Fragmented QRS Complex Predicts In-Hospital Adverse Events and Long-Term Mortality in Patients with Acute Pulmonary Embolism

Prognostic value of fragmented QRS in acute pulmonary embolism: a cross-sectional-analytic study of the Iranian population

BACKGROUND

Acute Pulmonary embolism (APE) is considered one of the deadliest cardiovascular diseases. Electrocardiographic (ECG) abnormalities in pulmonary embolism (PE) are increasingly reported. A growing number of studies have recommended that ECG plays a crucial role in the prognostic assessment of PE patients. However, there is scarce data on the prognostic importance of fragmented QRS (fQRS) on outcomes in patients with APE. This study aims to investigate the prognostic value of fQRS in APE patients.

MATERIALS AND METHODS

This is a cross-sectional-analytic study. This study included 280 patients diagnosed with APE admitted to Shahid Madani hospital, Tabriz, Iran. Computed tomography pulmonary angiography (CTPA) was used to diagnose APE. A checklist was prepared for all patients, demographic, clinical characteristics, and Major Adverse Cardiopulmonary events (MACPE), including in-hospital mortality, need for thrombolysis, mechanical ventilation, and surgical embolectomy, were recorded. Patients were divided into two groups: patients who manifested fQRS on their ECG and patients who did not; Then, demographic, clinical characteristics, and MACPE were compared in the two groups, as mentioned earlier. Furthermore, all statistical analyses were carried out using SPSS software.

RESULTS

48 patients (17.14%) had fQRS(+) on their ECG, and 232 patients (82.86%) did not have it on their ECG. In data analysis, 22 patients (8.7%) had in-hospital mortality, 35 patients (13.9%) needed thrombolysis, nine patients (3.9%) required mechanical ventilation, and 13 patients (5.1%) needed surgical embolectomy. fQRS was not significantly associated with in-hospital mortality (P = 0.225), need for thrombolysis (P = 0.684), mechanical ventilation (P = 1.000), and surgical embolectomy (P = 1.000). Demographic and clinical characteristics were also similar in both groups.

CONCLUSIONS

This study does not support the idea that fQRS on ECG is a valuable predictor of in-hospital mortality, the need for thrombolysis, mechanical ventilation, and surgical embolectomy.

The value of fragmented QRS in predicting the prognosis of chronic total occlusion patients with myocardial infarction history undergoing percutaneous coronary intervention: A 24-months follow-up study

BACKGROUND

Fragmented QRS (fQRS) is a marker of local myocardial scar. This study aimed to analyze the relationship between fQRS and coronary collateral circulation (CCC) and evaluate the predictive value of fQRS for long-term clinical outcomes among patients with chronic total occlusion (CTO) and prior myocardial infarction (MI) who underwent percutaneous coronary intervention (PCI).

METHODS

A total of 862 patients with a definite history of MI who had one CTO coronary artery and underwent PCI between 2013 and 2018 were continuously analyzed. Patients were divided into group A (no Q wave and fQRS, n = 206), group B (fQRS, n = 265), group C (Q wave, n = 391). All patients were followed up for 2 years.

RESULTS

The incidence rate of major adverse cardiovascular events (MACE) in group B was significantly lower than in group C (group B vs. C: 7.2% vs. 11.3%, P = 0.043). The percentage of good CCC was 94.2%, 88.3%, and 82.9% in group A, B, and C (p < .001), respectively. The improvement of cardiac function in group B and A were more significant than in group C. Multivariate Cox regression analysis showed fQRS was an independent protective factor of MACE after PCI within 2 years in CTO patients with prior MI (RR = 0.668, 95% CI [0.422-0.917], p = .001).

CONCLUSION

fQRS is an independent protective factor of prognosis in patients with prior MI and one CTO vessel who underwent PCI, presenting with a higher rate of good CCC, less occurrence of MACE, and better heart function than in Q wave patients.

Predicting the outcome of acute pulmonary embolism by dynamic changes of the QRS complex in lead V1

Electrocardiography can provide useful prognostic information in acute pulmonary embolism (APE). Several abnormal QRS changes in lead V1, including notched or fragmented QRS, incomplete or complete right bundle branch block (IRBBB or CRBBB) and the QR sign, which are associated with APE, are of prognostic significance. To illustrate this, we describe lead V1 QRS changes in combination with the clinical state of six APE patients. The dynamic ECG changes suggest that a change from a diminution of the S wave amplitude to notched S wave, next to RBBB and then to the QR sign indicate worsening of the patients' condition, and vice versa. Also, a diminution of the S wave amplitude in lead V1 associated with a final R' wave in the right precordial accessory leads indicates the possibility of hidden RBBB. Understanding dynamic QRS changes in APE may aid in risk stratification.

Could fragmented QRS predict mortality in aortic stenosis patients after transcatheter aortic valve replacement?

BACKGROUND

Fragmented QRS evaluated in 12-derivation electrocardiography has widely been accepted as a sign of myocardial fibrosis. The prognostic value of that marker has been demonstrated, particularly, in cardiac diseases that accompany myocardial scar and fibrosis. Myocardial fibrosis is also an issue in patients with aortic stenosis. In this study, we wanted to determine whether fragmented QRS could predict all-cause mortality in aortic stenosis patients after transcatheter aortic valve replacement (TAVR).

METHOD

In this study, we evaluated a total of 116 eligible patients on whom we performed TAVR between 2014 and 2018. Patients' demographic and clinical findings, echocardiography results, in-hospital and 30-day mortality, long-term survival statuses were noted. Patient's ECGs before the procedure were evaluated in regard to the occurrence of fragmented QRS. Predictors of mortality were evaluated using univariable and multivariable Cox regression analysis.

RESULTS

The study population consisted of 116 patients of median age 79 (IQR 75-83), 64 females (55.2%). Mortality occurred in 27 (23%) patients; median follow-up time was 319 (IQR 122-719) days. Fragmented QRS was observed in 44 out of 116 (37.9%) patients. The presence of a fragmented QRS (HR = 2.178, 95% CI 0.999-4.847, p = 0.050), a history of stroke (HR = 3.463, 95% CI 1.276-9.398, p = 0.015), and the creatinine levels at admission (HR = 2.198, 95% CI 1.068-4.520, p = 0.030) were associated with the long-term mortality in multivariable Cox regression analysis.

CONCLUSION

Like in the case of the other diseases associated with myocardial fibrosis, fragmented QRS could also predict mortality in aortic stenosis patients after TAVR procedure.

Use of fragmented QRS in prognosticating clinical deterioration and mortality in pulmonary embolism: A meta-analysis

BACKGROUND

Fragmented QRS (fQRS) on electrocardiography is potentially valuable in prognosticating acute pulmonary embolism (PE). ECG is one of the first tests performed in the emergency department, quickly interpretable, noninvasive, inexpensive, and available in remote areas. We aimed to review fQRS's role in PE prognostication.

METHODS

We searched MEDLINE, EMBASE, Google Scholar, Web of Science, abstracts, conference proceedings, and reference lists until October 2017. Eligible studies used fQRS to prognosticate patients for the main outcomes of death and clinical deterioration or escalation of therapy. Two authors independently selected studies, with disagreement resolved by consensus. Ad hoc piloted forms were used to extract data and assess risk of bias. We used a random-effects model to pool relevant data in meta-analysis with odds ratios (OR) and 95% confidence intervals (CI), while all other data were synthesized qualitatively. Statistical heterogeneity was assessed using the I² index.

RESULTS

We included five studies (1,165 patients). There was complete agreement in study selection. fQRS significantly predicted in-hospital mortality (OR [95% CI], 2.92 [1.73-4.91]; p < .001), cardiogenic shock (OR [95% CI], 4.71 [1.61-13.70]; p = .005), and total mortality at 2-year follow-up (OR [95% CI], 4.42 [2.57-7.60]; p < .001). Adjusted analyses were generally consistent with these results.

CONCLUSION

Although few studies have explored the current study's question, they showed that fQRS is potentially valuable in PE prognostication. fQRS should be considered as an entry, along with other clinical and ECG findings, in a PE risk score.

Fragmented QRS Complex Predicts In-Hospital Adverse Events and Long-Term Mortality in Patients with Acute Pulmonary Embolism

BACKGROUND

Electrocardiographic (ECG) abnormalities in pulmonary embolism (PE) are increasingly reported, and mounting data have recommended that ECG plays a crucial role in the prognostic assessment of PE patient population. However, there is scarce data on the prognostic importance of fragmented QRS (fQRS) on short- and long-term outcomes in patients with PE. Therefore, we aimed to investigate the prognostic role of fQRS in predicting in-hospital and long-term adverse outcomes in PE patients.

METHODS

A total of 249 patients (155 female, 66.2%; mean age, 66.0 ± 16.0) with the diagnosis of acute PE were enrolled and followed-up during median 24.8 months.

RESULTS

Compared with the fQRS (-) patient group, patients with fQRS showed higher rates of in-hospital adverse events including cardiogenic shock, the necessity of thrombolytic therapy, and in-hospital mortality as well as long-term all-cause mortality. In Kaplan-Meier survival analysis, during follow-up, all-cause mortality occurred more frequently in the fQRS (+) group (log-rank, P = 0.002). In multivariate Cox regression analysis, adjusted with other relevant parameters, the presence of fQRS were determined as an independent predictor of in-hospital adverse events (HR: 2.743, 95% CI: 1.267-5.937, P = 0.003) and long-term all-cause mortality (HR: 3.137, 95% CI: 1.824-6.840, P = 0.001).

CONCLUSIONS

The presence of fQRS complex, as a simple and feasible ECG marker, seems to be a novel predictor of in-hospital adverse events and long-term all-cause mortality in PE patient population. This parameter may utilize the identification of patients whom at higher risk for mortality and individualization of therapy.