ECG in patients with acute heart failure can predict in-hospital and long-term mortality

Abstract

Initial risk stratification in patients with acute heart failure (AHF) is poorly validated. Previous studies tended to evaluate the prognostic significance of only one or two selected ECG parameters. The aim of this study was to evaluate the impact of multiple ECG parameters on mortality in AHF. The Acute Heart Failure Database (AHEAD) registry collected data from 4,153 patients admitted for AHF to seven hospitals with Catheter Laboratory facilities. Clinical variables, heart rate, duration of QRS, QT and QTC intervals, type of rhythm and ST-T segment changes on admission were collected in a web-based database. 12.7 % patients died during hospitalisation, the remainder were discharged and followed for a median of 16.2 months. The most important parameters were a prolonged QRS and a junctional rhythm, which independently predict both in-hospital mortality [QRS > 100 ms, odds ratio (OR) 1.329, 95 % CI 1.052-1.680; junctional rhythm, OR 3.715, 95 % CI 1.748-7.896] and long-term mortality (QRS > 120 ms, OR 1.428, 95 % CI 1.160-1.757; junctional rhythm, OR 2.629, 95 % CI 1.538-4.496). Increased hospitalisation mortality is predicted by ST segment elevation (OR 1.771, 95 % CI 1.383-2.269) and prolonged QTC interval >475 ms (OR 1.483, 95 % CI 1.016-2.164). Presence of atrial fibrillation and bundle branch block is associated with increased unadjusted long-term mortality, but mostly reflects more advanced heart disease, and their predictive significance is attenuated in the multivariate analysis. ECG in patients admitted for acute heart failure carries significant short- and long-term prognostic information, and should be carefully evaluated.

Insights into the importance of the electrocardiogram in patients with acute heart failure

“…11 This is supported by the findings of AHEAD (Acute Heart Failure Database) registry, which found that an increased QRS duration was independently associated with increased in-hospital mortality and long-term mortality. 13 This is also seen in data from the KorHF (Korean Heart Failure) registry, where the presence of both a widened QRS (>120 ms) and a prolonged PR interval (>200 ms) was independently associated with in-hospital death, post-discharge death and rehospitalization. 15 However, the THESUS-HF (the Sub-Saharan Africa Survey of Heart Failure) 12 cohort did not find any association between QRS width and 60-day or 180-day mortality.…”

“…33 In the EHFS II (EuroHeart Failure Survey II) study, a statistically significant shorter QRS duration was observed among survivors at 1 year (100 ms IQR 82–120) compared with non‐survivors (110 ms IQR 90–130) . This is supported by the findings of AHEAD (Acute Heart Failure Database) registry, which found that an increased QRS duration was independently associated with increased in‐hospital mortality and long‐term mortality . This is also seen in data from the KorHF (Korean Heart Failure) registry, where the presence of both a widened QRS (>120 ms) and a prolonged PR interval (>200 ms) was independently associated with in‐hospital death, post‐discharge death and rehospitalization .…”

“…A combination of a prolonged QRS and a prolonged PR interval has been shown to be associated with an increased risk of in-hospital and post-discharge death, especially in patients with reduced ejection fractions. 15 While other studies have identified that prolonged QRS is associated with both long-and short-term outcomes, 13 other studies suggest that both a wide QRS and LBBB are associated with only long-term outcomes and are not a predictor of short-term outcomes. 11 The present study adds to the evidence that sinus rhythm appears to be protective in both the short-and long-term in patients with AHF, 12 and consistent with studies of chronic HF.…”

“…The prevalence of atrial fibrillation in the present study was 36%, which is comparable to other studies that report a prevalence ranging between 22% and 37%. [11][12][13][14]30 . The present study suggests that while atrial fibrillation is associated with rehospitalization, it is not an independent predictor of mortality.…”

Diagnosis and management of acute heart failure

“…arrhythmia) and suitable treatment can be planned. Abnormalities like QRS prolongation or junctional rhythm in the ECG obtained on admission have also prognostic importance and are associated with higher in-hospital and follow-up mortality (33). …”