Diagnostic and prognostic value of QRS duration and QTc interval in patients with suspected myocardial infarction
Abstract
Background: While prolongation of QRS duration and QTc interval during acute myocardial infarction (AMI) has been reported in animals, limited data is available for these readily available electrocardiography (ECG) markers in humans.
Methods: Diagnostic and prognostic value of QRS duration and QTc interval in patients with suspected AMI in a prospective diagnostic multicentre study were prospectively assessed. Digital 12-lead ECGs were recorded at presentation. QRS duration and QTc interval were automatically calculated in a blinded fashion. Final diagnosis was adjudicated by two independent cardiologists. The prognostic endpoint was all-cause mortality during 24 months of follow-up.
Results: Among 4042 patients, AMI was the final diagnosis in 19% of patients. Median QRS duration and median QTc interval were significantly greater in patients with AMI compared to those with other final diagnoses (98 ms [IQR 88–108] vs. 94 ms [IQR 86–102] and 436 ms [IQR 414–462] vs. 425 ms [IQR 407–445], p < 0.001 for both comparisons). The diagnostic value of both ECG signatures however was only modest (AUC 0.56 and 0.60). Cumulative mortality rates after 2 years were 15.9% vs. 5.6% in patients with a QRS > 120 ms compared to a QRS duration ≤ 120 ms (p < 0.001), and 11.4% vs. 4.3% in patients with a QTc > 440 ms compared to a QRS duration ≤ 440 ms (p < 0.001). After adjustment for age and important ECG and clinical parameters, the QTc interval but not QRS duration remained an independent predictor of mortality.
Conclusions: Prolongation of QRS duration > 120 ms and QTc interval > 440 ms predict mortality in patients with suspected AMI, but do not add diagnostic value.
Keywords: QRS durationQTc intervalchest pain
References
- Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012; 126(16): 2020–2035.
- Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2016; 37(3): 267–315.
- Steg PhG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33(20): 2569–2619.
- Holland RP, Brooks H. The QRS complex during myocardial ischemia. An experimental analysis in the porcine heart. J Clin Invest. 1976; 57(3): 541–550.
- Watanabe I, Kanda A, Engle CL, et al. Comparison of the effects of regional ischemia and hyperkalemia on the membrane action potentials of the in situ pig heart. Experimental Cardiology Group, University of North Carolina at Chapel Hill. J Cardiovasc Electrophysiol. 1997; 8(11): 1229–1236.
- Hamlin RL, Pipers FS, Hellerstein HK, et al. QRS alterations immediately following production of left ventricular free-wall ischemia in dogs. Am J Physiol. 1968; 215(5): 1032–1040.
- Michaelides A, Ryan JM, VanFossen D, et al. Exercise-induced QRS prolongation in patients with coronary artery disease: a marker of myocardial ischemia. Am Heart J. 1993; 126(6): 1320–1325.
- Kenigsberg DN, Khanal S, Kowalski M, et al. Prolongation of the QTc interval is seen uniformly during early transmural ischemia. J Am Coll Cardiol. 2007; 49(12): 1299–1305.
- GUSTO investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993; 329(10): 673–682.
- Sgarbossa EB, Pinski SL, Topol EJ, et al. Acute myocardial infarction and complete bundle branch block at hospital admission: clinical characteristics and outcome in the thrombolytic era. GUSTO-I Investigators. Global Utilization of Streptokinase and t-PA [tissue-type plasminogen activator] for Occluded Coronary Arteries. J Am Coll Cardiol. 1998; 31(1): 105–110.
- Juul SE, Kinsella MG, Wight TN, et al. Alterations in nonhuman primate (M. nemestrina) lung proteoglycans during normal development and acute hyaline membrane disease. Am J Respir Cell Mol Biol. 1993; 8(3): 299–310.
- Barthel P, Schneider R, Bauer A, et al. Risk stratification after acute myocardial infarction by heart rate turbulence. Circulation. 2003; 108(10): 1221–1226.
- Bauer A, Watanabe MA, Barthel P, et al. QRS duration and late mortality in unselected post-infarction patients of the revascularization era. Eur Heart J. 2006; 27(4): 427–433.
- Bonnemeier H, Hartmann F, Wiegand UK, et al. Course and prognostic implications of QT interval and QT interval variability after primary coronary angioplasty in acute myocardial infarction. J Am Coll Cardiol. 2001; 37(1): 44–50.
- Thygesen K, Mair J, Giannitsis E, et al. How to use high-sensitivity cardiac troponins in acute cardiac care. Eur Heart J. 2012; 33(18): 2252–2257.
- Reichlin T, Twerenbold R, Reiter M, et al. Introduction of high-sensitivity troponin assays: impact on myocardial infarction incidence and prognosis. Am J Med. 2012; 125(12): 1205–1213.e1.
- Reiter M, Twerenbold R, Reichlin T, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med. 2009; 361(9): 858–867.
- Reichlin T, Hochholzer W, Stelzig C, et al. Incremental value of copeptin for rapid rule out of acute myocardial infarction. J Am Coll Cardiol. 2009; 54(1): 60–68.
- Reichlin T, Irfan A, Twerenbold R, et al. Utility of absolute and relative changes in cardiac troponin concentrations in the early diagnosis of acute myocardial infarction. Circulation. 2011; 124(2): 136–145.
- Reichlin T, Schindler C, Drexler B, et al. One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med. 2012; 172(16): 1211–1218.
- Bossuyt PM, Reitsma JB, Bruns DE, et al. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Standards for Reporting of Diagnostic Accuracy. Clin Chem. 2003; 49(1): 1–6.
- Giannitsis E, Kurz K, Hallermayer K, et al. Analytical validation of a high-sensitivity cardiac troponin T assay. Clin Chem. 2010; 56(2): 254–261.
- Bazett HC. An analysis of the time-relations of electrocardiograms. Heart. 1920; 7: 353–70.
- Josephson ME. Clinical cardiac electrophysiology: techniques and interpretations. 3rd edn. Lippincott William & Wilkins, Philadelphia, PA 2002.
- Breidthardt T, Christ M, Matti M, et al. QRS and QTc interval prolongation in the prediction of long-term mortality of patients with acute destabilised heart failure. Heart. 2007; 93(9): 1093–1097.
- Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007(386): 1–32.
- Wagner NB, Sevilla DC, Krucoff MW, et al. Transient alterations of the QRS complex and ST segment during percutaneous transluminal balloon angioplasty of the left anterior descending coronary artery. Am J Cardiol. 1988; 62(16): 1038–1042.
- Jiménez-Candil J, González IC, González Matas JM, et al. Short- and long-term prognostic value of the corrected QT interval in the non-ST-elevation acute coronary syndrome. J Electrocardiol. 2007; 40(2): 180–187.
- Pratt CM, Greenway PS, Schoenfeld MH, et al. Exploration of the precision of classifying sudden cardiac death. Implications for the interpretation of clinical trials. Circulation. 1996; 93(3): 519–524.
