A new electrocardiogram marker to identify patients at low risk for ventricular tachyarrhythmias: sum magnitude of the absolute QRST integral.

OBJECTIVE We proposed and tested a novel electrocardiogram marker of risk of ventricular arrhythmias (VAs). METHODS Digital orthogonal electrocardiograms were recorded at rest before implantable cardioverter-defibrillator (ICD) implantation in 508 participants of a primary prevention ICDs prospective cohort study (mean ± SD age, 60 ± 12 years; 377 male [74%]). The sum magnitude of the absolute QRST integral in 3 orthogonal leads (SAI QRST) was calculated. A derivation cohort of 128 patients was used to define a cutoff; a validation cohort (n = 380) was used to test a predictive value. RESULTS During a mean follow-up of 18 months, 58 patients received appropriate ICD therapies. The SAI QRST was lower in patients with VA (105.2 ± 60.1 vs 138.4 ± 85.7 mV ms, P = .002). In the Cox proportional hazards analysis, patients with SAI QRST not exceeding 145 mV ms had about 4-fold higher risk of VA (hazard ratio, 3.6; 95% confidence interval, 1.96-6.71; P < .0001) and a 6-fold higher risk of monomorphic ventricular tachycardia (hazard ratio, 6.58; 95% confidence interval, 1.46-29.69; P = .014), whereas prediction of polymorphic ventricular tachycardia or ventricular fibrillation did not reach statistical significance. CONCLUSION High SAI QRST is associated with low risk of sustained VA in patients with structural heart disease.

[1]  W. Gregory.  Adjusting survival curves for imbalances in prognostic factors. , 1988, British Journal of Cancer.

[2]  Douglas L Packer,et al.  Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. , 2005, The New England journal of medicine.

[3]  P Kligfield,et al.  Electrocardiographic identification of increased left ventricular mass by simple voltage-duration products. , 1995, Journal of the American College of Cardiology.

[4]  J A ABILDSKOV,et al.  Cancellation of Electrocardiographic Effects During Ventricular Excitation , 1962, [Sogo rinsho] Clinic all-round.

[5]  Ernestfrank.  An Accurate, Clinically Practical System For Spatial Vectorcardiography , 1956 .

[6]  M. Josephson,et al.  QRS duration does not predict occurrence of ventricular tachyarrhythmias in patients with implanted cardioverter-defibrillators. , 2005, Journal of the American College of Cardiology.

[7]  Franklin D. Johnston,et al.  The determination and the significance of the areas of the ventricular deflections of the electrocardiogram , 1934 .

[8]  K. Malik,et al.  Circus Movement in Rabbit Atrial Muscle as a Mechanism of Tachycardia II . The Role of Nonuniform Recovery of Excitability in the Occurrence of Unidirectional Block , as Studied with Multiple Microelectrodes , 2005 .

[9]  P. Okin.  Serial evaluation of electrocardiographic left ventricular hypertrophy for prediction of risk in hypertensive patients. , 2009, Journal of electrocardiology.

[10]  M. Gold.  QRS duration predicts sudden cardiac death in hypertensive patients undergoing intensive medical therapy: the LIFE study , 2010 .

[11]  E. R. Smith,et al.  Vulnerability to ventricular arrhythmia: assessment by mapping of body surface potential. , 1986, Circulation.

[12]  Michael R Gold,et al.  Limitations of ejection fraction for prediction of sudden death risk in patients with coronary artery disease: lessons from the MUSTT study. , 2007, Journal of the American College of Cardiology.

[13]  M. Cheitlin.  Regression of Electrocardiographic Left Ventricular Hypertrophy During Antihypertensive Therapy and Reduction in Sudden Cardiac Death: The LIFE Study , 2008 .

[14]  M. Haissaguerre,et al.  Reliability and Reproducibility of QRS Duration in the Selection of Candidates for Cardiac Resynchronization Therapy , 2010, Journal of cardiovascular electrophysiology.

[15]  R E Ideker,et al.  Evaluation of a QRS Scoring System for Estimating Myocardial Infarct Size: I. Specificity and Observer Agreement , 1982, Circulation.

[16]  Beatriz Trénor,et al.  The Relative Role of Refractoriness and Source–Sink Relationship in Reentry Generation during Simulated Acute Ischemia , 2009, Annals of Biomedical Engineering.

[17]  A. Moss,et al.  Risk stratification for primary implantation of a cardioverter-defibrillator in patients with ischemic left ventricular dysfunction. , 2008, Journal of the American College of Cardiology.

[18]  G S Wagner,et al.  The Selvester QRS scoring system for estimating myocardial infarct size. The development and application of the system. , 1985, Archives of internal medicine.

[19]  N. Wald,et al.  When can a risk factor be used as a worthwhile screening test? , 1999, BMJ.

[20]  H. Calkins,et al.  Beat-to-beat QT interval variability: novel evidence for repolarization lability in ischemic and nonischemic dilated cardiomyopathy. , 1997, Circulation.

[21]  J. Goldberger.  Evidence-based analysis of risk factors for sudden cardiac death. , 2009, Heart rhythm.

[22]  D. Mark,et al.  Prognostic importance of defibrillator shocks in patients with heart failure. , 2008, The New England journal of medicine.

[23]  J. Ware.  The limitations of risk factors as prognostic tools. , 2006, The New England journal of medicine.

[24]  Wojciech Zareba,et al.  Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. , 2002, The New England journal of medicine.

[25]  A. Oulhaj,et al.  Electrocardiographic amplitudes: a new risk factor for sudden death in hypertrophic cardiomyopathy , 2009, European heart journal.

[26]  S. Cobbe,et al.  Dispersion of ventricular repolarization and refractory period. , 2001, Cardiovascular research.

[27]  M. Keller,et al.  A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. , 1997, The New England journal of medicine.

[28]  P. Kligfield,et al.  Electrocardiographic diagnosis of left ventricular hypertrophy by the time-voltage integral of the QRS complex. , 1994, Journal of the American College of Cardiology.

[29]  Y. Rudy,et al.  Basic mechanisms of cardiac impulse propagation and associated arrhythmias. , 2004, Physiological reviews.

[30]  D. Mozaffarian,et al.  Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. , 2009, Circulation.

[31]  R L Lux,et al.  The Electrocardiographic Recognition of Cardiac States at High Risk of Ventricular Arrhythmias: An Experimental Study in Dogs , 1978, Circulation research.

[32]  G. Moe,et al.  Nonuniform Recovery of Excitability in Ventricular Muscle , 1964, Circulation research.

[33]  H. C. Burger,et al.  A theoretical elucidation of the notion ventricular gradient. , 1957, American heart journal.

[34]  D. Geselowitz.  The Ventricular Gradient Revisited: Relation to the Area Under the Action Potential , 1983, IEEE Transactions on Biomedical Engineering.

[35]  M. Pepe,et al.  Limitations of the odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker. , 2004, American journal of epidemiology.

[36]  K Millar,et al.  Cancellation of electrocardiographic effects during ventricular recovery. , 1969, Journal of electrocardiology.

[37]  R E Ideker,et al.  Evaluation of a QRS scoring system for estimating myocardial infarct size. IV. Correlation with quantitative anatomic findings for posterolateral infarcts. , 1983, The American journal of cardiology.

[38]  D. Kent,et al.  Association of prolonged QRS duration with ventricular tachyarrhythmias and sudden cardiac death in the Multicenter Automatic Defibrillator Implantation Trial II (MADIT-II). , 2008, Heart rhythm.

[39]  F. Harrell,et al.  A QRS scoring system for assessing left ventricular function after myocardial infarction. , 1982, The New England journal of medicine.

[40]  D. Rosenbaum,et al.  Interdependence of Modulated Dispersion and Tissue Structure in the Mechanism of Unidirectional Block , 2000, Circulation research.