Prognostic Value of QRS Fragmentation in Patients with Acute Myocardial Infarction: A Meta‐Analysis

Güngör, Barış; Özcan, Kazım Serhan; Karataş, Mehmet Baran; Şahin, İrfan; Öztürk, Recep; Bolca, Osman

doi:10.1111/anec.12357

Cited by 31 publications

(33 citation statements)

References 27 publications

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“…As we have shown in our meta-analysis, and also in previous studies, the presence of fQRS is associated with more severe form of coronary atherosclerosis and left ventricular systolic dysfunction (Güngör et al, 2016). As we have shown in our meta-analysis, and also in previous studies, the presence of fQRS is associated with more severe form of coronary atherosclerosis and left ventricular systolic dysfunction (Güngör et al, 2016).…”

Section: Dear Editorsupporting

confidence: 86%

Response to letter to the editor: Prognostic value of QRS fragmentation in patients with acute myocardial infarction: a meta‐analysis

Güngör

Özcan²,

Karataş

et al. 2016

Noninvasive Electrocardiol

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We agree with the authors that, even though in three studies investigating admission electrocardiograms (ECGs) also showed increased rates of adverse events in patients with fragmented QRS (fQRS), our meta-analysis mainly implicates the clinical use of ECGs recorded within the 48 hours of hospitalization (Bekler et al., 2014; Bozbeyoğlu et al., 2015;Stavileci et al., 2014).The prognostic importance of fQRS and its correlation with myocardial scar formation and long-term adverse events have been investigated in patients with coronary artery disease and heart failure. As we have shown in our meta-analysis, and also in previous studies, the presence of fQRS is associated with more severe form of coronary atherosclerosis and left ventricular systolic dysfunction (Güngör et al., 2016). As noted by Tanrıverdi et al., the total number of leads with fQRS is correlated with the risk of adverse events (Yıldırım et al., 2014; Tanriverdi, Dursun, & Kaya, 2016). But in these studies, the prognostic value of presence of only one lead with fQRS was not reported. For standardization of the meta-analysis method, we have included only studies which defined QRS fragmentation according to Das, Khan, Jacob, Kumar, and Mahenthiran (2006) which necessitates presence of fQRS in at least two contiguous leads. Thus, from the published data it is not possible to investigate whether the presence of only one ECG lead with fQRS has prognostic value in this meta-analysis. It is well known that, acute myocardial infarction causes dynamic ECG changes compared to stable coronary artery disease patients. Serial ECG recordings become an important issue for analyzing the timing of appearance and disappearance of QRS fragmentation. In most of the studies, the timing of first ECG with fQRS and the disappearance of fQRS (if happened) were not reported in detail. Only in five studies the rate of fQRS persistence beyond 48 hours was reported and the rate of fQRS persistence was widely different between the studies. Thus, further studies are needed to clarify the importance of the presence of fQRS in a single lead.

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Section: Dear Editorsupporting

confidence: 86%

Response to letter to the editor: Prognostic value of QRS fragmentation in patients with acute myocardial infarction: a meta‐analysis

Güngör

Özcan²,

Karataş

et al. 2016

Noninvasive Electrocardiol

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“…Previous studies have demonstrated that ECGs might be used for risk stratification in patients who present with STEMI (Birnbaum & Sclarovsky, ; Nable & Brady, ). Several electrocardiographic parameters have been examined, including the magnitude of ST‐segment elevation, the T‐wave morphology, the presence of early repolarization, and fragmented QRS, on admission in patients with acute myocardial infarction (Atar & Birnbaum, ; Birnbaum et al, ; Güngör et al, ; Ozcan et al, ). Tomb‐ST is an electrocardiographic pattern of ST‐segment elevation in which the QRS complex, the ST segment, and the T wave merge to form a large upright monophasic deflection called a “tombstone” (Wimalaratna, ).…”

Section: Discussionmentioning

confidence: 99%

“…Previous studies have demonstrated that ECGs might be used for risk stratification in patients who present with STEMI (Birnbaum & Sclarovsky, 2001;Nable & Brady, 2009). Several electrocardiographic parameters have been examined, including the magnitude of ST-segment elevation, the T-wave morphology, the presence of early repolarization, and fragmented QRS, on admission in patients with acute myocardial infarction (Atar & Birnbaum, 2005;Güngör et al, 2016;Ozcan et al, 2014).…”

Section: Discussionmentioning

confidence: 99%

Long‐term clinical outcomes and prognoses of ST‐segment elevation myocardial infarction patients who present with tombstoning ST‐segment elevation

Tanık

Çınar²,

Şimşek³

et al. 2019

Noninvasive Electrocardiol

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Introduction Although patients with tombstoning ST‐segment elevation (Tomb‐ST) usually have poor in‐hospital and short‐term survival rates, no studies have examined the long‐term clinical outcomes and prognosis of ST‐segment elevation myocardial infarction (STEMI) patients who have this electrocardiographic pattern. Therefore, we aimed to evaluate the long‐term clinical events and mortality of such patients in this study. Methods In this retrospective analysis, we included 335 consecutive patients who were diagnosed with acute anterior wall‐STEMI from January 2015 to June 2018. The criteria for the definition of Tomb‐ST were accepted as provided in a previous study. Endpoints of the study were the incidence of significant in‐hospital and long‐term major adverse clinical events (MACE) including the composite of total death, myocardial reinfarction, and hospitalizations due to heart failure. Results Patients who presented with Tomb‐ST had significantly higher in‐hospital and long‐term mortality (10% [n = 12 patients] vs. 2.3% [n = 5 patients]; p < 0.001and 6.5% [n = 7 patients] vs. 1.9% [n = 4 patients]; p = .04, respectively). In a multivariate traditional and penalized Cox proportional hazard regression analysis, this type of electrocardiographic pattern was found as independent predictor of long‐term MACE (Odds ratio [OR]: 3.82, 95% confidence interval [CI]: 1.91–7.63, p < .001 and OR: 4.36, 95% CI: 1.97–9.66, p < .001, respectively). Conclusion In the present study, we observed that the presence of Tomb‐ST might be an independent predictor of long‐term MACE in STEMI patients. To the best of our knowledge, this is the first study to evaluate the long‐term MACE of such patients.

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“…Especially when occurring in the lateral territory fQRS has been noticed to increase not only the non-fatal cardiac events and long-term cardiovascular events but also mortality in patients with CAD (Jain et al, 2014; Gong and Li, 2016; Güngör et al, 2016). It is possible that fQRS could detect some subclinical regional left ventricle dysfunction in patients with CAD (Yan et al, 2012).…”

Section: Backgroundsmentioning

confidence: 99%

“…fQRS can also be associated with low LVEF. (Fares et al, 2013; Lorgis et al, 2014; Gong and Li, 2016; Güngör et al, 2016; Ma et al, 2016) and multi-vessel CAD in patients with STEMI (Ma et al, 2016) and NSTEMI (Güngör et al, 2016) which may explain the association with adverse prognosis. In silent MIs, which are problematic to discover in diabetics, women with unusual chest pain and in senile dementia, fQRS can be the only evidence of the ongoing event (Fares et al, 2013).…”

Section: Backgroundsmentioning

confidence: 99%

QRS Fragmentation Patterns Representing Myocardial Scar Need to Be Separated from Benign Normal Variants: Hypotheses and Proposal for Morphology based Classification

et al. 2016

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The presence of a fragmented QRS complex (fQRS) in two contiguous leads of a standard 12-lead electrocardiogram (ECG) has been shown to be an indicator of myocardial scar in multiple different populations of cardiac patients. QRS fragmentation is also a predictor of adverse prognosis in acute myocardial infarction, coronary artery disease, and ischemic cardiomyopathy and a prognostic tool in structural heart diseases. An increased risk of sudden cardiac death associated with fQRS has been documented in patients with ischemic cardiomyopathy and hypertrophic cardiomyopathy. However, fQRS is also frequently observed in apparently healthy subjects. Thus, a more detailed classification of different QRS fragmentations is needed to identify the pathological fragmentation patterns and refine the role of fQRS as a risk marker of adverse cardiac events and sudden cardiac death. In most studies fQRS has been defined by the presence of an additional R wave (R′), or notching in the nadir of the S wave, or the presence of >1 R′ in two contiguous leads corresponding to a major coronary territory. However, this approach does not discriminate between minor and major fragmentations and the location of the fQRS is also neglected. In addition to this, the method is susceptible to large interobserver variability. We suppose that some fQRS subtypes result from conduction delays in the His-Purkinje system, which is a benign finding and thus can weaken the prognostic values of fQRS. The classification of fQRSs to subtypes with unambiguous definitions is needed to overcome the interobserver variability related issues and to separate fQRSs caused by myocardial scarring from benign normal variants. In this paper, we review the anatomic correlates of fQRS and the current knowledge of prognostic significance of fQRS. We also propose a detailed fQRS classification for research purposes which can later be simplified after the truly pathological morphologies have been identified. The research material of our study consist of 15,245 ECGs from the random general population and approximately six thousands (n = 6,241) ECGs from subjects with a known cardiac disease.

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Prognostic Value of QRS Fragmentation in Patients with Acute Myocardial Infarction: A Meta‐Analysis

Cited by 31 publications

References 27 publications

Response to letter to the editor: Prognostic value of QRS fragmentation in patients with acute myocardial infarction: a meta‐analysis

Response to letter to the editor: Prognostic value of QRS fragmentation in patients with acute myocardial infarction: a meta‐analysis

Long‐term clinical outcomes and prognoses of ST‐segment elevation myocardial infarction patients who present with tombstoning ST‐segment elevation

QRS Fragmentation Patterns Representing Myocardial Scar Need to Be Separated from Benign Normal Variants: Hypotheses and Proposal for Morphology based Classification

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