The effect of the basal frontal QRS-T angle on disease severity and mortality in Covid-19 patients

Abstract

This study aimed to determine the relationship between the frontal QRS-T angle, the severity of the disease, and mortality, calculated with the ECG data taken during admission to the hospital. In this retrospective study, patients hospitalized in intensive care units and regular services with Covid-19 disease at Health Sciences University Mehmet Akif Inan Training and Research Hospital between April-September 2020 were included. Patients who were not given Covid-19 medication except for five days of Hydroxychloroquine (HC) and Azithromycin (AZ) with no cardiac disease history and daily taken ECGs were included in the study. A total of 135 patients were included in this study. While 45.9% of the patients received only HC treatment, 54.1% also received additional AZ treatment. It was observed that the frontal QRS-T angle was significantly longer in intensive care patients and intubated patients (p =<0.001). ROC curve analysis demonstrated that the best cut-off value for predicting mortality was 101.5o. The in-hospital mortality rate was significantly higher in patients with widened frontal QRS-T angle (p = 0.008). QRS widening, QTc prolongation, and QRS-T angle widening were substantially more frequent in intensive care patients (p=0.001,p<0.001, and p<0.001, respectively). Significantly QTc prolongation was observed more frequently in patients hospitalized in intensive care and followed up intubated (p<0.001 and p=0.003, respectively). The most common QTc prolongation time was on the 4th day of treatment in both groups (43.8% and 46.8%). Multivariate logistic regression analysis showed that frontal QRS-T angle ≥ 101.5o (OR: 7.08, 95%CI: 1.17-42.75, P = 0.033) was an independent predictor of mortality. The prolonged frontal QRS-T angle in Covid-19 patients increases the severity of the disease and mortality rates. The frontal QRS-T angle can be used to determine the prognosis of Covid-19 patients due to its advantages, such as easy evaluation and no extra costs.

Keywords

• Covid-19 disease
• QTc prolongation
• mortality
• frontal QRS-T angle

References

1. 1. COVID-19 Map. In: Johns Hopkins Coronavirus Resource Center [Internet]. [cited 5 October 2020]. Available: https://coronavirus.jhu.edu/map.html.
2. 2. Zumla A, Niederman MS. Editorial: The explosive epidemic outbreak of novel coronavirus disease 2019 (COVID-19) and the persistent threat of respiratory tract infectious diseases to global health security. Curr Opin Pulm Med. 2020 May;26(3):193-196. doi: 10.1097/MCP.0000000000000676.
3. 3. Chen CY, Wang FL, Lin CC. Chronic hydroxychloroquine use associated with QT prolongation and refractory ventricular arrhythmia. Clin Toxicol (Phila). 2006;44(2):173-5. doi: 10.1080/15563650500514558. PMID: 16615675.
4. 4. Hancox JC, Hasnain M, Vieweg WV, Crouse EL, Baranchuk A. Azithromycin, cardiovascular risks, QTc interval prolongation, torsade de pointes, and regulatory issues: A narrative review based on the study of case reports. Ther Adv Infect Dis. 2013 Oct;1(5):155-65. doi: 10.1177/2049936113501816. PMID: 25165550.
5. 5. Fiolet T, Guihur A, Rebeaud ME, Mulot M, Peiffer-Smadja N, Mahamat-Saleh Y. Effect of hydroxychloroquine with or without azithromycin on the mortality of coronavirus disease 2019 (COVID-19) patients: a systematic review and meta-analysis. Clin Microbiol Infect. 2020 Aug 26:S1198-743X(20)30505-X. doi: 10.1016/j.cmi.2020.08.022. Epub ahead of print. PMID: 32860962.
6. 6. Rosenberg ES, Dufort EM, Udo T, Wilberschied LA, Kumar J, Tesoriero J, et al. Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State. JAMA. 2020 Jun 23;323(24):2493-2502. doi: 10.1001/jama.2020.8630. PMID: 32392282.
7. 7. Oehler A, Feldman T, Henrikson CA, Tereshchenko LG. QRS-T angle: a review. Ann Noninvasive Electrocardiol. 2014 Nov;19(6):534-42. doi: 10.1111/anec.12206. Epub 2014 Sep 9. PMID: 25201032.
8. 8. Voulgari C, Pagoni S, Tesfaye S, Tentolouris N. The spatial QRS-T angle: implications in clinical practice. Curr Cardiol Rev. 2013;9(3):197-210. doi: 10.2174/1573403x113099990031. PMID: 23909632.

9. 9. Tanriverdi Z, Unal B, Eyuboglu M, Bingol Tanriverdi T, Nurdag A, Demirbag R. The importance of frontal QRS-T angle for predicting non-dipper status in hypertensive patients without left ventricular hypertrophy. Clin Exp Hypertens. 2018;40(4):318-323. doi: 10.1080/10641963.2017.1377214. PMID: 28949780.
10. 10. 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 Dec;15(12):MS31-4. PMID: 19946243.
11. 11. Walsh JA 3rd, Soliman EZ, Ilkhanoff L, Ning H, Liu K, Nazarian S, et al. Prognostic value of frontal QRS-T angle in patients without clinical evidence of cardiovascular disease (from the Multi-Ethnic Study of Atherosclerosis). Am J Cardiol. 2013 Dec 15;112(12):1880-4. doi: 10.1016/j.amjcard.2013.08.017. PMID: 24063831.
12. 12. Raposeiras-Roubín S, Virgós-Lamela A, Bouzas-Cruz N, López-López A, Castiñeira-Busto M, Fernández-Garda R, 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(8):1312-9. doi: 10.1016/j.amjcard.2014.01.406. PMID: 24685325.
13. 13. Tanriverdi Z, Besli F, Gungoren F, Tascanov MB. What is the normal range of the frontal QRS-T angle? Diabetes Res Clin Pract. 2020;160:107645. doi: 10.1016/j.diabres.2019.02.028.
14. 14. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol. 2020;5(7):802-810. doi: 10.1001/jamacardio.2020.0950. PMID: 32211816.
15. 15. Chen C, Chen C, Yan JT, Zhou N, Zhao JP, Wang DW. Analysis of myocardial injury in patients with COVID-19 and association between concomitant cardiovascular diseases and severity of COVID-19. Zhonghua Xin Xue Guan Bing Za Zhi. 2020 Jul 24;48(7):567-571. Chinese. doi: 10.3760/cma.j.cn112148-20200225-00123. PMID: 32141280.
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. Med Princ Pract. 2017;26(2):125-131. doi: 10.1159/000453267. PMID: 27829248.
17. 17. Sur S, Han L, Tereshchenko LG. Comparison of sum absolute QRST integral, and temporal variability in depolarization and repolarization, measured by dynamic vectorcardiography approach, in healthy men and women. PLoS One. 2013;8(2):e57175. doi: 10.1371/journal.pone.0057175. PMID: 23451181.
18. 18. Kahraman S, Kalkan AK, Turkyilmaz AB, Dogan AC, Avci Y, Uzun F, et al. Frontal QRS-T angle is related with hemodynamic significance of coronary artery stenosis in patients with single vessel disease. Anatol J Cardiol. 2019;22(4):194-201. doi: 10.14744/AnatolJCardiol.2019.99692. PMID: 31584447.
19. 19. Kurisu S, Nitta K, Sumimoto Y, Ikenaga H, Ishibashi K, Fukuda Y, et al. Myocardial perfusion defect assessed by single-photon emission computed tomography and frontal QRS-T angle in patients with prior anterior myocardial infarction. Heart Vessels. 2019;34(6):971-975. doi: 10.1007/s00380-018-01330-9. Epub 2019 Jan 2. PMID: 30604189.
20. 20. Kurisu S, Nitta K, Sumimoto Y, Ikenaga H, Ishibashi K, Fukuda Y, et al. Effects of Myocardial Perfusion Defect on the Frontal QRS-T Angle in Anterior Versus Inferior Myocardial Infarction. Intern Med. 2020;59(1):23-28. doi: 10.2169/internalmedicine.3348-19. Epub 2019 Sep 11. PMID: 31511480; PMCID: PMC6995697.
21. 21. Jensen CJ, Lambers M, Zadeh B, Wambach JM, Nassenstein K, Bruder O. QRS-T angle in patients with Hypertrophic Cardiomyopathy - A comparison with Cardiac Magnetic Resonance Imaging. Int J Med Sci. 2021;18(3):821-825. doi: 10.7150/ijms.52415. PMID: 33437218; PMCID: PMC7797532.
22. 22. Fischer K, Marggraf M, Stark AW, Kaneko K, Aghayev A, Guensch DP, et al. Association of ECG parameters with late gadolinium enhancement and outcome in patients with clinical suspicion of acute or subacute myocarditis referred for CMR imaging. PLoS One. 2020;15(1):e0227134. doi: 10.1371/journal.pone.0227134. PMID: 31923225; PMCID: PMC6953836.
23. 23. Shi B, Ferrier KA, Sasse A, Harding SA, Larsen PD. Correlation between vectorcardiographic measures and cardiac magnetic resonance imaging of the left ventricle in an implantable cardioverter defibrillator population. J Electrocardiol. 2014; 47(1):52-8. doi: 10.1016/j.jelectrocard.2013.06.018. Epub 2013 Aug 28. PMID: 23993862.
24. 24. Chorin E, Wadhwani L, Magnani S, Dai M, Shulman E, Nadeau-Routhier C, et al. QT interval prolongation and torsade de pointes in patients with COVID-19 treated with hydroxychloroquine/azithromycin. Heart Rhythm. 2020;17(9):1425-1433. doi: 10.1016/j.hrthm.2020.05.014. PMID: 32407884.
25. 25. Saleh M, Gabriels J, Chang D, Soo Kim B, Mansoor A, Mahmood E, et al. Effect of Chloroquine, Hydroxychloroquine, and Azithromycin on the Corrected QT Interval in Patients With SARS-CoV-2 Infection. Circ Arrhythm Electrophysiol. 2020;13(6):e008662. doi: 10.1161/CIRCEP.120.008662. PMID: 32347743.
26. 26. Jain S, Workman V, Ganeshan R, Obasare ER, Burr A, DeBiasi RM, et al. Enhanced electrocardiographic monitoring of patients with Coronavirus Disease 2019. Heart Rhythm. 2020;17(9):1417-1422. doi: 10.1016/j.hrthm.2020.04.047. PMID: 32387247.