THE ASSOCIATION BETWEEN FRAGMENTED QRS ON ELECTROCARDIOGRAPHY AND BLOOD PRESSURE PATTERN IN PATIENTS WITH HYPERTENSION

Öz

OBJECTIVE: Fragmented QRS (fQRS) complexes on electrocardiography (ECG) signify areal scar and fibrosis in the myocardium. Our aim was to investigate association between fragmented QRS and blood pressure pattern in hypertensive patients.

MATERIAL AND METHODS: Patients underwent ambulatory blood pressure were studied retrospectively. Patients whose systolic blood pressure was 10-20% lower during the night when compared to the day were grouped as “dipping group”, while those who had a decrease less than 10% during the night were grouped as “non-dipping group”. The fQRS was defined as the presence of a second R wave, notching of R or S wave or fragmentation in two contiguous leads on ECG corresponding to epicardial major coronary artery region.

RESULTS: The dipping group had 98 patients, while the non-dipping group had 89 patients. The groups were similar in terms of age, sex, body mass index, lipid profile and antihypertensive drugs. The fQRS was observed in 14 patients in the dipper group and 27 patients in the non-dipping group (p=0.008). The fQRS on ECG was found to be an independent predictor of non-dipping blood pressure pattern (p=0.046, odds ratio=2.27).

CONCLUSIONS: The presence of fQRS was more than in hypertensives with non-dipping pattern compared with dipping pattern and this variable was a predictor of non-dipping pattern.

Anahtar Kelimeler

• Blood Pressure Monitoring,electrocardiography,hypertension,fragmented QRS

Hipertansiyonu Olan Hastalarda Kan Basıncı Paterni ve EKG'de fragmante QRS arasındaki ilişki

Öz

AMAÇ: Fragmante QRS (FQRS) kompleksleri bölgesel mi-yokardiyal fibrozisi gösterir ve artmış kardiyovasküler mortalite ve morbidite ile ilişkilidir. Hipertansiflerde fQRS ve kan basıncı paterni arasındaki ilişkiyi araştıran bir ça-lışma yoktur. Bu çalışmanın amacı hipertansiflerde kan basıncı paterni ve fQRS arasındaki ilişkiyi araştırmaktır.

GEREÇ VE YÖNTEM: Kliniğimizde ambulatuvar kan basıncı izlemi yapılmış olan hastalar geriye dönük olarak incelendi. Gündüz değerlerine göre gece sistolik kan basıncının %10-20 düşmesi “dipping patern”, bu düşüşün olmaması ise “non-dipping patern” olarak gruplandırıldı. fQRS major koroner arter sulama bölgesi ile uyumlu ardışık iki derivasyonda, ilave bir R dalgasının varlığı, R/S dalgasının çentiklenmesi veya fragmantasyonu olarak tanımlandı.

BULGULAR: Dipping grubunda 98 hasta, non-dipping grubunda ise 89 hasta vardı. Her iki grup yaş, cinsiyet, beden kitle indeksi, lipit profili ve antihipertansif ilaç kullanımı yönünden benzerdi. EKG’de fQRS varlığı dipper grubunda 14 hastada (%14), non-dipper grubunda ise 27 hastada (%30) mevuttu (p=0.008). EGG’de fQRS varlığı non-dipper kan basıncı paterninin bir öngördürücüsüydü (p=0.046, odds oranı=2.27, %95 güven aralığı= 1.04-6.37).

SONUÇ: EKG’de fQRS varlığı non-dipper kan basıncı paternine sahip hastalarda daha fazla bulundu. Ayrıca, bu değişken non-dipper paterninin öngördürücüsüydü.

Anahtar Kelimeler

• Ambulatuvar Kan basıncı izlemi,Kan Basıncı paterni,Fragmante QRS

Kaynakça

1. 1. O'Brien E, Sheridan J, O'Malley K. Dippers and Nondippers. Lancet 1988; 2: 397.
2. 2. Brotman DJ, Davidson MB, Boumitri M, Vidt DG. Impaired diurnal blood pressure variation and all-cause mortality. Am J Hypertens 2008; 21: 92-7.
3. 3. Verdecchia P, Schillaci G, Guerrieri M, Gatteschi C, Benemio G, Boldrini F, et al. Circadian blood pressure changes and left ventricular hypertrophy in essential hypertension. Circulation 1990; 8: 528-36.
4. 4. Cuspidi C, Macca G, Sampieri L, Michev I, Salerno M, Fusi V, et al. Target organ damage and non-dipping pattern defined by two sessions of ambulatory blood pressure monitoring in recently diagnosed essential hypertensive patients. J Hypertens 2001; 19: 1539-45.
5. 5. Cuspidi C, Meani S, Salerno M, Valerio C, Fusi V, Severgnini B, et al. Cardiovascular target organ damage in essential hypertensives with or without reproducible nocturnal fall in blood pressure. J Hypertens 2004; 22: 273-80.
6. 6. Gardner PI, Ursell PC, Fenoglio JJ Jr, Witt AL. Electrophysiologic and anatomic basis for fractionated electrograms recorded from healed myocardial infarcts. Circulation 1985; 72: 596-611.
7. 7. Pietrasik G, Goldenberg I, Zdzienicka J, Moss AJ, Zareba W. Prognostic significance of fragmented QRS complex for predicting the risk of recurrent cardiac events in patients with Q-wave myocardial infarction. Am J Cardiol 2007; 100: 583-6.
8. 8. Das MK, Saha C, El Masry H, Peng J, Dandamudi G, Mahenthiran J, et al. Fragmented QRS on a 12-lead ECG: a predictor of mortality and cardiac events in patients with coronary artery disease. Heart Rhythm 2007; 4: 1385-92.

9. 9. Sokolow M, Lyon TP. The ventricular complex in left ventricular hypertrophy as obtained by unipolar and limb leads. Am Heart J 1949; 37: 161-86.
10. 10. Das MK, Khan B, Jacob S, Kumar A, Mahenthiran J. Significance of a fragmented QRS complex versus a Q wave in patients with coronary artery disease. Circulation 2006; 113: 2495-501.
11. 11. Sherwood A, Steffen PR, Blumenthal JA, Kuhn C, Hinderliter AL. Nighttime blood pressure dipping: The role of the sympathetic nervous system. Am J Hypertens 2002; 5: 111-8.
12. 12. Kohara K, Nishida W, Maguchi M, Hiwada K. Autonomic nervous function in non-dipper essential hypertensive subjects. Evaluation by power spectral analysis of heart rate variability. Hypertension 1995; 26: 808-14.
13. 13. Nakano Y, Oshima T, Ozono R, Higashi Y, Sasaki S, Matsumoto T, et al. Autonomic nervous system activity in essential hypertension: A comparison between dippers and nondippers. J Hum Hypertens 1997; 11: 665-71.
14. 14. Mann DL, Kent RL, Parsons B, Cooper G, 4th. Adrenergic Effects on the Biology of the Adult Mammalian Cardiocyte. Circulation 1992; 85: 790-804.
15. 15. Liu W, Wang X, Mei Z, Gong J, Gao X, Zhao Y, et al. Chronic stress promotes the progression of pressure overload-induced cardiac dysfunction through inducing more apoptosis and fibrosis. Physiol Res 2015; 64: 325-34.
16. 16. Gupta MK, Neelakantan TV, Sanghamitra M, Tyagi RK, Dinda A, Maulik S, et al. An assessment of the role of reactive oxygen species and redox signaling in norepinephrine-induced apoptosis and hypertrophy of H9c2 cardiac myoblasts. Antioxid Redox Signal 2006; 8: 1081-93.
17. 17. Basaran Y, Tigen K, Karaahmet T, Isiklar I, Cevik C, Gurel E, et al. Fragmented QRS complexes are associated with cardiac fibrosis and significant intraventricular systolic dyssynchrony in nonischemic dilated cardiomyopathy patients with a narrow QRS interval. Echocardiography 2011; 28: 62-8.
18. 18. 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.
19. 19. Homsi M, Alsayed L, Safadi B, Mahenthiran J, Das MK. Fragmented QRS complexes on 12-lead ECG: A marker of cardiac sarcoidosis as detected by gadolinium cardiac magnetic resonance imaging. Ann Noninvasive Electrocardiol 2009; 14: 319-26.
20. 20. Kadi H, Kevser A, Ozturk A, Koc F, Ceyhan K. Fragmented QRS complexes are associated with increased left ventricular mass in patients with essential hypertension. Ann Noninvasive Electrocardiol 2013; 18: 547-54.
21. 21. 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.
22. 22. Cuspidi C, Michev I, Meani S, Severgnini B, Fusi V, Corti C, et al. Reduced nocturnal fall in blood pressure, assessed by two ambulatory blood pressure monitorings and cardiac alterations in early phases of untreated essential hypertension. J Hum Hypertens 2003; 17: 245-51.
23. 23. Grandi AM, Broggi R, Jessula A, Laurita E, Cassinerio E, Piperno F, et al. Relation of extent of nocturnal blood pressure decrease to cardiovascular remodeling in never-treated patients with essential hypertension. Am J Cardiol 2002; 89: 1193-6.
24. 24. Casiglia E, Schiavon L, Tikhonoff V, Bascelli A, Martini B, Mazza A, et al. Electrocardiographic criteria of left ventricular hypertrophy in general population. Eur J Epidemiol 2008; 23: 261-71.
25. 25. de la Sierra, Redon J, Banegas JR, Segura J, Parati G, Gorostidi M, et al. Prevalence and factors associated with circadian blood pressure patterns in hypertensive patients. Hypertension 2009; 53: 466-72