ST Segment Yükselmesiz Myokard İnfarktüsünde Gensini Skoru İle Elektrokardiyografik Frontal QRS-T Açısı Arasındaki İlişki

Abstract

Amaç: Gensini skoruna dayalı risk sınıflandırması, ST Segment Yükselmesiz Myokard İnfarktüsü (NSTEMI) hastalarında erken revaskülarizasyon ihtiyacını belirlemek için önemli bir rol oynamaktadır. Frontal QRS-T açısının [f(QRS-T)] koroner arter hastalığının aterosklerotik yükünü öngörmedeki prediktif rolü, NSTEMI hastalarında STEMI hastalarıyla kıyaslandığında daha belirsizdir. Bu çalışmada NSTEMI hastalarında f(QRS-T) açısı ve Gensini skoru arasındaki ilişkiyi araştırmayı amaçladık. Materyal ve metot: Çalışmaya NSTEMI tanısıyla koroner yoğun bakımda takip edilen 248 hasta dahil edildi. f(QRS-T) açısı, EKG cihazının otomatik analizine göre frontal düzlemde QRS ve T dalgalarının eksenleri arasındaki farkın mutlak değeri olarak hesaplandı. Gensini skoru, birbirinden bağımsız olarak iki kardiyolog tarafından bir Gensini skor hesaplayıcısı kullanılarak hesaplandı. Çalışmaya dahil edilen hastalar düşük Gensini skorlu (≤45) ve yüksek Gensini skorlu (> 45) olmak üzere iki gruba ayrıldı. Bulgular: Sol ventrikül ejeksiyon fraksiyonu (LVEF) Gensini skoru yüksek olan grupta anlamlı derecede düşük saptandı (46,1±8 vs. 53,±7; p<0,001). Hastaların anjiyografik görüntüleri incelendiğinde sorumlu lezyonun en sık LAD'de (P<0.001) olduğu, revaskülarizasyon stratejileri kıyaslandığında ise en sık LAD’ye (P<0.001) yönelik revaskülarizasyon yapıldığı tespit edildi. Çalışmanın primer sonlanım noktası olan f(QRS-T) açısı, Gensini skoru yüksek olan grupta anlamlı derecede daha yüksek saptandı (54±47 vs. 84±54; p<0,001). Tek değişkenli ve çok değişkenli lojistik regresyon analizi sonucuna göre f(QRS-T) açısının yüksek Gensini skoru için bağımsız bir gösterge olduğunu tespit ettik. Receiver-operating characteristic (ROC) analizine göre, NSTEMI hastalarında f(QRS-T) açısının 61,5° üzerinde olması, yüksek Gensini skorlu (>45) hastaları %70 sensitivite ve % 61 spesifite ile öngörmektedir (Şekil 1). Sonuç: NSTEMI hastalarında f (QRS-T) açısının, Gensini skorunu öngörerek erken invaziv girişim ihtiyacını değerlendirmek için yararlı bir yöntem olabileceği bulunmuştur.

Keywords

• Frontal QRS-T açısı
• Gensini skoru
• NSTEMI

The relationship between Electrocardiographic Frontal QRS-T angle and Gencini score in Non- ST segment elevated Myocardial İnfarction

Abstract

Aim: Early risk stratification based on Gensini score plays a crucial role to identify the need for early invasive strategy in patients with NSTEMI. The predictive role of frontal QRS-T angle [f(QRS-T)] on the atherosclerotic burden of coronary artery disease is less clear in NSTEMI patients compared to STEMI patients. In this study, we aimed to investigate the relationship between f(QRS-T) and Gensini score in NSTEMI patients. Material and method: Total of 248 patients with the diagnosis of NSTEMI transferred to coronary care unit were included in the study. f(QRS-T) was calculated as the absolute value of the difference between the frontal plane QRS and T axes based on automatic report of ECG machine. Gensini score was computed using an Gensini score calculator by well-experienced two cardiologists.The study population was divided into two groups based on the low (≤45), and high Gensini score (>45). Results: Left ventricular ejection fraction was significantly lower in the group with high Gensini score (46.1 ± 8 vs. 53,3 ± 7; p <0.001). When the angiographic views was examined and revascularization strategies were compared, it was detected that responsible lesion was seen in LAD most frequently (p<0.001) and revascularization was performed most frequently for LAD (P <0.001). The f(QRS-T) angle, the primary endpoint of the study, were significantly higher in the group with high Gensini score ( 54±47 vs. 84±54; p<0,001). We determined that f(QRS-T) angle is an independent indicator for high Gensini score, based on the univariate and multivariate logistic regression analysis. Based on Receiver-operating characteristic (ROC) analysis, finding f(QRS-T) angle higher than 61.5° in NSTEMI patients predicts patients with high Gensini score (>45) with %70 sensitivity and % 61 specificity. Conclusion: In NSTEMI patients, f(QRS-T) has been found to be a useful decision-making tool to predict Gensini score to assess early invasive strategy.

Keywords

• Frontal QRS angle
• Gensini score
• NSTEMI

References

1. 1. He C, Song Y, Wang CS, Yao Y, Tang XF, Zhao XY et al. Prognostic value of the clinical SYNTAX score on 2-year outcomes in patients with acute coronary syndrome who underwent percutaneous coronary intervention. Am J Cardiol. 2017;119(10):1493–9.
2. 2. Gensini GG (1983). A more meaningful scoring system for determining the severity of coronary heart disease. Am J Cardiol 1983;51: 606.
3. 3. Oehler A, Feldman T, Henrikson CA, Tereshchenko LG. QRS-T angle: a review. Ann Noninvasive Electrocardiol 2014;19(6:) 534-42.
4. 4. Macfarlane PW. The frontal plane QRS-T angle. Europace. 2012;14(6):773–5.
5. 5. Lown MT, Munyombwe T, Harrison W, West RM, Hall CA, Morrell C et al. Association of frontal QRS-T angle–age risk score on admission electrocardiogram with mortality in patients admitted with an acute coronary syndrome. Am J Cardiol 2012;109:307–13.
6. 6. Bayam E, Yıldırım E, Kalcık M, Karaduman A, Kalkan S, Guner A et al, Relationship between P wave peak time and coronary artery disease severity in non-ST elevation acute coronary syndrome. Herz 2019.
7. 7. Lang, R.M., Badano LP, Avi VM, Afilalo J, Armstrong A, Ernande L et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28: 1-39
8. 8. Dogan A, Kahraman S. Frontal QRS-T Angle Predicts Coronary Atherosclerotic Burden in Patients With ST Segment Elevation Myocardial Infarction. J Electrocardiol. 2019;58:155-9.

9. 9. Terkelsen CJ, Lassen JF, Nørgaard BL, Gerdes CJ, Jensen T, Gotzsche LBH, et al. Mortality rates in patients with ST-elevation vs. non-ST elevation acute myocardial linfarction: observations from an unselected cohort. Eur Heart J 2005;26: 18-26.
10. 10. Hevia JC, Antzelevitch C, Barzaga FT, Sanchez MD, Balea FD, Molina RZ, et al. T peak-T end and T peak-T end dispersion as risk factors for ventricular tachycardia/ventricular fibrillation in patients with the Brugada syndrome. J Am Coll Cardiol. 2006;47:1828–34.
11. 11. Zencirci AE, Zencirci E, Degirmencioglu A, Karakus G, Ugurlu-can M, Gunduz S et al. The relationship between Gensini score and ST-segment resolution in patients with acute ST-segment elevation myocardial infarction undergoing primary percutane-ous coronary intervention. Kardiol Pol. 2014;72(6):494-503.
12. 12. Aytemir K, Ozer N, Atalar E, Sade E, Aksöyek S, Ovünç K et al. P wave dispersion on 12-lead electrocardiography in patients with paroxysmal atrial fibrillation. Pacing Clin Electrophysiol . 2000;23(7):1109‐12.
13. 13. Turhan H , Yetkin E, Senen K, Yilmaz MB, Ileri M, Atak R et al. Effects of percutaneous mitral balloon valvuloplasty on P-wave dispersion in patients with mitral stenosis. J Cardiol 2002;89(5):607‐9
14. 14. Okin PM. Electrocardiography in women: taking the initiative. Circulation 2006;113(4): 464‐6
15. 15. Zhang ZM, Prineas RJ, Case D, Soliman EZ, Rautaharju PM;ARIC Research Group. 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):844‐9.
16. 16. Gungor M, Celik M, Yalcinkaya E, Polat AT, Yuksel UC, Yildirim E et al. The value of frontal planar QRS‐T angle in patients without angiographically apparent atherosclerosis. Medical Principles and Practice 2017;26: 125–31
17. 17. Palaniswamy C, Singh T, Aronow WS, Ahn C, Kalapatapu K, Weiss MB et al. Aplanar QRS-T angle N90 degrees is associated with multivessel coronary artery disease in patients undergoing coronary angiography. Med Sci Monit 2009;15: 31–4.
18. 18. Colluoglu T, Tanriverdi Z, Unal B, Ozcan EE, Dursun H, Kaya D. The role of baseline and post-procedural frontal plane QRS-T angles for cardiac risk assessment in patients with acute STEMI. Ann Noninvasive Electrocardiol 2018;23: e12558.
19. 19. Selvaraj S, Ilkhanoff L, Burke MA, Freed BH, Lang RM, Martinez EE et al. Association of the frontal QRS-T angle with adverse cardiac remodeling impaired left and right ventricular function, and worse outcomes in heart failure with preserved ejection fraction. Journal of the American Society of Echocardiography 2013;27: 74-82.
20. 20. Raposeiras-Roubin S, Virgos-Lamela A, Bouzas-Cruz N, Lopez AL, Busto MC, Garda RF et al. Usefulness of the QRS-T angle to improve long-term risk stratification of patients with acute myocardial infarction and depressed left ventricular ejection fraction. Am J Cardiol. 2014;113:1312–9.