The prognostic implications of a fragmented QRS pattern in patients diagnosed with heart failure

Abstract

Objectives: The purpose of this study was to investigate the potential association between the presence of a fragmented QRS (fQRS) pattern on electrocardiogram (ECG) and prognostic outcomes in patients with heart failure (HF).

Methods: In the study, 238 patients with a left ventricular ejection fraction of less than 35% were included. The presence of fQRS pattern on ECG was analyzed in all patients. Patients were divided into two groups based on the presence or absence of fQRS on ECG. The primary clinical end points were all-cause mortality and rehospitalization.

Results: Baseline demographic characteristics were comparable between the groups. Patients with fQRS had a higher frequency of coronary artery disease and atrial fibrillation (72 (76%) vs 90 (62%), (p = 0.023; 27 (29%) vs 25 (17%), (p = 0.038, respectively). Additionally, patients with fQRS had a higher rate of mortality and rehospitalization during the 5-year follow-up period compared to patients without fQRS. (30 (32%) / 28 (19%), (p = 0.028; 56 (60%) / 50 (35%), p < 0.001, respectively). Multivariable logistic regression analysis revealed that the presence of fQRS was independently associated with mortality and rehospitalization ((p = 0.02 and p < 0.001, respectively).

Conclusions: The results of this study suggest that the presence of fQRS on ECG in patients with HF is independently related to a higher risk of mortality and hospitalization. Therefore, the presence of fQRS may be a useful indicator of poor prognosis in these patients.

Keywords

• Fragmented QRS
• heart failure
• hospitalization
• mortality

References

1. 1. Murphy SP, Ibrahim NE, Januzzi JL, Jr. Heart failure with reduced ejection fraction: a review. JAMA 2020;324:488-504.
2. 2. Xie J, Liu Y, Wei X, Ye W, Ma Z, Lu G, et al. Relationship between fragmented QRS complex and left ventricular fibrosis and function in patients with Danon disease. Front Cardiovasc Med 2022;9:790917.
3. 3. Liu T, Song D, Dong J, Zhu P, Liu J, Liu W, et al. Current understanding of the pathophysiology of myocardial fibrosis and its quantitative assessment in heart failure. Front Physiol 2017;8:238
4. 4. Lorgis L, Cochet A, Chevallier O, Angue M, Gudjoncik A, Lalande A, et al. Relationship between fragmented QRS and no-reflow, infarct size, and peri-infarct zone assessed using cardiac magnetic resonance in patients with myocardial infarction. Can J Cardiol 2014;30:204-10.
5. 5. Torigoe K, Tamura A, Kawano Y, Shinozaki K, Kotoku M, Kadota J. The number of leads with fragmented QRS is independently associated with cardiac death or hospitalization for heart failure in patients with prior myocardial infarction. J Cardiol 2012;59:36-41.
6. 6. Gong B, Li Z. Total mortality, major adverse cardiac events, and echocardiographic-derived cardiac parameters with fragmented QRS complex. Ann Noninvasive Electrocardiol 2016;21:404-12.
7. 7. Ogura S, Nakamura K, Morita H, Nakagawa K, Nishii N, Akagi S, et al. Fragmented QRS as a predictor of cardiac events in patients with cardiac sarcoidosis. J Cardiol 2022;79:446-52.
8. 8. Cheema A, Khalid A, Wimmer A, Bartone C, Chow T, Spertus JA, et al. Fragmented QRS and mortality risk in patients with left ventricular dysfunction. Circ Arrhythm Electrophysiol 2010;3:339-44.

9. 9. Das MK, Maskoun W, Shen C, Michael MA, Suradi H, Desai M, et al. Fragmented QRS on twelve-lead electrocardiogram predicts arrhythmic events in patients with ischemic and nonischemic cardiomyopathy. Heart Rhythm 2010;7:74-80.
10. 10. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;42:3599-726.
11. 11. Mitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, et al. Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2019;32:1-64.
12. 12. Schiller NB, Acquatella H, Ports TA, Drew D, Goerke J, Ringertz H, et al. Left ventricular volume from paired biplane two-dimensional echocardiography. Circulation 1979;60:547-55.
13. 13. Maggioni AP, Dahlström U, Filippatos G, Chioncel O, Leiro MC, Drozdz J, et al. EURObservational Research Programme: regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HF Pilot). Eur J Heart Fail 2013;15:808-17.
14. 14. Poole JE, Johnson GW, Hellkamp AS, Anderson J, Callans DJ, Raitt MH, et al. Prognostic importance of defibrillator shocks in patients with heart failure. N Engl J Med 2008;359:1009-17.
15. 15. Bello D, Fieno DS, Kim RJ, Pereles FS, Passman R, Song G, et al. Infarct morphology identifies patients with substrate for sustained ventricular tachycardia. J Am Coll Cardiol 2005;45:1104-8.
16. 16. Mahenthiran J, Khan BR, Sawada SG, Das MK. Fragmented QRS complexes not typical of a bundle branch block: a marker of greater myocardial perfusion tomography abnormalities in coronary artery disease. J Nucl Cardiol 2007;14:347-53.
17. 17. Peters S, Trümmel M, Koehler B. QRS fragmentation in standard ECG as a diagnostic marker of arrhythmogenic right ventricular dysplasia–cardiomyopathy. Heart Rhythm 2008;5:1417-21.
18. 18. Morita H, Kusano KF, Miura D, Nagase S, Nakamura K, Morita AT, et al. Fragmented QRS as a marker of conduction abnormality and a predictor of prognosis of Brugada syndrome. Circulation 2008;118:1697-704.
19. 19. Kanitsoraphan C, Rattanawong P, Mekraksakit P, Chongsathidkiet P, Riangwiwat T, Kanjanahattakij N, et al. Baseline fragmented QRS is associated with increased all-cause mortality in heart failure with reduced ejection fraction: A systematic review and meta-analysis. Ann Noninvasive Electrocardiol 2019;24:e12597.
20. 20. Korhonen P, Husa T, Konttila T, Tierala U, Makijarvi M, Vaananen H, et al. Fragmented QRS in prediction of cardiac deaths and heart failure hospitalizations after myocardial infarction. Ann Noninvasive Electrocardiol 2010;15:130-7.