QTc prolongation is associated with impaired right ventricular function and predicts mortality in pulmonary hypertension.

BACKGROUND: In rodent models of pulmonary hypertension (PH) and right ventricular hypertrophy (RVH), the QTc interval is prolonged, reflecting downregulation of repolarizing Kv channels in RV myocytes. The significance of QTc prolongation in human PH is unknown. We hypothesized that QTc prolongation occurs in human PH, is associated with RVH and decreased RV function, and predicts adverse prognosis. METHODS: Patients receiving a PAH-specific therapy (a prostanoid, endothelin-receptor antagonist and/or a phosphodiesterase-5 inhibitor), who had a 12-lead electrocardiogram (ECG) (n=202) were compared to age- and sex-matched controls (n=100). The duration of QTc on ECG was correlated with invasive hemodynamics (n=156) and with the status of the RV, as measured by Brain Natriuretic Peptide (NT-proBNP, n=145) and magnetic resonance imaging (n=24). Survival of the entire PH cohort and a subgroup with WHO Groups 1 and 4 PAH was prospectively determined from the Social Security Death Index. RESULTS: QTc intervals were longer in PH vs. controls (454.8 ± 29 ms vs. 429.8 ± 18 ms, p<0.001) and did not differ based on PAH-specific therapy. NT-proBNP increased proportionately with QTc and was higher for those in the upper quintile (QTc ≥ 480 ms) vs. those with QTc<480 ms (4004 ± 6682 pg/mL vs. 1501 ± 1822 pg/mL, p<0.001). The QTc interval also correlated directly with increasing RV end-diastolic volume (r=.67, p<0.001) and mass (r=.0.51, p<0.05), and inversely with RV ejection fraction (r=-.49, p<0.05). In the entire PH cohort and WHO Groups 1 and 4 subgroup, QTc ≥ 480 ms and cardiac index were independent predictors of mortality. CONCLUSIONS: QTc prolongation in PH patients reflects the status of the RV and is an independent predictor of mortality.

Atrial repolarization: its impact on electrocardiography.

The repolarizing T(a) wave of normal sinus rhythm is not fully visible unless there is a long P-R interval or complete atrioventicular block. Even with the latter, it is often of unseeably low voltage. It can powerfully influence inferior lead ST deviation in the stress test. The T(a) of inverted or retrograde P waves is of higher voltage than that of sinus rhythm and can simulate inferior injury. Evidence of specialized internodal tracts resides in 2 specific atrial action potential properties: resistance to gross hyperkalemia and supernormality. The T(a) wave figures essentially in the diagnosis of acute atrial infarction.

Torsades: adjacent and triggering electrocardiographic events.

Torsades de pointes (TdP) is a particular variant of ventricular arrhythmia associated with the long QT syndrome. The background of the latter is essentially 2-fold: patients under treatment with QT-prolonging drugs and subjects with congenital ionopathies. A third category is composed of subjects with both of these backgrounds. The fundamental feature of TdP is its provocation by pause-related augmentation of the repolarizing TU wave. The substrate electrocardiogram (ECG) shows prominent U waves in regular rhythm. The exaggeration of the U wave voltage following a pause is more marked the longer the pause and, for a given pause, more marked the faster the prepause rate. The pause-related sequences figure frequently adjacent to that which actually triggers the attack of TdP and continues to be seen after the event, serving to advise the physician as to the diagnosis, even following cardiac resuscitation, so that preventive measures can be taken (pacing, intravenous magnesium sulfate, or infusion with isoproterenol). The U wave of the regular rhythm ECG may show amplitude instability: an especially tall U triggering a premature ventricular complexe (PVC) that then in turn generates a pause-related sequence. TU alternans is common. Because these patients may not be in a monitored bed, recognition of pause-related phenomena in a patient with a long QT requires the ECG reader of the day to alert the floor as to the running danger. The mechanism of the pause-related TU augmentation is the generation of early afterdepolarizations.

Features of an exceptionally narrow QRS data set.

BACKGROUND: Little attention has been directed to the characteristics of electrocardiograms (ECGs) with brief QRS durations (BD). METHODS: From a database of 859,977 computer-analyzed (Marquette 12SL, GE Healthcare, Milwaukee, WI, USA) ECGs of 216,148 patients, 1805 patients (data set of BD: 19,718 ECGs; age, >18 years, unpaced), had, in at least one ECG, a QRS duration of less than 62 milliseconds, a prevalence of 0.8%. RESULTS: The QRS duration ranged from 46 to 188 milliseconds; values fluctuated between excessive brevity and the traditionally normal (80-95 milliseconds), with many values in the 60's. The average age at first acquisition was 56 years (range, 18-96 years); 1371 were female (76%) and 433 were males (24%); and 416 were white (23%), 1243 African American (69%), 109 other (6%). The summed 12-lead QRS amplitude (SigmaQRS) ranged from 2800 to 32,929 microV (mean +/- SD, 11,154 +/- 4101), and heart rate ranged from 40 to 269 (98 +/- 26). There was a statistically positive relationship between QRS duration (in the range 52-105 milliseconds) and SigmaQRS (P < 0001): for each 1000 microV increment, duration increased by 0.7 milliseconds (95% confidence interval [CI], 0.66-0.73 milliseconds). Conversely, for each 5-millisecond increment in duration, SigmaQRS increased by 475 microV (95% CI, 450-498 microV). There was an inverse relationship between QRS duration and heart rate (P < .0001): for every 10 beat rate increase, the duration dropped by 1.14 milliseconds (95% CI, 1.09-1.19 milliseconds). An additional data set of normal QRS durations ND consisted of 2902 subjects, none of whose 40,327 ECGs showed a QRS duration less than 62 milliseconds; 2.8% of ND ECGs had durations in the 62-69 millisecond range, 26% in BD. Sinus tachycardia was 43% in BD and 24% in ND. The average age of ND was 58 years (range, 18-100 years); 44% were male and 56% female; and 39% were white and 57% were African American. A positive relationship between duration and amplitude was found among ND subjects as well: for each 1000 point increase in SigmaQRS, duration increased by 0.45 milliseconds (P < .0001; 95% CI, 0.42-0.47 milliseconds). The duration amplitude relationship did not hold for durations greater than 105 milliseconds in either data set. CONCLUSION: Over the full extended span of QRS durations (46-106 milliseconds), the value of the latter is directly related to the total summed amplitude of the 12-lead QRS. An inverse relationship is demonstrable with heart rate.

Pseudo pacemaker stimuli.

Current electrocardiographic technology is limited in its ability to detect pacemaker stimuli secondary to the use of 150 Hz low-pass bandwidth filters designed to block high-frequency interference. Software solutions to improve the sensitivity of pacemaker stimulus detection are associated with imperfect specificity. The following case reports include three patients who do not have a pacing device, but were identified by a computer-based preliminary interpretation of a routine 12-lead surface electrocardiogram (ECG) as having a paced rhythm.

Recommendations for the standardization and interpretation of the electrocardiogram: part I: the electrocardiogram and its technology 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.

This statement examines the relation of the resting ECG to its technology. Its purpose is to foster understanding of how the modern ECG is derived and displayed and to establish standards that will improve the accuracy and usefulness of the ECG in practice. Derivation of representative waveforms and measurements based on global intervals are described. Special emphasis is placed on digital signal acquisition and computer-based signal processing, which provide automated measurements that lead to computer-generated diagnostic statements. Lead placement, recording methods, and waveform presentation are reviewed. Throughout the statement, recommendations for ECG standards are placed in context of the clinical implications of evolving ECG technology.

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.

This statement provides a concise list of diagnostic terms for ECG interpretation that can be shared by students, teachers, and readers of electrocardiography. This effort was motivated by the existence of multiple automated diagnostic code sets containing imprecise and overlapping terms. An intended outcome of this statement list is greater uniformity of ECG diagnosis and a resultant improvement in patient care. The lexicon includes primary diagnostic statements, secondary diagnostic statements, modifiers, and statements for the comparison of ECGs. This diagnostic lexicon should be reviewed and updated periodically.

Recommendations for the standardization and interpretation of the electrocardiogram. Part I: The electrocardiogram and its technology. 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.

This statement examines the relation of the resting ECG to its technology. Its purpose is to foster understanding of how the modern ECG is derived and displayed and to establish standards that will improve the accuracy and usefulness of the ECG in practice. Derivation of representative waveforms and measurements based on global intervals are described. Special emphasis is placed on digital signal acquisition and computer-based signal processing, which provide automated measurements that lead to computer-generated diagnostic statements. Lead placement, recording methods, and waveform presentation are reviewed. Throughout the statement, recommendations for ECG standards are placed in context of the clinical implications of evolving ECG technology.

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.

This statement provides a concise list of diagnostic terms for ECG interpretation that can be shared by students, teachers, and readers of electrocardiography. This effort was motivated by the existence of multiple automated diagnostic code sets containing imprecise and overlapping terms. An intended outcome of this statement list is greater uniformity of ECG diagnosis and a resultant improvement in patient care. The lexicon includes primary diagnostic statements, secondary diagnostic statements, modifiers, and statements for the comparison of ECGs. This diagnostic lexicon should be reviewed and updated periodically.