1
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Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm 2023; 20:e17-e91. [PMID: 37283271 PMCID: PMC11062890 DOI: 10.1016/j.hrthm.2023.03.1538] [Citation(s) in RCA: 85] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 06/08/2023]
Abstract
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eugene H Chung
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | | | | | - Anne M Dubin
- Stanford University, Pediatric Cardiology, Palo Alto, California
| | | | - Taya V Glotzer
- Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Eiran Z Gorodeski
- University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Weijian Huang
- First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peter B Imrey
- Cleveland Clinic, Cleveland, Ohio; Case Western Reserve University, Cleveland, Ohio
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Saima Karim
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter P Karpawich
- The Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Yaariv Khaykin
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | | | - Jordana Kron
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph E Marine
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg Genk, Belgium and Hasselt University, Hasselt, Belgium
| | - Seung-Jung Park
- Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Ratika Parkash
- QEII Health Sciences Center, Halifax, Nova Scotia, Canada
| | | | - Rajeev Kumar Pathak
- Australian National University, Canberra Hospital, Garran, Australian Capital Territory, Australia
| | | | | | | | | | | | - Morio Shoda
- Tokyo Women's Medical University, Tokyo, Japan
| | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Slotwiner
- Weill Cornell Medicine Population Health Sciences, New York, New York
| | | | | | | | | | | | | | - Cynthia M Tracy
- George Washington University, Washington, District of Columbia
| | | | | | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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2
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Berger M, Kumowski N, Straw S, Verket M, Marx N, Witte KK, Schütt K. Clinical implications and risk factors for QRS prolongation over time in heart failure patients. Clin Res Cardiol 2023; 112:312-322. [PMID: 36378295 PMCID: PMC9898415 DOI: 10.1007/s00392-022-02122-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND QRS prolongation is an established prognostic marker in heart failure (HF). In contrast, the role of QRS width progression over time has been incompletely explored. The current study investigates the role of QRS width progression over time on clinical status and identifies underlying predictors. METHODS Datasets of ≥ 2 consecutive visits from 100 attendees to our HF clinic between April and August 2021 were analysed for changes in QRS complex duration. RESULTS In total 240 datasets were stratified into tertiles based on change in QRS duration (mm/month) (1st tertile: - 1.65 [1.50] 'regression'; 2nd tertile 0.03 [0.19] 'stable', 3rd tertile 3.57 [10.11] 'progression'). The incidence of the combined endpoint HF hospitalisation and worsening of symptomatic heart failure was significantly higher in the group with QRS width progression (3rd tertile) compared with the stable group (2nd tertile; log-rank test: p = 0.013). These patients were characterised by higher plasma NT-pro-BNP levels (p = 0.008) and higher heart rate (p = 0.007). A spline-based prediction model identified patients at risk of QRS width progression when NT-pro-BNP and heartrate were > 837 pg/ml and > 83/bpm, respectively. These markers were independent of guideline-directed medical HF therapy. Patients beyond both thresholds had a 14-fold increased risk of QRS width progression compared to those with neither or either alone (HR: 14.2 [95% 6.9 - 53.6]; p < 0.0001, p for interaction = 0.016). CONCLUSIONS This pilot study demonstrates that QRS width progression is associated with clinical deterioration of HF. NTproBNP plasma levels and heart rate indicate patients at risk QRS width progression, independently of HF therapy.
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Affiliation(s)
- Martin Berger
- grid.412301.50000 0000 8653 1507Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Nina Kumowski
- grid.412301.50000 0000 8653 1507Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Sam Straw
- grid.9909.90000 0004 1936 8403Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Marlo Verket
- grid.412301.50000 0000 8653 1507Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Nikolaus Marx
- grid.412301.50000 0000 8653 1507Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Klaus K. Witte
- grid.412301.50000 0000 8653 1507Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Katharina Schütt
- grid.412301.50000 0000 8653 1507Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
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3
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Nomoto M, Suzuki A, Shiga T, Shoda M, Hagiwara N. Impact of signal-averaged electrocardiography findings on appropriate shocks in prophylactic implantable cardioverter defibrillator patients with nonischemic systolic heart failure. BMC Cardiovasc Disord 2022; 22:374. [PMID: 35974317 PMCID: PMC9382808 DOI: 10.1186/s12872-022-02811-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Appropriate shock therapy is associated with subsequent all-cause death in heart failure (HF) patients who receive an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death. To evaluate the impact of signal-averaged electrocardiography (SAECG) findings on appropriate shocks in prophylactic ICD patients with nonischemic systolic HF. METHODS We studied 86 patients with nonischemic HF and a left ventricular ejection fraction ≤ 35% who underwent new ICD implantation for the primary prevention of sudden cardiac death. We excluded patients who had a previously implanted permanent pacemaker and patients who received cardiac resynchronization therapy with an ICD. SAECG was performed before implantation. Abnormal SAECG findings were defined if 2 of the following 3 conditions were identified: filtered QRS duration (fQRS) ≥ 114 ms, root-mean-square voltage during the last 40 ms of the fQRS (RMS 40) < 20 μV, and duration of the low-amplitude potentials < 40 μV (LAS 40) > 38 ms; additionally, patients with a QRS complex ≥ 120 ms who met both the RMS 40 and LAS 40 criteria were also considered to have abnormal SAECG findings. The primary outcome was the first occurrence of appropriate shock after implantation of the ICD. The secondary outcomes were the first occurrence of inappropriate shock and all-cause mortality. RESULTS Forty-two patients met the criteria for abnormal SAECG findings (49%). During a median follow-up period of 61 months, 17 patients (20%) died, 24 (28%) received appropriate shock therapy, and 19 (22%) received inappropriate shock therapy. There was a significantly higher incidence of appropriate shocks in patients with abnormal SAECG findings than in those with normal SAECG findings (log-rank test, p = 0.025). Multivariate analysis revealed that abnormal SAECG findings were independently associated with the occurrence of appropriate shock (hazard ratio 2.67, 95% confidential interval 1.14-6.26). However, abnormal SAECG findings were not related to inappropriate shock. There was no difference in the incidence of all-cause death between patients with abnormal and normal SAECG findings. CONCLUSIONS Our results suggest that abnormal SAECG findings are associated with a high probability of appropriate shocks in prophylactic ICD patients with nonischemic systolic HF.
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Affiliation(s)
- Michiru Nomoto
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan. .,Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Morio Shoda
- Clinical Research Division for Heart Rhythm Management, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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4
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Sobhani S, Raji S, Aghaee A, Pirzadeh P, Ebrahimi Miandehi E, Shafiei S, Akbari M, Eslami S. Body mass index, lipid profile, and hypertension contribute to prolonged QRS complex. Clin Nutr ESPEN 2022; 50:231-237. [DOI: 10.1016/j.clnesp.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/24/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
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5
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Hedeer F, Ostenfeld E, Hedén B, Prinzen FW, Arheden H, Carlsson M, Engblom H. To what extent are perfusion defects seen by myocardial perfusion SPECT in patients with left bundle branch block related to myocardial infarction, ECG characteristics, and myocardial wall motion? J Nucl Cardiol 2021; 28:2910-2922. [PMID: 32451797 PMCID: PMC8709823 DOI: 10.1007/s12350-020-02180-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/25/2020] [Indexed: 12/04/2022]
Abstract
INTRODUCTION We investigated if uptake pattern on myocardial perfusion SPECT (MPS) in patients with left bundle branch block (LBBB) is related to myocardial fibrosis, myocardial wall motion, and electrocardiography (ECG) characteristics. METHODS Twenty-three patients (9 women) with LBBB, examined with MPS and cardiac magnetic resonance (CMR), were included. Tracer uptake on MPS was classified by visual interpretation as typical LBBB pattern (Defect+, n = 13) or not (Defect-, n = 10) and quantitatively. CMR images were evaluated for wall thickness and for myocardial wall motion both by visual assessment and by regional myocardial radial strain from feature tracking, and for presence and location of myocardial fibrosis. ECGs were analyzed regarding QRS duration and the presence of strict criteria for LBBB. RESULTS Wall thickness was slightly lower in the septum compared to the lateral wall in Defect+ patients (5.6 ± 1.1 vs 6.0 ± 1.3 mm, P = 0.03) but not in Defect- patients (5.6 ± 1.0 vs 5.6 ± 0.9 mm, P = 0.84). Defect+ patients showed a larger proportion of dyskinetic segments in the septum and hyperkinetic segments in the lateral wall compared to Defect- patients (P = 0.006 and P = 0.004, respectively). Decreased myocardial radial strain was associated with decreased tracer uptake by MPS (R = 0.37, P < 0.001). Areas of fibrosis did not match areas with uptake defect on MPS. No differences in ECG variables were seen. CONCLUSION The heterogeneous regional tracer uptake in some patients with LBBB is related to underlying regional myocardial dyskinesia, wall thickening, and wall thickness rather than stress-induced ischemia, myocardial fibrosis, or specific ECG characteristics.
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Affiliation(s)
- Fredrik Hedeer
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ellen Ostenfeld
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Bo Hedén
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Håkan Arheden
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marcus Carlsson
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Henrik Engblom
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden.
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6
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Wannamethee SG, Papacosta O, Lennon L, Hingorani A, Whincup P. Adult height and incidence of atrial fibrillation and heart failure in older men: The British Regional Heart Study. IJC HEART & VASCULATURE 2021; 35:100835. [PMID: 34286063 PMCID: PMC8274296 DOI: 10.1016/j.ijcha.2021.100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/15/2021] [Accepted: 06/23/2021] [Indexed: 12/05/2022]
Abstract
Aims Taller stature has been associated with increased risk of atrial fibrillation (AF). AF and heart failure (HF) often co-occur but the association between height and risk of HF in older adults has not been well studied. We have examined the association between height and incident AF and incident HF in older adults. Methods Prospective study of 3346 men aged 60–79 years with no diagnosed HF, myocardial infarction or stroke at baseline (1998–2000) followed up for a mean period of 16 years, in whom there were 294 incident HF cases and 456 incident AF. Men were divided into 5 height groups: <168.2, 168.2–172.5, 172.6–176.9, 177.0–183.0 and >183.0 cms based on the 25th, 50th, 75th and 95th centiles distribution of height. Results CVD risk factors tended to decrease with increasing height but a positive association was seen between height and electrocardiographic QRS duration and incident AF. Both short stature (<168.2 cm) and tall stature (>183.0 cm) was associated with significantly increased risk of HF in age-adjusted analysis compared to those in the second height quartile [HR (95 %CI) = 1.62 (1.15, 2.26) and 2.04 (1.23, 3.39) respectively]. In short men the increased risk remained after adjustment for adverse CVD risk factors; in tall men the association was largely associated with AF and QRS duration. Conclusion Tall stature is associated with significantly increased risk of AF leading to increased risk of HF. Short stature was associated with increased HF risk which was not explained by known adverse CVD risk factors.
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Key Words
- AF, atrial fibrillation
- Atrial fibrillation
- CHD, coronary heart disease
- CRP, C-reactive protein
- CVD, cardiovascular disease
- ECG, electrocardiogram
- Epidemiology
- FEV1, forced expiratory volume in 1 s
- HF, heart failure
- Heart failure
- Height
- LVH, left ventricular hypertrophy
- MI, myocardial infarction
- NT-proBNP, N-terminal pro-brain natriuretic peptide
- SBP, systolic blood pressure
- hsTnT, high sensitive troponin T
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Affiliation(s)
- S Goya Wannamethee
- Department Primary Care and Population Health, UCL London, United Kingdom
| | - Olia Papacosta
- Department Primary Care and Population Health, UCL London, United Kingdom
| | - Lucy Lennon
- Department Primary Care and Population Health, UCL London, United Kingdom
| | - Aroon Hingorani
- Institute of Cardiovascular Sciences, UCL, London, United Kingdom
| | - Peter Whincup
- Population Health Research Institute, St George's, University of London, United Kingdom
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7
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Chen X, Hansson PO, Thunström E, Mandalenakis Z, Caidahl K, Fu M. Incremental changes in QRS duration as predictor for cardiovascular disease: a 21-year follow-up of a randomly selected general population. Sci Rep 2021; 11:13652. [PMID: 34211015 PMCID: PMC8249416 DOI: 10.1038/s41598-021-93024-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/27/2021] [Indexed: 02/08/2023] Open
Abstract
The QRS complex has been shown to be a prognostic marker in coronary artery disease. However, the changes in QRS duration over time, and its predictive value for cardiovascular disease in the general population is poorly studied. So we aimed to explore if increased QRS duration from the age of 50–60 is associated with increased risk of major cardiovascular events during a further follow-up to age 71. A random population sample of 798 men born in 1943 were examined in 1993 at 50 years of age, and re-examined in 2003 at age 60 and 2014 at age 71. Participants who developed cardiovascular disease before the re-examination in 2003 (n = 86) or missing value of QRS duration in 2003 (n = 127) were excluded. ΔQRS was defined as increase in QRS duration from age 50 to 60. Participants were divided into three groups: group 1: ΔQRS < 4 ms, group 2: 4 ms ≤ ΔQRS < 8 ms, group 3: ΔQRS ≥ 8 ms. Endpoints were major cardiovascular events. And we found compared with men in group 1 (ΔQRS < 4 ms), men with ΔQRS ≥ 8 ms had a 56% increased risk of MACE during follow-up to 71 years of age after adjusted for BMI, systolic blood pressure, smoking, hyperlipidemia, diabetes and heart rate in a multivariable Cox regression analysis (HR 1.56, 95% CI:1.07–2.27, P = 0.022). In conclusion, in this longitudinal follow-up over a decade QRS duration increased in almost two out of three men between age 50 and 60 and the increased QRS duration in middle age is an independent predictor of major cardiovascular events.
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Affiliation(s)
- Xiaojing Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China. .,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Per-Olof Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - Erik Thunström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - Zacharias Mandalenakis
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - Kenneth Caidahl
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska Universtity Hospital, Stockholm, Sweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
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8
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Sahiti F, Morbach C, Cejka V, Albert J, Eichner FA, Gelbrich G, Heuschmann PU, Störk S. Left Ventricular Remodeling and Myocardial Work: Results From the Population-Based STAAB Cohort Study. Front Cardiovasc Med 2021; 8:669335. [PMID: 34179134 PMCID: PMC8232934 DOI: 10.3389/fcvm.2021.669335] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/06/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction: Left ventricular (LV) dilatation and LV hypertrophy are acknowledged precursors of myocardial dysfunction and ultimately of heart failure, but the implications of abnormal LV geometry on myocardial function are not well-understood. Non-invasive LV myocardial work (MyW) assessment based on echocardiography-derived pressure-strain loops offers the opportunity to study detailed myocardial function in larger cohorts. We aimed to assess the relationship of LV geometry with MyW indices in general population free from heart failure. Methods and Results: We report cross-sectional baseline data from the Characteristics and Course of Heart Failure Stages A-B and Determinants of Progression (STAAB) cohort study investigating a representative sample of the general population of Würzburg, Germany, aged 30–79 years. MyW analysis was performed in 1,926 individuals who were in sinus rhythm and free from valvular disease (49.3% female, 54 ± 12 years). In multivariable regression, higher LV volume was associated with higher global wasted work (GWW) (+0.5 mmHg% per mL/m2, p < 0.001) and lower global work efficiency (GWE) (−0.02% per mL/m2, p < 0.01), while higher LV mass was associated with higher GWW (+0.45 mmHg% per g/m2, p < 0.001) and global constructive work (GCW) (+2.05 mmHg% per g/m2, p < 0.01) and lower GWE (−0.015% per g/m2, p < 0.001). This was dominated by the blood pressure level and also observed in participants with normal LV geometry and concomitant hypertension. Conclusion: Abnormal LV geometric profiles were associated with a higher amount of wasted work, which translated into reduced work efficiency. The pattern of a disproportionate increase in GWW with higher LV mass might be an early sign of hypertensive heart disease.
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Affiliation(s)
- Floran Sahiti
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Vladimir Cejka
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany
| | - Judith Albert
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Felizitas A Eichner
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany.,Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Götz Gelbrich
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany.,Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Peter U Heuschmann
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany.,Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
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9
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Varma N, Baker J, Tomassoni G, Love CJ, Martin D, Sheppard R, Niazi I, Cranke G, Lee K, Corbisiero R. Left Ventricular Enlargement, Cardiac Resynchronization Therapy Efficacy, and Impact of MultiPoint Pacing. Circ Arrhythm Electrophysiol 2020; 13:e008680. [DOI: 10.1161/circep.120.008680] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background:
Left ventricular (LV) epicardial pacing results in slowly propagating paced wavefronts. We postulated that this effect might limit cardiac resynchronization therapy efficacy in patients with LV enlargement using conventional biventricular pacing with single-site LV pacing, but be mitigated by LV stimulation from 2 widely spaced sites using MultiPoint pacing with wide anatomic separation (MPP-AS: ≥30 mm). We tested this hypothesis in the multicenter randomized MPP investigational device exemption trial.
Methods:
Following implant, quadripolar biventricular single-site pacing was activated in all patients (n=506). From 3 to 9 months postimplant, among patients with available baseline LV end-diastolic volume (LVEDV) measures, 188 received biventricular single-site pacing and 43 received MPP-AS. Patients were dichotomized by median baseline LVEDV indexed to height (LVEDVI
Median
). Outcomes were measured by the clinical composite score (primary efficacy end point), quality of life, LV structural remodeling (↑EF >5% and ↓ESV 10%) and heart failure event/cardiovascular death.
Results:
LVEDVI
Median
was 1.1 mL/cm. Baseline characteristics differed in patients with LVEDVI
>Median
versus LVEDVI
≤Median
. Among patients with LVEDVI
>Median
, biventricular single-site pacing was less efficacious compared to patients with LVEDVI
≤Median
(clinical composite score, 65% versus 79%). In contrast, MPP-AS programming generated greater clinical composite score response (92% versus 65%,
P
=0.023) and improved quality of life (−31.0±29.7 versus −15.7±22.1,
P
=0.038) versus biventricular single-site pacing in patients with LVEDVI
>Median
. Reverse remodeling trended better with MPP-AS programming. In patients with LVEDVI
>Median
, heart failure event rate increased following the 3-month randomization point with biventricular single-site pacing (0.0150±0.1725 in LVEDVI
>Median versus
−0.0190±0.0808 in LVEDVI
≤Median
,
P
=0.012), but no heart failure event occurred in patients with MPP-AS programming between 3 and 9 months in LVEDVI
>Median
. All measured outcomes did not differ in patients receiving MPP-AS and biventricular single-site pacing with LVEDVI
≤Median
.
Conclusions:
Conventional biventricular single-site pacing, even with a quadripolar lead, has reduced efficacy in patients with LV enlargement. However, the greatest response rate in patients with larger hearts was observed when programmed to MPP-AS pacing.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic Foundation, Cleveland, OH (N.V.)
| | - James Baker
- Saint Thomas Research Institute, Nashville, TN (J.B.)
| | | | | | | | | | - Imran Niazi
- Aurora Cardiovascular Services, Milwaukee, WI (I.N.)
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10
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Combination of Left Ventricular End-Diastolic Diameter and QRS Duration Strongly Predicts Good Response to and Prognosis of Cardiac Resynchronization Therapy. Cardiol Res Pract 2020; 2020:1257578. [PMID: 32411441 PMCID: PMC7201746 DOI: 10.1155/2020/1257578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/26/2019] [Indexed: 11/17/2022] Open
Abstract
Background Approximately 20–40% of recipients of cardiac resynchronization therapy (CRT) do not respond to it based on the current patient selection criteria. The purpose of this study was to identify baseline parameters that can predict CRT response and to evaluate the effect of those predictive parameters on long-term prognosis. Methods This was a retrospective, nonrandomized, noncontrolled cohort study. Patients who received CRT in our centre were divided into responders and nonresponders by the definition of CRT response (an increase in left ventricular ejection fraction (LVEF) of ≥5% and improvement of ≥1 New York Heart Association (NYHA) class from baseline to the 6-month follow-up). Results Of the 101 patients, 68 were responders and 33 were nonresponders. Left ventricular end-diastolic diameter (LVEDD; OR: 0.88, 95% CI: 0.81–0.95, P=0.001) and QRS duration (OR: 1.07, 95% CI: 1.04–1.10, P < 0.001) were independent predictors of CRT response. The combination of LVEDD and QRS duration was more valuable for predicting CRT response (AUC 0.836; 95% CI: 0.76–0.91; P < 0.001). Moreover, the combination of LVEDD ≤ 71 mm and QRS duration ≥ 170 ms had a low incidence of all-cause mortality, HF hospitalisation, and the composite endpoint. In addition, baseline LVEDD had a positive correlation with QRS duration (R=0.199, P=0.046). Responders to CRT had better LV reverse remodeling. Conclusion The combination of LVEDD and QRS duration provided more robust prediction of CRT response. Moreover, the combination of LVEDD ≤ 71 mm and QRS duration ≥ 170 ms was associated with a low incidence of all-cause mortality, HF hospitalisation, and the composite endpoint. Our results may be useful to provide individualized patient selection for CRT.
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11
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Ma J, Liu Y, Dong Y, Chen M, Xia L, Xu M. Association between changes in QRS width and echocardiographic responses to cardiac resynchronization therapy: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e18684. [PMID: 31914066 PMCID: PMC6959877 DOI: 10.1097/md.0000000000018684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Numerous studies have illustrated the association of QRS width with the incidence of echocardiographic response to cardiac resynchronization therapy (CRT). This study aimed to summarize the observational studies regarding the magnitude of change in QRS width between responders and nonresponders to CRT. METHODS The PubMed, Embase, and the Cochrane Library were systematically searched for relevant studies investigating the changes of QRS width with the incidence of echocardiographic response to CRT from inception till May 2019. The pooled weighted mean difference (WMD) with 95% confidence interval (CI) was calculated through random-effects model. RESULTS Five prospective and 6 retrospective studies with a total of 1524 patients were selected for final analysis. The reduction of QRS width in responders was significantly greater than nonresponders (WMD: -20.54 ms; 95% CI: -26.78 to -14.29; P < .001). Moreover, responders were associated with greater percentage reduction in QRS width when compared with nonresponders (WMD: -8.80%; 95% CI: -13.08 to -4.52; P < .001). Finally, the mean change in QRS width between responders and nonresponders differed when stratified by country, study design, mean age, percentage male, ejection fraction, measuring time of postimplanted QRS, ischemic cardiomyopathy, atrial fibrillation, and study quality. CONCLUSIONS These findings indicated that shortening QRS width after CRT device implantation showed association with greater incidence of echocardiographic responses to CRT. Further prospective studies should be conducted to evaluate the prognostic values of QRS width on the incidence of echocardiographic response to CRT.
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Affiliation(s)
- Jing Ma
- Division of Cardiology, Xuhui Central Hospital, Zhongshan-Xuhui Hospital, Fudan University
| | - Yi Liu
- Department of Ultrasonography, Shuguang Hospital, University of Traditional Chinese Medicine
| | - Yun Dong
- Department of Ultrasonography, East Hospital, Tongji University, Shanghai, China
| | - Ming Chen
- Department of Ultrasonography, East Hospital, Tongji University, Shanghai, China
| | - Lianghua Xia
- Department of Ultrasonography, East Hospital, Tongji University, Shanghai, China
| | - Min Xu
- Department of Ultrasonography, East Hospital, Tongji University, Shanghai, China
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12
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Leyva F, Qiu T, Zegard A, McNulty D, Evison F, Ray D, Gasparini M. Sex-Specific Differences in Survival and Heart Failure Hospitalization After Cardiac Resynchronization Therapy With or Without Defibrillation. J Am Heart Assoc 2019; 8:e013485. [PMID: 31718445 PMCID: PMC6915284 DOI: 10.1161/jaha.119.013485] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Women are underrepresented in cardiac resynchronization therapy (CRT) trials. Some studies suggest that women fare better than men after CRT. We sought to explore clinical outcomes in women and men undergoing CRT‐defibrillation or CRT‐pacing in real‐world clinical practice. Methods and Results A national database (Hospital Episode Statistics for England) was used to quantify clinical outcomes in 43 730 patients (women: 10 890 [24.9%]; men: 32 840 [75.1%]) undergoing CRT over 7.6 years, (median follow‐up 2.2 years, interquartile range, 1–4 years). In analysis of the total population, the primary end point of total mortality (adjusted hazard ratio [aHR], 0.73; 95% CI, 0.69–0.76) and the secondary end point of total mortality or heart failure hospitalization (aHR, 0.79, 95% CI 0.75–0.82) were lower in women, independent of known confounders. Total mortality (aHR, 0.73; 95% CI, 0.70–0.76) and total mortality or heart failure hospitalization (aHR, 0.79; 95% CI, 0.75–0.82) were lower for CRT‐defibrillation than for CRT‐pacing. In analyses of patients with (aHR, 0.89; 95% CI, 0.80–0.98) or without (aHR, 0.70; 95% CI, 0.66–0.73) a myocardial infarction, women had a lower total mortality. In sex‐specific analyses, total mortality was lower after CRT‐defibrillation in women (aHR, 0.83; P=0.013) and men (aHR, 0.69; P<0.001). Conclusions Compared with men, women lived longer and were less likely to be hospitalized for heart failure after CRT. In both sexes, CRT‐defibrillation was superior to CRT‐pacing with respect to survival and heart failure hospitalization. The longest survival after CRT was observed in women without a history of myocardial infarction.
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Affiliation(s)
- Francisco Leyva
- Aston Medical Research Institute Aston Medical School Aston University Birmingham United Kingdom
| | - Tian Qiu
- Quality and Outcomes Research Unit Queen Elizabeth Hospital Birmingham United Kingdom
| | - Abbasin Zegard
- Aston Medical Research Institute Aston Medical School Aston University Birmingham United Kingdom
| | - David McNulty
- Quality and Outcomes Research Unit Queen Elizabeth Hospital Birmingham United Kingdom
| | - Felicity Evison
- Quality and Outcomes Research Unit Queen Elizabeth Hospital Birmingham United Kingdom
| | - Daniel Ray
- NHS Digital and Farr Institute London United Kingdom
| | - Maurizio Gasparini
- Electrophysiology and Pacing Unit Humanitas Research Hospital IRCCS Rozzano-Milano Italy
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13
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Mincholé A, Zacur E, Ariga R, Grau V, Rodriguez B. MRI-Based Computational Torso/Biventricular Multiscale Models to Investigate the Impact of Anatomical Variability on the ECG QRS Complex. Front Physiol 2019; 10:1103. [PMID: 31507458 PMCID: PMC6718559 DOI: 10.3389/fphys.2019.01103] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/08/2019] [Indexed: 01/07/2023] Open
Abstract
AIMS Patient-to-patient anatomical differences are an important source of variability in the electrocardiogram, and they may compromise the identification of pathological electrophysiological abnormalities. This study aims at quantifying the contribution of variability in ventricular and torso anatomies to differences in QRS complexes of the 12-lead ECG using computer simulations. METHODS A computational pipeline is presented that enables computer simulations using human torso/biventricular anatomically based electrophysiological models from clinically standard magnetic resonance imaging (MRI). The ventricular model includes membrane kinetics represented by the biophysically detailed O'Hara Rudy model modified for tissue heterogeneity and includes fiber orientation based on the Streeter rule. A population of 265 torso/biventricular models was generated by combining ventricular and torso anatomies obtained from clinically standard MRIs, augmented with a statistical shape model of the body. 12-lead ECGs were simulated on the 265 human torso/biventricular electrophysiology models, and QRS morphology, duration and amplitude were quantified in each ECG lead for each of the human torso-biventricular models. RESULTS QRS morphologies in limb leads are mainly determined by ventricular anatomy, while in the precordial leads, and especially V1 to V4, they are determined by heart position within the torso. Differences in ventricular orientation within the torso can explain morphological variability from monophasic to biphasic QRS complexes. QRS duration is mainly influenced by myocardial volume, while it is hardly affected by the torso anatomy or position. An average increase of 0.12 ± 0.05 ms in QRS duration is obtained for each cm3 of myocardial volume across all the leads while it hardly changed due to changes in torso volume. CONCLUSION Computer simulations using populations of human torso/biventricular models based on clinical MRI enable quantification of anatomical causes of variability in the QRS complex of the 12-lead ECG. The human models presented also pave the way toward their use as testbeds in silico clinical trials.
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Affiliation(s)
- Ana Mincholé
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Ernesto Zacur
- Institute of Biomedical Engineering (IBME), University of Oxford, Oxford, United Kingdom
| | - Rina Ariga
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Vicente Grau
- Institute of Biomedical Engineering (IBME), University of Oxford, Oxford, United Kingdom
| | - Blanca Rodriguez
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
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14
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Nishimura M, Birgersdotter-Green U. Gender-Based Differences in Cardiac Resynchronization Therapy Response. Card Electrophysiol Clin 2019; 11:115-122. [PMID: 30717843 DOI: 10.1016/j.ccep.2018.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cardiac resynchronization therapy (CRT) has been shown to have a multitude of beneficial effects in select patients with systolic heart failure, by enhancing reverse remodeling, improving quality of life and functional status, reducing risk of heart failure admission, and most importantly, improving survival. Although women were underrepresented in the clinical trials, they were demonstrated to derive greater therapeutic benefit from CRT compared with men. Importantly, women were noted to derive benefit at a lesser degree of QRS prolongation than men, well below the now generally accepted cutoff of QRS ≥150 milliseconds.
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Affiliation(s)
- Marin Nishimura
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, 9500 Gilman Drive, Mail Code 7411, La Jolla, CA 92037-7411, USA
| | - Ulrika Birgersdotter-Green
- Pacemaker and ICD Services, Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, 9444 Medical Center Drive, MC 7411, La Jolla, CA 92037, USA.
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15
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van Dongen IM, Kolk MZH, Elias J, Meijborg VMF, Coronel R, de Bakker JMT, Claessen BEPM, Delewi R, Ouweneel DM, Scheunhage EM, van der Schaaf RJ, Suttorp MJ, Bax M, Marques KM, Postema PG, Wilde AAM, Henriques JPS. The effect of revascularization of a chronic total coronary occlusion on electrocardiographic variables. A sub-study of the EXPLORE trial. J Electrocardiol 2018; 51:906-912. [PMID: 30177338 DOI: 10.1016/j.jelectrocard.2018.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/10/2018] [Accepted: 07/18/2018] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Chronic total coronary occlusions (CTOs) have been associated with a higher prevalence of ventricular arrhythmias compared to patients without a CTO. We evaluated the effect of CTO revascularization on electrocardiographic (ECG) variables. METHODS We studied a selection of ST-elevation myocardial infarction patients with a concomitant CTO enrolled in the EXPLORE trial. ECG variables and cardiac function were analysed at baseline and at 4 months follow-up. RESULTS Patients were randomized to percutaneous coronary intervention (PCI) of their CTO (n = 77) or to no-CTO PCI (n = 81). At follow-up, median QT dispersion was significantly lower in the CTO PCI group compared to the no-CTO PCI group (46 ms [33-58] vs. 54 ms [37-68], P = 0.043). No independent association was observed between ECG variables and cardiac function. CONCLUSION Revascularization of a CTO after STEMI significantly shortened QT dispersion at 4 months follow-up. These findings support the hypothesis that CTO revascularization reduces the pro-arrhythmic substrate in CTO patients.
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Affiliation(s)
- Ivo M van Dongen
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands.
| | - Maarten Z H Kolk
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - Joëlle Elias
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | | | - Ruben Coronel
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Ronak Delewi
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - Dagmar M Ouweneel
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - Esther M Scheunhage
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Matthijs Bax
- Haga Teaching Hospital, The Hague, The Netherlands
| | - Koen M Marques
- Free University Medical Center, Amsterdam, The Netherlands
| | - Pieter G Postema
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - José P S Henriques
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
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16
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Zweerink A, Wu L, de Roest GJ, Nijveldt R, de Cock CC, van Rossum AC, Allaart CP. Improved patient selection for cardiac resynchronization therapy by normalization of QRS duration to left ventricular dimension. Europace 2018; 19:1508-1513. [PMID: 27707784 DOI: 10.1093/europace/euw265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/02/2016] [Indexed: 01/23/2023] Open
Abstract
Aims This study evaluates the relative importance of two components of QRS prolongation, myocardial conduction velocity and travel distance of the electrical wave front (i.e. path length), for the prediction of acute response to cardiac resynchronization therapy (CRT) in left bundle branch block (LBBB) patients. Methods and results Thirty-two CRT candidates (ejection fraction <35%, LBBB) underwent cardiac magnetic resonance (CMR) imaging to provide detailed information on left ventricular (LV) dimensions. Left ventricular end-diastolic volume (LVEDV) was used as a primary measure for path length, subsequently QRSd was normalized to LV dimension (i.e. QRSd divided by LVEDV) to adjust for conduction path length. Invasive pressure-volume loop analysis at baseline and during CRT was used to assess acute pump function improvement, expressed as LV stroke work (SW) change. During CRT, SW improved by +38 ± 46% (P < 0.001). The baseline LVEDV was positively related to QRSd (R = 0.36, P = 0.044). Despite this association, a paradoxical inverse relation was found between LVEDV and SW improvement during CRT (R = -0.40; P = 0.025). Baseline unadjusted QRSd was found to be unrelated to SW changes during CRT (R = 0.16; P = 0.383), whereas normalized QRSd (QRSd/LVEDV) yielded a strong correlation with CRT response (R = 0.49; P = 0.005). Other measures of LV dimension, including LV length, LV diameter, and LV end-systolic volume, showed similar relations with normalized QRSd and SW improvement. Conclusion Since normalized QRSd reflects myocardial conduction properties, these findings suggest that myocardial conduction velocity rather than increased path length mainly determines response to CRT. Normalizing QRSd to LV dimension might provide a relatively simple method to improve patient selection for CRT.
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Affiliation(s)
- A Zweerink
- Department of Cardiology, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands.,Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - L Wu
- Department of Cardiology, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands.,Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - G J de Roest
- Department of Cardiology, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands.,Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - R Nijveldt
- Department of Cardiology, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands.,Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - C C de Cock
- Department of Cardiology, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands.,Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - A C van Rossum
- Department of Cardiology, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands.,Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - C P Allaart
- Department of Cardiology, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands.,Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
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17
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Varma N, Sogaard P, Bax JJ, Abraham WT, Borer JS, Dickstein K, Singh JP, Gras D, Holzmeister J, Brugada J, Ruschitzka F. Interaction of Left Ventricular Size and Sex on Outcome of Cardiac Resynchronization Therapy Among Patients With a Narrow QRS Duration in the EchoCRT Trial. J Am Heart Assoc 2018; 7:JAHA.118.009592. [PMID: 29807890 PMCID: PMC6015380 DOI: 10.1161/jaha.118.009592] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Longer QRS duration (QRSd) improves, but increased left ventricular (LV) end-diastolic volume (LVEDV) reduces, efficacy of cardiac resynchronization therapy (CRT). QRSd/LVEDV ratios differ between sexes. We hypothesized that in the EchoCRT (Echocardiography Guided Cardiac Resynchronization Therapy) trial enrolling patients with heart failure with QRSd <130 ms, those with larger LVEDV would deteriorate but those with the highest QRSd/LVEDV would improve with CRT. METHODS AND RESULTS Primary outcome in patients (n=787, 72% men, 93% New York Heart Association class III, QRSd <130 ms, LV ejection fraction ≤35%, LV dilation and dyssynchrony) randomized to CRT-ON or CRT-OFF and followed up for 19 months was compared according to LVEDV (height indexed) or QRSd/LVEDV ratio, in multivariable analysis. Structural remodeling was assessed echocardiographically 6 months after implantation. Patients with baseline LVEDV higher than or equal to median worsened with CRT (death/heart failure hospitalization: CRT-ON versus CRT-OFF, 35.2% versus 24.5% [hazard ratio, 1.64; 95% confidence interval, 1.11-2.42; P=0.012]), but those with LVEDV lower than median remained unaffected. Patients with the highest QRSd/LVEDV ratio improved with CRT (death/heart failure hospitalization in top quartile: 20.9% in CRT-ON [n=91] versus 28.3% in CRT-OFF [n=106] [hazard ratio, 0.64; 95% confidence interval, 0.34-1.24; P=0.188], versus the remaining quartiles: 31.7% in CRT-ON [n=300] versus 24.8% in CRT-OFF [n=290] [hazard ratio, 1.47; 95% confidence interval, 1.07-2.02; P=0.016], test for interaction P=0.046). QRSd and dyssynchrony were similar between groups. The 3-way test for interaction indicated no sex-specific effects. However, numerically, men with LVEDV higher than or equal to median accounted for worse outcomes of CRT-ON. Women, with the highest QRSd/LVEDV ratio exhibited significant reverse remodeling. CONCLUSION CRT has opposite effects among patients with heart failure with QRSd <130 ms according to LV size: worsening outcomes in patients with larger LV, but inducing beneficial effects in those with smaller LV. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00683696.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH
| | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - William T Abraham
- Division of Cardiovascular Medicine, Ohio State University Medical Center, Davis Heart and Lung Research Institute, Columbus, OH
| | - Jeffrey S Borer
- Division of Cardiovascular Medicine and Howard Gilman and Ron and Jean Schiavone Institutes, State University of New York Downstate College of Medicine, Brooklyn, NY
| | - Kenneth Dickstein
- University of Bergen Stavanger University Hospital, Stavanger, Norway
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Corrigan Minehan Heart Center, Boston, MA
| | - Daniel Gras
- Nouvelles Cliniques Nantaises, Nantes, France
| | | | - Josep Brugada
- Cardiology Department, Thorax Institute, Hospital Clinic, University of Barcelona, Spain
| | - Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
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18
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Alqarawi W, Birnie DH, Burwash IG. Mitral valve repair results in suppression of ventricular arrhythmias and normalization of repolarization abnormalities in mitral valve prolapse. HeartRhythm Case Rep 2018; 4:191-194. [PMID: 29915716 PMCID: PMC6003536 DOI: 10.1016/j.hrcr.2018.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- Wael Alqarawi
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - David H Birnie
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Ian G Burwash
- Echocardiography Laboratory, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
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19
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Biering-Sørensen T, Kabir M, Waks JW, Thomas J, Post WS, Soliman EZ, Buxton AE, Shah AM, Solomon SD, Tereshchenko LG. Global ECG Measures and Cardiac Structure and Function: The ARIC Study (Atherosclerosis Risk in Communities). Circ Arrhythm Electrophysiol 2018; 11:e005961. [PMID: 29496680 PMCID: PMC5836803 DOI: 10.1161/circep.117.005961] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/16/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Electric excitation initiates myocardial mechanical contraction and coordinates myocardial pumping. We hypothesized that ECG global electric heterogeneity (GEH) and its longitudinal changes are associated with cardiac structure and function. METHODS AND RESULTS Participants from the ARIC study (Atherosclerosis Risk in Communities) (N=5114; 58% female; 22% blacks) with resting 12-lead ECGs (visits 1-5) and echocardiographic assessment of left ventricular (LV) ejection fraction, LV global longitudinal strain, LV mass index, LV end-diastolic volume index, and LV end-systolic volume index at visit 5 were included. Longitudinal analysis included ARIC participants (N=14 609) with measured GEH at visits 1 to 4. GEH was quantified by spatial ventricular gradient, QRS-T angle, and sum absolute QRS-T integral. Cross-sectional and longitudinal regressions were adjusted for manifest and subclinical cardiovascular disease. Having 4 abnormal GEH parameters was associated with a 6.4% (95% confidence interval, 5.5-7.3) LV ejection fraction decline, a 24.2 g/m2 (95% confidence interval, 21.5-26.9) increase in LV mass index, a 10.3 mL/m2 (95% confidence interval, 8.9-11.7) increase in LV end-diastolic volume index, and a 7.8 mL/m2 (95% confidence interval, 6.9-8.6) increase in LV end-systolic volume index. Altogether, clinical and ECG parameters accounted for approximately one third of LV volume and 20% of systolic function variability. The associations were significantly stronger in cardiovascular disease. Sum absolute QRS-T integral increased by 20 mV*ms for each 3-year period in participants who demonstrated LV dilatation at visit 5. Sudden cardiac death victims demonstrated rapid GEH worsening, whereas those with LV dysfunction demonstrated slow GEH worsening. Healthy aging was associated with a distinct pattern of spatial ventricular gradient azimuth decrement. CONCLUSIONS GEH is a marker of subclinical abnormalities in cardiac structure and function.
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Affiliation(s)
- Tor Biering-Sørensen
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Muammar Kabir
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Jonathan W Waks
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Jason Thomas
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Wendy S Post
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Elsayed Z Soliman
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Alfred E Buxton
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Amil M Shah
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Scott D Solomon
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.)
| | - Larisa G Tereshchenko
- From the Brigham and Women's Hospital (T.B.-S., A.M.S., S.D.S.) and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center (J.W.W., A.E.B.), Harvard Medical School, Boston, MA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland (M.K., J.T., L.G.T.); Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.S.P., L.G.T.); and Epidemiological Cardiology Research Center, Cardiology Section, Department of Medicine, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.).
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20
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Vancheri F, Vancheri S, Henein M. Relationship between QRS measurements and left ventricular morphology and function in asymptomatic individuals. Echocardiography 2017; 35:301-307. [PMID: 29280530 DOI: 10.1111/echo.13782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND AIM QRS amplitude and duration are associated with increased left ventricular (LV) volume, mass and dysfunction. However, the diagnostic concordance between QRS measurements and LV morphology and function, as shown by Doppler echocardiography, is not well established. We investigated the relationships of QRS duration and amplitude with echocardiographic measurements of LV morphology and systolic and diastolic function in normal individuals. METHODS Individuals without signs or symptoms of coronary artery disease or heart failure, who underwent clinical examination as a part of a cross-sectional survey for the prevalence of coronary risk factors, randomly selected from the population list in Caltanissetta, Italy, were included in the study. QRS duration and amplitude were automatically measured using inbuilt software. LV ejection and filling patterns were studied using Doppler echocardiography. RESULTS We studied 184 individuals (96 men and 88 women), mean age 55.9 (11.3). QRS duration increased by 5.4 ms for every 100 g increase in LV mass, and by 4.6 ms for each 10 mm increase in LV end-diastolic diameter. The amplitude increased by 0.8 mm for every 100 g increase in LV mass. There was no relationship with LV dimensions. A nonlinear correlation was found between QRS amplitude and indexes of global dyssynchrony. The time-voltage QRS area correlated with LV mass, dimensions and indexes of dyssynchrony. There was no relationship between QRS measurements and ejection fraction. CONCLUSIONS QRS prolongation and increase in amplitude are strongly influenced by LV increased mass and volume, as well as by dyssynchrony, independently of ejection fraction.
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Affiliation(s)
| | | | - Michael Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.,Molecular and Clinical Sciences Research Institute, St George University, London, UK
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21
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Deen JF, Rhoades DA, Noonan C, Best LG, Okin PM, Devereux RB, Umans JG. Comparison of QRS Duration and Associated Cardiovascular Events in American Indian Men Versus Women (The Strong Heart Study). Am J Cardiol 2017; 119:1757-1762. [PMID: 28416200 DOI: 10.1016/j.amjcard.2017.02.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 02/22/2017] [Accepted: 02/22/2017] [Indexed: 01/19/2023]
Abstract
Electrocardiographic QRS duration at rest is associated with sudden cardiac death and death from coronary heart disease in the general population. However, its relation to cardiovascular events in American Indians, a population with persistently high cardiovascular disease mortality, is unknown. The relation of QRS duration to incident cardiovascular disease during 17.2 years of follow-up was assessed in 1,851 male and female Strong Heart Study participants aged 45 to 74 years without known cardiovascular disease at baseline. Cox regression with robust standard error estimates was used to determine the association between quintiles of QRS duration and incident cardiovascular disease in gender-stratified analyses, adjusted for age, systolic blood pressure, hypertension, antihypertensive medication use, body mass index, current smoking, diabetes, total cholesterol, high-density lipoprotein cholesterol, and albuminuria. In women only, QRS duration in the highest quintile (≥105 ms) conferred significantly higher risk of cardiovascular disease than QRS duration in the lowest quintile (64 to 84 ms) (hazard ratio 1.6, 95% CI 1.1 to 2.4) likely because of higher risks of coronary heart disease (hazard ratio 1.8, 95% CI 1.1 to 3.1) and myocardial infarction (hazard ratio 2.1, 95% CI 1.0 to 4.7). Furthermore, when added to the Strong Heart Study Coronary Heart Disease Risk Calculator, QRS duration significantly improved prediction of future coronary heart disease events in women (Net Reclassification Index 0.17, 95% CI 0.06 to 0.47). In conclusion, QRS duration is an independent predictor of cardiovascular disease in women in the Strong Heart Study cohort and may have value in estimating risk in populations with similar risk profiles and a high lifetime incidence of cardiovascular disease.
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Affiliation(s)
- Jason F Deen
- Division of Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington; Division of Cardiology, University of Washington Medical Center, Seattle, Washington.
| | - Dorothy A Rhoades
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Carolyn Noonan
- Initiative for Research and Education to Advance Community Health, Washington State University, Seattle, Washington
| | - Lyle G Best
- Missouri Breaks Industries Research Inc., Eagle Butte, South Dakota
| | - Peter M Okin
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Richard B Devereux
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Jason G Umans
- MedStar Health Research Institute, Hyattsville, Maryland; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, District of Columbia
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22
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Varma N, Lappe J, He J, Niebauer M, Manne M, Tchou P. Sex-Specific Response to Cardiac Resynchronization Therapy: Effect of Left Ventricular Size and QRS Duration in Left Bundle Branch Block. JACC Clin Electrophysiol 2017; 3:844-853. [PMID: 29759781 DOI: 10.1016/j.jacep.2017.02.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/10/2017] [Accepted: 02/16/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES In this study, the authors sought to assess the impact of body and heart size on sex-specific cardiac resynchronization therapy (CRT) response rate, according to QRS duration (QRSd) as a continuum. BACKGROUND Effects of CRT differ between sexes for any given QRSd. METHODS New York Heart Association functional class III/IV patients with nonischemic cardiomyopathy and "true" left bundle branch block (LBBB) were evaluated. Left ventricular mass (LVM) and end-diastolic volume were measured echocardiographically. Positive response was defined by left ventricular ejection fraction (LVEF) improvement post-CRT. RESULTS Among 130 patients (LVEF 19 ± 7.1%; QRSd 165 ± 20 ms; 55% female), CRT improved LVEF to 32 ± 14% (p < 0.001) during a median 2 years follow-up. Positive responses occurred in 103 of 130 (79%) (78% when QRSd <150 ms vs. 80% when QRSd ≥150 ms; p = 0.8). Body surface area (BSA), QRSd, and LVM were lower in women, but QRSd/LVM ratio greater (p < 0.0001). Sexes did not differ for pharmacotherapy and comorbidities, but female CRT response was greater: 90% (65 of 72) versus 66% (38 of 58) in males (p < 0.001). With QRSd as a continuum, the overall CRT-response relationship showed a progressive increase to plateau between 150 and 170 ms, then a decrease. Sex-specific differences were conspicuous: among females, a peak effect was observed between 135 and 150 ms, thereafter a decline, with the male response rate lower, but with a gradual increase as QRSd lengthened. Sex-specific differences were unaltered by BSA, but resolved with integration of LVM or end-diastolic volume. CONCLUSIONS Sex differences in the QRSd-response relationship among CRT patients with LBBB were unexplained by application of strict LBBB criteria or by BSA, but resolved by QRSd normalization for heart size using LV mass or volume.
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Affiliation(s)
- Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Jason Lappe
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jiayan He
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Mark Niebauer
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mahesh Manne
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Tchou
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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23
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Rickard J, Baranowski B, Grimm RA, Niebauer M, Varma N, Tang WHW, Wilkoff BL. Left Ventricular Size does not Modify the Effect of QRS Duration in Predicting Response to Cardiac Resynchronization Therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:482-487. [PMID: 28164328 DOI: 10.1111/pace.13043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/08/2016] [Accepted: 08/23/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND QRS duration (QRSd) may be impacted by both left ventricular (LV) dilatation and conduction delay. It is possible therefore that the same QRSd may portend significantly different amounts of LV activation delay in patients with small versus large left ventricles. We hypothesized that LV size modifies the effect of QRSd on predicting outcomes in patients undergoing CRT implant. METHODS We extracted data on consecutive patients presenting for initial CRT implant. In patients with a follow-up echocardiogram, response was defined as an absolute improvement in LV ejection fraction ≥5%. Multivariate models were created to determine if left ventricular end-diastolic diameter (LVEDD) modified the effect of QRSd on its association with both long-term survival free of left ventricular assist device (LVAD) and heart transplant and echocardiographic response. RESULTS 464 patients met inclusion criteria. At a mean follow-up of 4.9 ± 2.6 years, there were 210 deaths, 13 heart transplants, and 12 LVAD placements. There was a weak but significant correlation between baseline QRSd and LVEDD (Spearman's Rho 0.106, P < 0.001). In a multivariate analysis, there was no evidence of effect modification of LVEDD on QRSd (LVEDDi*QRS interaction term HR 1.0 [0.995-1.006], P = 0.94). Note that 305 patients had a follow-up echocardiogram, of whom 193 met the criteria for response. In a multivariate analysis, there was no evidence of effect modification of LVEDD on QRSd (LVEDDi*QRS interaction term odds ratio 0.998 (0.988-1.008), P = 0.65). CONCLUSION LV size does not modify the effect of QRSd and its association with outcomes following CRT. The correlation between LV size and QRSd in patients with a QRSd ≥ 120 ms is weak.
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Affiliation(s)
- John Rickard
- Heart and Vascular Institute Cleveland Clinic, Cleveland, Ohio
| | | | - Richard A Grimm
- Heart and Vascular Institute Cleveland Clinic, Cleveland, Ohio
| | - Mark Niebauer
- Heart and Vascular Institute Cleveland Clinic, Cleveland, Ohio
| | - Niraj Varma
- Heart and Vascular Institute Cleveland Clinic, Cleveland, Ohio
| | - W H Wilson Tang
- Heart and Vascular Institute Cleveland Clinic, Cleveland, Ohio
| | - Bruce L Wilkoff
- Heart and Vascular Institute Cleveland Clinic, Cleveland, Ohio
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24
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Maanja M, Wieslander B, Schlegel TT, Bacharova L, Abu Daya H, Fridman Y, Wong TC, Schelbert EB, Ugander M. Diffuse Myocardial Fibrosis Reduces Electrocardiographic Voltage Measures of Left Ventricular Hypertrophy Independent of Left Ventricular Mass. J Am Heart Assoc 2017; 6:JAHA.116.003795. [PMID: 28111363 PMCID: PMC5523623 DOI: 10.1161/jaha.116.003795] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Myocardial fibrosis quantified by myocardial extracellular volume fraction (ECV) and left ventricular mass (LVM) index (LVMI) measured by cardiovascular magnetic resonance might represent independent and opposing contributors to ECG voltage measures of left ventricular hypertrophy (LVH). Diffuse myocardial fibrosis can occur in LVH and interfere with ECG voltage measures. This phenomenon could explain the decreased sensitivity of LVH detectable by ECG, a fundamental diagnostic tool in cardiology. Methods and Results We identified 77 patients (median age, 53 [interquartile range, 26–60] years; 49% female) referred for contrast‐enhanced cardiovascular magnetic resonance with ECV measures and 12‐lead ECG. Exclusion criteria included clinical confounders that might influence ECG measures of LVH. We evaluated ECG voltage‐based LVH measures, including Sokolow‐Lyon index, Cornell voltage, 12‐lead voltage, and the vectorcardiogram spatial QRS voltage, with respect to LVMI and ECV. ECV and LVMI were not correlated (R2=0.02; P=0.25). For all voltage‐related parameters, higher LVMI resulted in greater voltage (r=0.33–0.49; P<0.05 for all), whereas increased ECV resulted in lower voltage (r=−0.32 to −0.57; P<0.05 for all). When accounting for body fat, LV end‐diastolic volume, and mass‐to‐volume ratio, both LVMI (β=0.58, P=0.03) and ECV (β=−0.46, P<0.001) were independent predictors of QRS voltage (multivariate adjusted R2=0.39; P<0.001). Conclusions Myocardial mass and diffuse myocardial fibrosis have independent and opposing effects upon ECG voltage measures of LVH. Diffuse myocardial fibrosis quantified by ECV can obscure the ECG manifestations of increased LVM. This provides mechanistic insight, which can explain the limited sensitivity of the ECG for detecting increased LVM.
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Affiliation(s)
- Maren Maanja
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Björn Wieslander
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Todd T Schlegel
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.,Nicollier-Schlegel SARL, Trélex, Switzerland
| | - Ljuba Bacharova
- International Laser Center, Bratislava, Slovak Republic.,Institute of Pathophysiology, Medical School, Comenius University, Bratislava, Slovak Republic
| | - Hussein Abu Daya
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yaron Fridman
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Timothy C Wong
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Erik B Schelbert
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
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25
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Leng YLY, Zhou Y, Ke H, Jelinek H, McCabe J, Assareh H, McLachlan CS. Electrocardiogram Derived QRS Duration >120 ms is Associated With Elevated Plasma Homocysteine Levels in a Rural Australian Cross-Sectional Population. Medicine (Baltimore) 2015; 94:e1080. [PMID: 26166085 PMCID: PMC4504556 DOI: 10.1097/md.0000000000001080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Homocysteine levels in the low to moderate range for cardiovascular risk have been previously associated with left ventricular cardiac hypertrophy (LVH). Electrocardiogram (ECG) derived QRS duration has also been used as an epidemiological screening marker for cardiac hypertrophy risk. QRS duration cut offs have not been previously modeled to assess homocysteine levels in community populations. Our aims are to determine if QRS duration is associated with an elevated homocysteine level in a cross-sectional Australian aging rural population.A retrospective study design utilizing a rural health diabetic screening clinic database containing observational data from the period January 9, 2002 till September 25, 2012. One hundred seventy-eight individuals (>21 years of age) from the database were included in the study. Inclusion criteria included being nondiabetic and having both a QRS duration measure and a matching homocysteine level within the same subject. All participants were from the Albury-Wodonga area, with a mean age of >64 years for both sexes.Mean population homocysteine plasma levels were 10.4 μmol/L (SD = 3.6). The mean QRS duration was 101.8 ms (SD = 17.4). Groups were stratified on the basis of QRS duration (≤120 ms [n = 157] and >120 ms [n = 21]). QRS duration subgroup (≤120 ms vs >120 ms) mean differences across homocysteine levels were 10.1 μmol/L (SD = 3.3) and 12.2 μmol/L (SD = 4.7), respectively (P = 0.016). Other ECG parameters (PQ interval, QTc interval, and QT dispersion) measurements were not significantly associated with differences in plasma homocysteine (P = not significant).We conclude that in community populations homocysteine may be moderately elevated when QRS durations are >120 ms. Small additional increases in homocysteine levels may suggest a risk factor for ECG diagnosis of LVH.
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Affiliation(s)
- Yvonne Lee Yin Leng
- From the Rural Clinical School, Faculty of Medicine, University of New South Wales (UNSW), Sydney, NSW, Australia (YLYL, YZ, JM, HA, CSM); Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China (HK); and School of Community Health, Centre for Research in Complex Systems, Charles Sturt University, Albury, NSW, Australia (HJ)
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26
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Comparison of the relation between left ventricular anatomy and QRS duration in patients with cardiomyopathy with versus without left bundle branch block. Am J Cardiol 2014; 113:1717-22. [PMID: 24698465 DOI: 10.1016/j.amjcard.2014.02.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/18/2014] [Accepted: 02/18/2014] [Indexed: 12/12/2022]
Abstract
QRS duration (QRSd) is used to diagnose left bundle branch block (LBBB) and is important to determine cardiac resynchronization therapy eligibility. The same QRSd thresholds established decades ago are used for all patients. However, significant interpatient variability of normal QRSd exists, and individualized QRSd thresholds might improve diagnosis and intervention strategies. Previous work reported left ventricular (LV) mass and papillary muscle location predicted QRSd in healthy subjects, but the relation in diseased ventricles is unknown. The aim of the present study was to determine the association between LV anatomy and QRSd in patients with cardiomyopathy. Patients referred for primary prevention implantable defibrillators (n = 166) received cardiac magnetic resonance imaging, and those with normal conduction (without bundle branch or fascicular block) and LBBB were studied. The LV mass, length, internal diameter, LV end-diastolic volume, septal and lateral wall thicknesses, and papillary muscle location were measured. In patients with normal conduction, LV length (r = 0.35, p <0.001), mass (r = 0.32, p <0.001), diameter (r = 0.20, p = 0.03), and septal wall thickness (r = 0.20, p = 0.03) had positive correlations with QRSd. In patients with LBBB, LV length (r = 0.32, p = 0.03), mass (r = 0.39, p = 0.01), diameter (r = 0.34, p = 0.02), and LV end-diastolic volume (r = 0.32, p = 0.04) had positive correlations with QRSd. Contrary to previous studies in healthy subjects, papillary muscle angle (location) was not associated with QRSd in cardiomyopathy patients with normal conduction or LBBB. In conclusion, increasing LV anatomical measurements were associated with increasing QRSd in patients with cardiomyopathy. Future work should investigate the use of LV anatomical measurements in developing individualized QRSd thresholds for diagnosing conduction abnormalities such as LBBB and identifying candidates for cardiac resynchronization therapy.
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27
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Assanelli D, Di Castelnuovo A, Rago L, Badilini F, Vinetti G, Gianfagna F, Salvetti M, Zito F, Donati MB, de Gaetano G, Iacoviello L. T-wave axis deviation and left ventricular hypertrophy interaction in diabetes and hypertension. J Electrocardiol 2013; 46:487-91. [DOI: 10.1016/j.jelectrocard.2013.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Indexed: 10/26/2022]
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Abstract
Left bundle branch block (LBBB) is generally associated with a poorer prognosis in comparison to normal intraventricular conduction, but also in comparison to right bundle branch block which is generally considered to be benign in the absence of an underlying cardiac disorder like congenital heart disease. LBBB may be the first manifestation of a more diffuse myocardial disease. The typical surface ECG feature of LBBB is a prolongation of QRS above 0.11 s in combination with a delay of the intrinsic deflection in leads V5 and V6 of more than 60 ms and no septal q waves in leads I, V5, and V6 due to the abnormal septal activation from right to left. LBBB may induce abnormalities in left ventricular performance due to abnormal asynchronous contraction patterns which can be compensated by biventricular pacing (resynchronization therapy). Asynchronous electrical activation of the ventricles causes regional differences in workload which may lead to asymmetric hypertrophy and left ventricular dilatation, especially due to increased wall mass in late-activated regions, which may aggravate preexisting left ventricular pumping performance or even induce it. Of special interest are patients with LBBB and normal left ventricular dimensions and normal ejection fraction at rest but who may present with an abnormal increase in pulmonary artery pressure during exercise, production of lactate during high-rate pacing, signs of ischemia on myocardial scintigrams (but no coronary artery narrowing), and abnormal ultrastructural findings on myocardial biopsy. For this entity, the term latent cardiomyopathy had been suggested previously.
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Affiliation(s)
- Günter Breithardt
- Department of Cardiology and Angiology, Hospital of the University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Germany.
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29
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Desai CS, Ning H, Lloyd-Jones DM. Competing cardiovascular outcomes associated with electrocardiographic left ventricular hypertrophy: the Atherosclerosis Risk in Communities Study. Heart 2011; 98:330-4. [PMID: 22139711 DOI: 10.1136/heartjnl-2011-300819] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Individuals with electrocardiographically determined left ventricular hypertrophy (ECG LVH) are at risk of multiple cardiovascular disease (CVD) outcomes simultaneously. The study sought to characterise the competing incidences for subtypes of first CVD events or non-CVD death in those with and without ECG LVH. METHODS Participants in the Atherosclerosis Risk in Communities (ARIC) Study were included. ECG LVH was defined according to Sokolow-Lyon criteria. Competing Cox models were used to compare hazards for diverse outcomes within groups (e.g., among those with ECG LVH) and for a given event between groups (ECG LVH vs. no ECG LVH). RESULTS After 15 years, men with ECG LVH at baseline (N=383) had a cumulative incidence of first CVD events and non-CVD deaths of 29.2% and 6.1%, respectively (HR 4.86; 95% CI 3.04 to 7.77). In men without ECG LVH (N=6576) the incidence of any first CVD event and non-CVD death was 18.9% and 6.9%, respectively (HR 2.67; 2.39 to 2.98). Similar associations were observed in women (N=381 with and N=8187 without ECG LVH). Coronary heart disease (CHD) was the most common first event in men with ECG LVH (15.0%) and heart failure was the most common first event in women with ECG LVH (10.5%). After adjustment for risk factors including systolic blood pressure, any CVD event remained the most likely first event. CONCLUSIONS Among middle-aged individuals with ECG LVH, the most likely first events are CHD in men and heart failure in women; these results may have implications for preventive approaches.
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Affiliation(s)
- Chintan S Desai
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1402, Chicago, IL 60611, USA
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