Relationship between the Spatial QRS-T angle and Syntax and Gensini Scores in patients with non-ST-elevation Acute Coronary Syndrome

Year 2025, Volume: 5 Issue: 3, 103 - 113, 23.09.2025

Erdoğan Sökmen , Alp Yıldırım

Abstract

Background:
Frontal and spatial QRS-T angles reflect ventricular repolarization heterogeneity and may be associated with coronary artery disease severity. This study aimed to evaluate their relationship with SYNTAX and Gensini scores in non-ST elevation myocardial infarction (NSTMI) patients.
Methods:
A total of 1188 patients with NSTMI were retrospectively analyzed. Frontal and spatial QRS-T angles were calculated from 12-lead digital ECGs using the Rautaharju method. Correlation, univariate and multivariate linear regression, ROC, and logistic regression analyses were performed to assess their associations with SYNTAX and Gensini scores.
Results:
The spatial QRS-T angle was independently associated with SYNTAX and Gensini scores in multivariate linear regression, whereas the frontal QRS-T angle showed no significant association. Patients with SYNTAX score >32 had significantly higher spatial QRS-T angles. ROC analysis demonstrated that spatial QRS-T angle >105.2° predicted high SYNTAX scores with an AUC of 0.80. Logistic regression confirmed the spatial angle as an independent predictor of high SYNTAX score (OR: 1.04, 95% CI: 1.02–1.06; p<0.001).
Conclusion:
The spatial QRS-T angle, but not the frontal angle, is a significant independent predictor of severe coronary artery disease in NSTMI patients. It may serve as a simple, non-invasive ECG marker for identifying patients with high atherosclerotic burden.

Keywords

Non-ST elevation myocardial infarction , Spatial QRS-T angle , Frontal QRS-T angle , SYNTAX score , Gensini score

Non-ST elevasyonlu Akut Koroner Sendromlu hastalarda Spasyal QRS-T açısı ile SYNTAX ve Gensini skorları arasındaki ilişki

Abstract

Giriş:
Frontal ve spatial QRS-T açıları ventriküler repolarizasyon heterojenliğini yansıtarak koroner arter hastalığının şiddetiyle ilişkili olabilir. Bu çalışmada non-ST elevasyonlu miyokart enfarktüsü (NSTMI) hastalarında bu açıların SYNTAX ve Gensini skorları ile ilişkisi değerlendirildi.
Yöntem:
NSTMI tanılı 1188 hasta retrospektif olarak incelendi. Dijital 12 derivasyonlu EKG’lerden Rautaharju yöntemiyle frontal ve spatial QRS-T açıları hesaplandı. Korelasyon, univaryant ve multivaryant lineer regresyon, ROC ve lojistik regresyon analizleri ile SYNTAX ve Gensini skorlarıyla ilişkileri değerlendirildi.
Bulgular:
Multivaryant lineer regresyon analizinde spatial QRS-T açısı SYNTAX ve Gensini skorları ile bağımsız olarak ilişkilendirilirken, frontal QRS-T açısı anlamlı bulunmadı. SYNTAX skoru >32 olan hastalarda spatial QRS-T açısı anlamlı şekilde yüksekti. ROC analizinde spatial QRS-T açısının >105.2° olması yüksek SYNTAX skorunu AUC 0.80 ile öngördü. Lojistik regresyon spatial açının yüksek SYNTAX skorunun bağımsız belirleyicisi olduğunu doğruladı (OR:1.04, %95 GA:1.02–1.06; p<0.001).
Sonuç:
NSTMI hastalarında sadece spatial QRS-T açısı, ağır koroner arter hastalığının bağımsız anlamlı belirleyicisidir. Bu açı, yüksek aterosklerotik yük taşıyan hastaların belirlenmesinde pratik, non-invaziv bir EKG göstergesi olabilir.

Keywords

Non-ST segment elevasyonlu miyokart enfarktüsü , Spatial QRS-T açısı , Frontal QRS-T açısı , SYNTAX skoru , Gensini skoru

References

• 1. Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367.
• 2. Sökmen E, Ateş MS, Kök Z, Bingöl B. Relationship between ECG-derived T-wave amplitude and T/R ratio and Syntax score in patients with acute non-st segment elevation myocardial infarction. J Electrocardiol. 2025;88:153829.
• 3. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961-972.
• 4. Ateş MS, Sökmen E. Electrocardiographic P-Wave Indices in Metabolic Dysfunction-Associated Fatty Liver Disease and Their Relationship to Hepatic Fibrosis Risk. J Clin Med. 2025;14(13): 4650.
• 5. Zhang ZM, Prineas RJ, Case D, Soliman EZ, Rautaharju PM. Comparison of the prognostic significance of the electrocardiographic QRS/T angles in predicting incident coronary heart disease and total mortality (from the atherosclerosis risk in communities study). Am J Cardiol. 2007;100(5):844-849.
• 6. Aro AL, Huikuri HV, Tikkanen JT, Junttila MJ, Rissanen HA, Reunanen A, et al. QRS-T angle as a predictor of sudden cardiac death in a middle-aged general population. Europace. 2012;14(6):872-876.
• 7. Gotsman I, Keren A, Hellman Y, Banker J, Lotan C, Zwas DR. Usefulness of electrocardiographic frontal QRS-T angle to predict increased morbidity and mortality in patients with chronic heart failure. Am J Cardiol. 2013;111(10):1452-1459.
• 8. Rautaharju PM, Zhang ZM, Prineas R, Heiss G. Assessment of prolonged QT and JT intervals in ventricular conduction defects. Am J Cardiol. 2004;93(8):1017-1021.
• 9. Dogan A, Kahraman S. Frontal QRS-T angle predicts coronary atherosclerotic burden in patients with ST segment elevation myocardial infarction. J Electrocardiol. 2020;58:155-159.
• 10. Erdogan G, Yontar OC, Yenercag M, Gul S, Arslan U. Frontal QRS-T angle predicts syntax score in patients with non-ST elevation myocardial infarction. J Electrocardiol. 2020;61:86-91.
• 11. Scherptong RW, Henkens IR, Man SC, Le Cessie S, Vliegen HW, Draisma HH, et al. Normal limits of the spatial QRS-T angle and ventricular gradient in 12-lead electrocardiograms of young adults: dependence on sex and heart rate. J Electrocardiol. 2008;41(6):648-655.
• 12. Sardella G, Lucisano L, Garbo R, Pennacchi M, Cavallo E, Stio RE, et al. Single-Staged Compared With Multi-Staged PCI in Multivessel NSTEMI Patients: The SMILE Trial. J Am Coll Cardiol. 2016;67(3):264-272.
• 13. Gensini GG. A more meaningful scoring system for determining the severity of coronary heart disease. Am J Cardiol. 1983;51(3):606.
• 14. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth Universal Definition of Myocardial Infarction (2018). Circulation. 2018;138(20):e618-e51.
• 15. Kors JA, Kardys I, van der Meer IM, van Herpen G, Hofman A, van der Kuip DA, et al. Spatial QRS-T angle as a risk indicator of cardiac death in an elderly population. J Electrocardiol. 2003;36 Suppl:113-114.
• 16. Mason JW, Hancock EW, Gettes LS, Bailey JJ, Childers R, Deal BJ, et al. Recommendations for the standardization and interpretation of the electrocardiogram: part II: electrocardiography diagnostic statement list a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2007;49(10):1128-1135.
• 17. Koo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med. 2016;15(2):155-163.
• 18. Birnbaum Y, Sclarovsky S. The grades of ischemia on the presenting electrocardiogram of patients with ST elevation acute myocardial infarction. J Electrocardiol. 2001;34 Suppl:17-26.
• 19. Gardner PI, Ursell PC, Fenoglio JJ, Jr., Wit AL. Electrophysiologic and anatomic basis for fractionated electrograms recorded from healed myocardial infarcts. Circulation. 1985;72(3):596-611.
• 20. Kardys I, Kors JA, van der Meer IM, Hofman A, van der Kuip DA, Witteman JC. Spatial QRS-T angle predicts cardiac death in a general population. Eur Heart J. 2003;24(14):1357-1364.
• 21. Rautaharju PM, Prineas RJ, Zhang ZM. A simple procedure for estimation of the spatial QRS/T angle from the standard 12-lead electrocardiogram. J Electrocardiol. 2007;40(3):300-304.
• 22. Oehler A, Feldman T, Henrikson CA, Tereshchenko LG. QRS-T angle: a review. Ann Noninvasive Electrocardiol. 2014;19(6):534-542.
• 23. Brown RA, Schlegel TT. Diagnostic utility of the spatial versus individual planar QRS-T angles in cardiac disease detection. J Electrocardiol. 2011;44(4):404-409.
• 24. Ateş MS, Yıldırım A, Sökmen E. Association Between Pan-Immune-Inflammation Value and Dipper/Non-Dipper Status in Newly Diagnosed Hypertensive Patients. J Inflamm Res. 2025;18:6217-28.
• 25. Sökmen E, Ateş MS, Celik M, Kaleli MF. Utility of pan-immune-inflammation index in the diagnosis of masked hypertension in patients with type 2 diabetes mellitus. Hormones (Athens). 2025.
• 26. Dilaveris P, Antoniou CK, Gatzoulis K, Tousoulis D. T wave axis deviation and QRS-T angle - Controversial indicators of incident coronary heart events. J Electrocardiol. 2017;50(4):466-475.
• 27. Kors JA, van Herpen G, Sittig AC, van Bemmel JH. Reconstruction of the Frank vectorcardiogram from standard electrocardiographic leads: diagnostic comparison of different methods. Eur Heart J. 1990;11(12):1083-1092.
• 28. Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, et al. The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention. 2005;1(2):219-227.
• 29. Neeland IJ, Patel RS, Eshtehardi P, Dhawan S, McDaniel MC, Rab ST, et al. Coronary angiographic scoring systems: an evaluation of their equivalence and validity. Am Heart J. 2012;164(4):547-52.e1.
• 30. Bittencourt MS, Hulten E, Ghoshhajra B, O'Leary D, Christman MP, Montana P, et al. Prognostic value of nonobstructive and obstructive coronary artery disease detected by coronary computed tomography angiography to identify cardiovascular events. Circ Cardiovasc Imaging. 2014;7(2):282-291.
• 31. Gül S, Erdoğan G, Yontar OC, Arslan U. The Relationship Between Electrocardiographic Frontal QRS-T Angle and Gencini Score in Non-ST Segment Elevated Myocardial Infarction. Kafkas Journal of Medical Sciences. 2021;11(2):268-274.
• 32. Akın H, Bilge Ö. Relationship between frontal QRS-T duration and the severity of coronary artery disease in who were non-diabetic and had stable angina pectoris. Anatol J Cardiol. 2021;25(8):572-578.
• 33. Palaniswamy C, Singh T, Aronow WS, Ahn C, Kalapatapu K, Weiss MB, et al. A planar QRS-T angle >90 degrees is associated with multivessel coronary artery disease in patients undergoing coronary angiography. Med Sci Monit. 2009;15(12):Ms31-4.