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Ethnic differences in the association of QRS duration with ejection fraction and outcome in heart failure
  1. Crystel M Gijsberts1,2,
  2. Lina Benson3,
  3. Ulf Dahlström4,5,
  4. David Sim6,
  5. Daniel P S Yeo7,
  6. Hean Yee Ong8,
  7. Fazlur Jaufeerally9,10,
  8. Gerard K T Leong11,
  9. Lieng H Ling12,13,
  10. A Mark Richards12,13,14,15,
  11. Dominique P V de Kleijn1,2,12,14,
  12. Lars H Lund16,17,
  13. Carolyn S P Lam6,10,12,14
  1. 1ICIN-Netherlands Heart Institute, Utrecht, The Netherlands
  2. 2Laboratory of Experimental Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
  3. 3Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
  4. 4Department of Cardiology, Linköping University, Linköping, Sweden
  5. 5Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  6. 6National Heart Centre, Singhealth, Singapore, Singapore
  7. 7Department of Cardiology, Tan Tock Seng Hospital, Singapore, Singapore
  8. 8Department of Cardiology, Khoo Teck Puat Hospital, Singapore, Singapore
  9. 9Department of Medicine/Cardiology, Singapore General Hospital, Singapore, Singapore
  10. 10Duke-NUS, Singapore, Singapore
  11. 11Department of Cardiology, Changi General Hospital, Singapore, Singapore
  12. 12Yong Loo Lin School of Medicine, National University, Singapore, Singapore
  13. 13Cardiac Department, National University Health System, Singapore, Singapore
  14. 14Cardiovascular Research Institute, National University, Singapore, Singapore
  15. 15Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
  16. 16Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  17. 17Department of Cardiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  1. Correspondence to Dr Carolyn S P Lam, National Heart Centre Singapore, Singhealth, 5 Hospital Drive, Singapore 169609, Singapore; carolyn_lam{at}


Background QRS duration (QRSd) criteria for device therapy in heart failure (HF) were derived from predominantly white populations and ethnic differences are poorly understood.

Methods We compared the association of QRSd with ejection fraction (EF) and outcomes between 839 Singaporean Asian and 11 221 Swedish white patients with HF having preserved EF (HFPEF)and HF having reduced EF (HFREF) were followed in prospective population-based HF studies.

Results Compared with whites, Asian patients with HF were younger (62 vs 74 years, p<0.001), had smaller body size (height 163 vs 171 cm, weight 70 vs 80 kg, both p<0.001) and had more severely impaired EF (EF was <30% in 47% of Asians vs 28% of whites). Overall, unadjusted QRSd was shorter in Asians than whites (101 vs 104 ms, p<0.001). Lower EF was associated with longer QRSd (p<0.001), with a steeper association among Asians than whites (pinteraction<0.001), independent of age, sex and clinical covariates (including body size). Excluding patients with left bundle branch block (LBBB) and adjusting for clinical covariates, QRSd was similar in Asians and whites with HFPEF, but longer in Asians compared with whites with HFREF (p=0.001). Longer QRSd was associated with increased risk of HF hospitalisation or death (absolute 2-year event rate for ≤120 ms was 40% and for >120 ms it was 52%; HR for 10 ms increase of QRSd was 1.04 (1.03 to 1.06), p<0.001), with no interaction by ethnicity.

Conclusion We found ethnic differences in the association between EF and QRSd among patients with HF. QRS prolongation was similarly associated with increased risk, but the implications for ethnicity-specific QRSd cut-offs in clinical decision-making require further study.

  • ECG/electrocardiogram

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