI than increased duration and dispersion of the corrected QT interval.
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Relation of dispersion of QRS and QT in patients with advanced congestive heart failure to cardiac and sudden death mortality

Abstract

Section snippets

Methods

Results

Study summary and implications

J Am Coll Cardiol

Am J Cardiol

Lancet

Am J Cardiol

J Am Coll Cardiol

Reduction in QT interval dispersion by successful thrombolytic therapy in acute myocardial infarction

Circulation

Assessment of QT dispersion for prediction of mortality or arrhythmic events after myocardial infarction. Results of a prospective, long-term follow-up study

Circulation