BackgroundElevated N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) concentrations predict heart failure (HF) and mortality, but whether NT‐proBNP predicts ventricular arrhythmias (VA) is not clear.HypothesisWe hypothesize that high NT‐proBNP concentrations associate with the risk of incident VA, defined as adjudicated ventricular fibrillation or sustained ventricular tachycardia.MethodsIn a prospective, observational study of patients treated with implantable cardioverter defibrillator (ICD), we analyzed NT‐proBNP concentrations at baseline and after mean 1.4 years in association to incident VA.ResultsWe included 490 patients (age 66 ± 12 years, 83% men) out of whom 51% had a primary prevention ICD indication. The median NT‐proBNP concentration was 567 (25–75 percentile 203–1480) ng/L and patients with higher concentrations were older with more HF and ICD for primary prevention. During mean 3.1 ± 0.7 years, 137 patients (28%) had ≥1 VA. Baseline NT‐proBNP concentrations were associated with the risk of incident VA (hazard ratio [HR]: 1.39, 95% confidence interval [95% CI]: 1.22–1.58, p < .001), HF hospitalizations (HR: 3.11, 95% CI: 2.53–3.82, p < .001), and all‐cause mortality (HR: 2.49, 95% CI: 2.04–3.03, p < .001), which persisted after adjusting for age, sex, body mass index, coronary artery disease, HF, renal function, and left ventricular ejection fraction. The association with VA was stronger in secondary versus primary prevention ICD indication: HR: 1.59 (95% CI: 1.34–1.88 C‐statistics 0.71) versus HR: 1.24, 95% CI: 1.02–1.51, C‐statistics 0.55), p‐for‐interaction = 0.06. Changes in NT‐proBNP during the first 1.4 years did not associate with subsequent VA.ConclusionsNT‐proBNP concentrations are associated with the risk of incident VA after adjustment for established risk factors, with the strongest association in patients with a secondary prevention ICD indication.
Introduction QRS fragmentation (fQRS), defined as the presence of additional spikes within the QRS complex, has been associated with myocardial conduction abnormalities and arrhythmogenicity. Objective We aimed to assess whether fQRS is associated with incident ventricular arrhythmias (VA) in high‐risk patients treated with implantable cardioverter‐defibrillator (ICD) for primary and secondary prevention. Methods In a prospective observational multicenter study, we included 495 patients treated with ICD. fQRS was analyzed according to previously validated criteria, by two physicians blinded for outcome data. Incident VA were obtained from ICD recordings. Results ECG recordings interpretable for fQRS were available in 459 patients (93%), aged 66 ± 12 years with left ventricular ejection fraction 40% ± 13%. fQRS was present in 52 patients (11%) with comparable baseline characteristics to patients without fQRS, except higher age, higher prevalence of coronary artery disease (CAD), lower prevalence of cardiomyopathy, and more frequently a secondary prevention ICD indication. Among patients with native QRS, those with fQRS had similar QRS duration and axis to those without fQRS. During 3.1 ± 0.7 years follow‐up, 126 patients (28%) had ≥1 VA . fQRS was associated with increased risk of VA (HR 3.41 [95% CI 2.27–5.13], p < .001), which persisted after adjusting for age, gender, sex, BMI, CAD, heart failure, renal function, ICD indication, QRS duration, QRS axis, Q waves, and bundle branch block. fQRS was more strongly associated with VA in patients with a primary (HR 6.05 [95% CI 3.16–11.60]) versus secondary (HR 2.39 [95% CI 1.41–4.04]) ICD indication (p‐for‐interaction = .047). Conclusions fQRS is associated with threefold increased risk of VA in high‐risk patients, independent of established risk factors.
Background Fragmentation of the QRS complex (fQRS) on ECG is defined as the presence of additional spikes within the QRS complex. fQRS has been associated with myocardial conduction abnormalities, but whether it predicts ventricular arrhythmias (VA) is uncertain. Purpose To assess the association between the presence of fQRS on standard 12-leads ECG and the risk of VA. Methods In a prospective observational study, we included 243 patients treated with implantable cardioverter-defibrillator (ICD). Baseline ECG was analyzed for fQRS by a trained physician blinded for outcome data. fQRS was defined according to Das (ref) as the presence of an additional R wave (R'), notching in the S wave nadir, or >1 R' in 2 contiguous leads. For wide QRS (≥120ms), fQRS was defined as >2 R waves (R”), >2 notches in the R or S wave in 2 contiguous leads (Figure). Patients were followed at regular ICD controls, and incident ventricular tachycardia (VT), ventricular fibrillation (VF) and treatment with antitachycardia pacing (ATP) or DC-shock were recorded. Results In total, 168 baseline ECG recordings (69%) were interpretable for fQRS, while the remaining were uninterpretable mainly due to low quality and low QRS voltage. The included patients were aged 66±11 years, 14% female, with BMI 27±4 kg/m2 and left ventricular ejection fraction (LVEF) 42±11%. Twenty-two percent had diabetes mellitus (DM), 40% atrial fibrillation, 61% history of myocardial infarction (MI), 81% heart failure and 18% in New York Heart Association Class ≥3. fQRS was present in 16 (10%) patients who had comparable baseline characteristics to those without fQRS, except lower prevalence of DM (p=0.05). Patients with versus without fQRS had comparable QRS duration (p=0.72), QRS axis (p=0.28), corrected QT duration (QTc) (p=0.35) and heart rate (p=0.66). During mean 3.2±0.7 years follow-up 65 (28%) patients had ≥1 VA, including 60 with VT, 21 with VF, and 59 with appropriate ICD-therapy. Presence of fQRS was associated with a 4-fold increased risk of VA (OR 4.15, [95% CI 1.38–12.4], p=0.011). This association persisted after adjusting for age, gender, DM, MI, LVEF and QRS duration (OR 3.99, [95% CI 1.16–13.65], p=0.03). fQRS was strongly associated with incident VT (OR 4.66 [95% CI 1.55–14.0], p=0.006, which persisted after adjustment [p=0.018]), while there was no significant association with incident VF (OR 1.45, [95% CI 0.29–7.09], p=0.64) (Figure). fQRS associated with incident VA irrespective of ICD indication (primary versus secondary, p-for-interaction = 0.80). fQRS was superior to established ECG variables in predicting VA, including QRS-duration, QTc, and presence of Q-waves. Conclusions Interpretation of fQRS in standard ECG is feasible in 70%. fQRS is associated with increased risk of VA, independent of established risk factors, and is an easily available tool that may be useful in identifying patients at increased risk of VA. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Akershus University Hospital fQRS and ventricular arrhythmias
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