Prognostic Significance of Quantitative QRS Duration

doi:10.1016/j.amjmed.2005.08.028

The American Journal of Medicine

Volume 119, Issue 7, July 2006, Pages 600-606

https://doi.org/10.1016/j.amjmed.2005.08.028 Get rights and content

Abstract

Background

Although QRS duration is known to be a predictor of mortality in patients with left ventricular dysfunction, our purpose was to evaluate the prognostic power of computer-measured QRS duration in a general medical population.

Methods

Analyses were performed on the first electrocardiogram digitally recorded on 46,933 consecutive patients at the Palo Alto Veterans Affairs Medical Center between 1987 and 2000. Patients with electrocardiograms exhibiting Wolff-Parkinson-White were excluded (n = 44), and those with bundle branch block or electronic pacing were considered separately, leaving 44,280 patients for analysis (mean age 56 ± 15 years; 90% were males). There were 3659 (8.3%) cardiovascular deaths (mean follow-up of 6.0 ± 3.8 years).

Results

A survival plot showed significant separation according to a QRS duration score. After adjustment in the Cox model for age, gender, and heart rate, the QRS duration score was a strong independent predictor of cardiovascular mortality. For every 10-ms increase in QRS duration, there was an 18% increase in cardiovascular risk. The results were similar in patients with an abnormal electrocardiogram, a bundle branch block, and a paced rhythm.

Conclusion

Quantitative QRS duration was a significant and independent predictor of cardiovascular mortality in a general medical population.

Section snippets

Study Design

The study design is a retrospective analysis of all ECGs obtained at the Palo Alto Veterans Affairs Medical Center from March 1987 to 2000. They were digitally recorded and stored in the General Electric cardiology database system (MUSE, General Electric Medical Systems, Milwaukee, Wis). ECGs obtained in an inpatient or emergency department setting were flagged. When a patient had more than one ECG in the database, only the first one was considered. Standardized, computerized ECG criteria as

Results

Thirty-five percent of the ECGs with QRS greater than 135 ms were not recognized as paced rhythms by the computer program and were subsequently reclassified after visual inspection and placed in the correct groups. There were 44,280 patients without BBB or paced rhythms and 18,403 patients in the abnormal ECG subset. The breakdown of patients with BBB and paced rhythms was as follows: 625 with LBBB, 1675 with right bundle branch block (RBBB), and 309 with paced rhythms.

Discussion

This study of a large cohort of general medical patients demonstrates that an increase in QRS duration is associated with an increase in the risk of CV death. Patients were separated into two main groups: those with BBB and paced rhythms and those without these findings. In patients with BBB and paced rhythms, a markedly prolonged QRS duration (>150 ms for BBB and >180 ms for paced rhythms) was found to be associated with a higher CV mortality risk. More important, in patients without BBB or

Conclusion

QRS duration provides a simple method to stratify patients as to their risk of CV death. In a general medical sample without BBB or paced rhythms, those with a QRS duration greater than 130 ms experience nearly twice the risk of CV death compared with those with a QRS duration of 110 ms or less. Similarly in patients with LBBB and RBBB, a QRS duration greater than 150 ms is associated with greater risk of CV death.

References (25)

D.W. Romhilt et al.
A point-score system for the ECG diagnosis of left ventricular hypertrophy
Am Heart J
(1968)
M.G. Jones et al.
Prognostic use of a QRS scoring system after hospital discharge for initial acute myocardial infarction in the Framingham cohort
Am J Cardiol
(1990)
J.M. Dekker et al.
The Cardiac Infarction Injury Score and coronary heart disease in middle-aged and elderly menthe Zutphen Study
J Clin Epidemiol
(1995)
G.J. Fahy et al.
Natural history of isolated bundle branch block
Am J Cardiol
(1996)
R.A. Freedman et al.
Bundle branch block in patients with chronic coronary artery diseaseangiographic correlates and prognostic significance
J Am Coll Cardiol
(1987)
S. Baldasseroni et al.
Left bundle-branch block is associated with increased 1-year sudden and total mortality rate in 5517 outpatients with congestive heart failurea report from the Italian network on congestive heart failure
Am Heart J
(2002)
J.F. Schneider et al.
Clinical-electrocardiographic correlates of newly acquired left bundle branch blockthe Framingham Study
Am J Cardiol
(1985)
J.F. Schneider et al.
Comparative features of newly acquired left and right bundle branch block in the general populationthe Framingham study
Am J Cardiol
(1981)
E.S. Brilakis et al.
Usefulness of QRS duration in the absence of bundle branch block as an early predictor of survival in non-ST elevation acute myocardial infarction
Am J Cardiol
(2002)
H.J. Shenkman et al.
Congestive heart failure and QRS durationestablishing prognosis study
Chest
(2002)

S. Iuliano et al.

QRS duration and mortality in patients with congestive heart failure

Am Heart J

(2002)

C. Bruch et al.

Electrocardiography and Doppler echocardiography for risk stratification in patients with chronic heart failureincremental prognostic value of QRS duration and a restrictive mitral filling pattern

J Am Coll Cardiol

(2005)

Cited by (121)

Residential greenness alleviated the adverse associations of long-term exposure to ambient PM<inf>1</inf> with cardiac conduction abnormalities in rural adults
2023, Environmental Research
Ambient air pollution was linked to elevated risks of adverse cardiovascular events, and alterations in electrophysiological properties of the heart might be potential pathways. However, there is still lacking research exploring the associations between PM₁ exposure and cardiac conduction parameters. Additionally, the interactive effects of PM₁ and residential greenness on cardiac conduction parameters in resource-limited areas remain unknown.
A total of 27483 individuals were enrolled from the Henan Rural Cohort study. Cardiac conduction parameters were tested by 12-lead electrocardiograms. Concentrations of PM₁ were evaluated by satellite-based spatiotemporal models. Levels of residential greenness were assessed using Enhanced Vegetation Index (EVI) and Normalized difference vegetation index (NDVI). Logistic regression models and restricted cubic splines were fitted to explore the associations of PM₁ and residential greenness exposure with cardiac conduction abnormalities risk, and the interaction plot method was performed to visualize their interaction effects.
The 3-year median concentration of PM₁ was 56.47 (2.55) μg/m³, the adjusted odds rate (ORs) and 95% confidence intervals (CIs) for abnormal HR, PR, QRS, and QTc interval risk in response to 1 μg/m³ increase in PM₁ were 1.064 (1.044, 1.085), 1.037 (1.002, 1.074), 1.061 (1.044, 1.077) and 1.046 (1.028, 1.065), respectively. Participants exposure to higher levels of PM₁ had increased risks of abnormal HR (OR = 1.221, 95%CI: 1.144, 1.303), PR (OR = 1.061, 95%CI: 0.940, 1.196), QRS (OR = 1.225, 95%CI: 1.161, 1.294) and QTc interval (OR = 1.193, 95%CI: 1.121, 1.271) compared with lower levels of PM₁. Negative interactive effects of exposure to PM₁ and residential greenness on abnormal HR, QRS, and QTc intervals were observed (P _{for interaction} < 0.05).
Long-term PM₁ exposure was associated with elevated cardiac conduction abnormalities risks, and this adverse association might be mitigated by residential greenness to some extent. These findings emphasize that controlling PM₁ pollution and increasing greenness levels might be effective strategies to reduce cardiovascular disease burdens in resource-limited areas.
Associations between primary care electrocardiography and non-Alzheimer dementia
2022, Journal of Stroke and Cerebrovascular Diseases
To determine whether electrocardiogram (ECG) markers are associated with incident non-Alzheimer's dementia (non-AD) and whether these markers also improve risk prediction for non-AD.
We retrospectively included 170,605 primary care patients aged 60 years or older referred for an ECG by their general practitioner and followed them for a median of 7.6 years. Using Cox regression, we reported hazard ratios (HRs) for electrocardiogram markers. Subsequently, we evaluated if addition of these electrocardiogram markers to a clinical model improved risk prediction for non-AD using change in area under the receiver-operator characteristics curve (AUC).
The 5-year cumulative incidence of non-AD was 3.4 %. Increased heart rate (HR=1.06 pr. 10 bpm [95% confidence interval: 1.04–1.08], p<0.001), shorter QRS duration (HR=1.07 pr. 10 ms [1.05–1.09], p<0.001), elevated J-amplitude (HR=1.16 pr. mm [1.08–1.24], p<0.001), decreased T-peak amplitude (HR=1.02 pr. mm [1.01–1.04], p=0.002), and increased QTc (HR=1.08 pr. 20 ms [1.05–1.10], p<0.001) were associated with an increased rate of non-AD. Atrial fibrillation on the ECG (HR=1.18 [1.08–1.28], p<0.001) Sokolow-Lyon index > 35 mm (HR=1.31 [1.18–1.46], p<0.001) and borderline (HR=1.18 [1.11–1.26], p<0.001) or abnormal (HR=1.40 [1.27–1.55], p<0.001) QRS-T angle were also associated with an increased rate of non-AD. Upon addition of ECG markers to the Cox model, 5-year and 10-year C-statistic (AUC) improved significantly (delta-AUC, 0.36 [0.18–0.50] and 0.20 [0.03–0.35] %-points, respectively).
ECG markers typical of an elevated cardiovascular risk profile were associated with non-AD and improved both 5-year and 10-year risk predictions for non-AD.
Optimizing single-chamber pacing in dogs Part 1: Rate determinations, rate interventions and hysteresis
2021, Veterinary Journal
Determining ideal pacing rates to meet physiological needs and optimizing programming to prevent unnecessary right ventricular pacing in dogs requires an understanding of heart rate profiles and applicable pacing technology. The heart rate and rhythm of the dog is complex necessitating investigation of rate requirements of activity and circadian influences. Overlaying this information are a multiplicity of other factors such as age, breed, temperament, cardiovascular disease and underlining rhythm disorders that contribute to the difficulty in making general conclusions. However, all such information permits better implementation of programming options with the goal of better outcomes. In this review (Part 1 of a two-part review) instantaneous heart rate, rolling average heart rate, simple average heart rate, heart rate tachograms, RR interval tachograms (2D, 3D and dynamic), and Poincaré plots (2D, 3D and dynamic) are discussed as they apply to decisions in the determination and examination of pacing rates for dogs programmed in the VVI pacing mode (Ventricular paced, Ventricular sensed, Inhibited pacing). The applicable pacing operations available for three pacemaker companies are reviewed (Abbott, Biotronik/Dextronix, and Medtronic). The programmable options considered include: slowest pacing rate without additional features to extend the pacing interval, sleep/rest rate preferences, hysteresis to lengthen pacing interval following intrinsic beats, and intermittent increases in pacing following abrupt loss of intrinsic rhythm. Recommendations are suggested for follow-up of individual dogs with examination of pacing statistics and Holter monitoring.
Clinical factors associated with the intraventricular conduction disturbances in Swiss middle-aged adults: The CoLaus|PsyCoLaus study
2021, International Journal of Cardiology
Intraventricular conduction disturbances are associated with an increased risk of adverse cardiovascular outcomes. However, data about factors associated with intraventricular conduction disturbances are sparse. We aimed to identify the clinical factors associated with intraventricular conduction disturbances in the general population.
Cross-sectional study in a sample of 3704 participants (age range 45–86 years, 55.2% women). Intraventricular conduction disturbances were defined as QRS > 110 ms on electrocardiograms, and classified into right bundle branch block (RBBB), left bundle branch block (LBBB), left anterior fascicular block (LAFB) and non-specific intraventricular conduction disturbances (NIVCD).
The number of participants, the resulting prevalence (square brackets) and 95% CI (round brackets) of intraventricular conduction disturbances and subtypes (RBBB, LBBB, LAFB and NIVCD) were 187 [5.1% (4.4–5.8%)], 103 [2.9%, (2.3–3.4%)], 29 [0.8% (0.6–1.1%)], 31 (0.9% [0.6–1.2%]), and 47 [1.3% (0.9–1.7)], respectively. Multivariable logistic regression identified male sex [odds ratio and (95% CI): 2.55 (1.34–4.86)] and increasing age (p-value for trend <0.001) as being associated with RBBB; hypertension [3.08 (1.20–7.91)] and elevated NT-proBNP [3.26 (1.43–7.41)] as being associated with LBBB; elevated NT-proBNP [3.14 (1.32–7.46)] as being associated with LFAB; and male sex [5.97 (1.91–18.7)] and increased height [1.31 (1.06–1.63)] as being associated with NIVCD.
In a sample of the Swiss middle-aged population, the clinical factors associated with intraventricular conduction disturbances differed according to the intraventricular conduction disturbances subtype: male sex and ageing for RBBB; hypertension and elevated NT-proBNP for LBBB; elevated NT-proBNP for LAFB; and male sex and increased height for NIVCD.
Associations of long-term exposure to ambient air pollution with cardiac conduction abnormalities in Chinese adults: The CHCN-BTH cohort study
2020, Environment International
Evidence regarding the effects of long-term and high-level ambient air pollution exposure on cardiac conduction systems remains sparse.
To investigate the associations of long-term exposure to air pollution and cardiac conduction abnormalities in Chinese adults and explore the susceptibility characteristics.
In 2017, a total of 27,047 participants aged 18–80 years were recruited from the baseline survey of the Cohort Study on Chronic Disease of Communities Natural Population in Beijing, Tianjin and Hebei (CHCN-BTH). The three year (2014–2016) average pollutant concentrations were assessed by a spatial statistical model for PM_2.5 and air monitoring stations for PM₁₀, SO₂, NO₂, O₃ and CO. Residential proximity to a roadway was calculated by neighborhood analysis. Associations were estimated by two-level generalized linear mixed models. Stratified analyses related to demographic characteristics, health behaviors, and cardiometabolic risk factors were performed. Two-pollutant models were used to evaluate the possible role of single pollutants.
We detected significant associations of long-term air pollutant exposure with increased heart rate (HR), QRS and QTc, such that an interquartile range increase in PM_2.5 was associated with 3.63% (95% CI: 3.07%, 4.19%), 1.21% (95% CI: 0.83%, 1.60%), and 0.13% (95% CI: 0.07%, 0.18%) changes in HR, QRS and QTc, respectively. Compared to the other pollutants, the estimates of PM_2.5 remained the most stable across all two-pollutant models. Similarly, significant associations were observed between living closer to a major roadway and higher HR, QRS and QTc. Stratified analyses showed generally greater association estimates in older people, males, smokers, alcohol drinkers, and those with obesity, hypertension and diabetes.
Long-term exposure to ambient air pollution was associated with cardiac conduction abnormalities in Chinese adults, especially in older people, males, smokers, alcohol drinkers, and those with cardiometabolic risk factors. PM_2.5 may be the most stable pollutant to reflect the associations.
Assessing safety of leadless pacemaker (MICRA) at various implantation sites and its impact on paced QRS in Indian population
2020, Indian Heart Journal
In this study we report our experience in implanting MICRA TPS (transcatheter pacing system) at various RV sites; observing its safety, and impact on paced QRS in Indian population.
35 patients with MICRA TPS deployed from March 2017 to December 2019 at Army Hospital Research and Referral, New Delhi, at RVOT, apical septum and mid septum of RV were enrolled in the study. These patents were followed up and impact of implantation site, procedure related complications, change in pacing parameters, left ventricular ejection fraction and duration of paced QRS were monitored.
Sick sinus syndrome was the commonest indication of pacing in this study (51.5%), followed by high degree AV block (34.2%). Mean follow up of 1.4 years showed no change in left ventricular ejection fraction, electrical parameters or change in pacing thresholds after implantation. Mean pQRS was broadest (166.60 ms) in apically implanted MICRA TPS and narrowest in mid septum group 139.33 ms. Among 35 cases, in our study one patient developed pericardial effusion, and other had intermittent diaphragmatic pacing.
Among these three implantation sites mid septum deployment is associated with narrowest paced QRS in Indian population.

View all citing articles on Scopus

: Manuscript submitted on May 27, 2005, and accepted in revised form on August 12, 2005.

View full text

AJM Theme Issue: CardiologyClinical research studyPrognostic Significance of Quantitative QRS Duration

Abstract

Background

Methods

Results

Conclusion

Section snippets

Study Design

Results

Discussion

Conclusion

Am Heart J

Am J Cardiol

J Clin Epidemiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Cardiol

Chest

Am Heart J

J Am Coll Cardiol

AJM Theme Issue: Cardiology
Clinical research study
Prognostic Significance of Quantitative QRS Duration