Relation of QRS Width in Healthy Persons to Risk of Future Permanent Pacemaker Implantation

doi:10.1016/j.amjcard.2010.04.021

The American Journal of Cardiology

Volume 106, Issue 5, 1 September 2010, Pages 668-672

https://doi.org/10.1016/j.amjcard.2010.04.021 Get rights and content

In the setting of acute myocardial infarction, prolongation of the QRS interval on electrocardiography identifies patients at risk for needing permanent pacemaker implantation. However, the implications of prolonged QRS intervals in healthy subjects are unclear, especially given that the QRS prolongation encountered in this setting is typically mild. The aim of this study was to assess the relation between QRS duration and incident pacemaker implantation in a community-based cohort of 8,311 subjects (mean age 54 years, 55% women) who attended 17,731 routine examinations with resting 12-lead electrocardiography. QRS duration was analyzed as a continuous and a categorical variable (<100, 100 to <120, and ≥120 ms). During up to 35 years of follow-up, 157 participants (56 women) developed need for permanent pacemakers. In multivariable Cox regression models adjusting for cardiovascular risk factors and previous myocardial infarction or heart failure, mild QRS prolongation was associated with a threefold risk for pacemaker implantation (adjusted hazard ratio 2.90, 95% confidence interval 1.81 to 4.66, p <0.0001), and bundle branch block was associated with a fourfold risk for pacemaker implantation (hazard ratio 4.43, 95% confidence interval 2.94 to 6.68, p <0.0001). Each standard deviation increment in QRS duration (11 ms) was associated with an adjusted hazard ratio of 1.14 (95% confidence interval 1.11 to 1.18, p <0.0001) for pacemaker placement. This association remained significant after excluding subjects with QRS durations ≥120 ms. In conclusion, subjects with prolonged QRS durations, even without bundle branch block, are at increased risk for future pacemaker implantation. Such individuals may warrant monitoring for progressive conduction disease.

Section snippets

Methods

The design and selection criteria of the Original and Offspring cohorts of the Framingham Heart Study (FHS) have been described previously.9, 10 In this study, we used pooled epochs from repeated examinations. Original cohort participants were eligible if they attended examination 11 (1968 to 1971, n = 2,955), examination 17 (1981 to 1984, n = 2,179), or examination 23 (1993 to 1995, n = 1,026). Offspring cohort participants were eligible if they attended examination 1 (1971 to 1975, n =

Results

The study cohort (17,731 examinations) was aged 20 to 98 years, and 55% were women, as listed in Table 1. Across all examinations, 40% of subjects had hypertension, and only 4% had histories of myocardial infarction or heart failure. The mean QRS duration was 79 ± 14 ms; 93% had QRS durations <100 ms, 4% had mild QRS prolongation (100 to <120 ms), and 3% had QRS durations ≥120 ms.

During follow-up, 157 participants (56 women) had permanent pacemakers implanted. Pacemakers were implanted

Discussion

Our results suggest that individuals in the community with even mildly prolonged QRS intervals are at substantially increased risk for developing cardiac rhythm disturbances severe enough to require pacemaker implantation. Mild QRS prolongation and bundle branch block were associated with three- and fourfold risks for incident pacemaker implantation, respectively. Furthermore, we observed a graded increase in the risk for pacemaker events across increasing QRS values, even after excluding those

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Progressive Conduction System Disease
2018, Cardiac Electrophysiology: From Cell to Bedside: Seventh Edition
Electrocardiographic abnormalities and arrhythmic risk markers in adult patients with beta thalassemia major
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Citation Excerpt :
QRS duration has been examined only in one small case–control study which failed to demonstrate any difference [10]. It has been demonstrated that increased QRS duration, even within normal limits, predicts mortality in the general population while it has been associated with increased risk for pacemaker implantation due to progressive conduction disease [26,27]. QRS fragmentation represents an abnormality in ventricular depolarization that has been associated with increased risk of arrhythmic events and mortality in a variety of cardiac disorders [28].
There seems to be a significant arrhythmia burden in β-thalassemia major (TM) patients without overt cardiomyopathy. Apart from conventional electrocardiographic (ECG) and arrhythmic risk markers we studied novel markers of ventricular repolarization and autonomic imbalance both at rest and after exercise testing.
We studied 47 adult TM patients without systolic heart failure and 47 age and sex-matched healthy control subjects. The median age of the studied population was 36 [32–43] years, 57% men. Baseline demographic and clinical characteristics were recorded while 12-lead electrocardiograms, 24-hour ECG Holter recordings, and treadmill exercise stress tests were analyzed.
TM patients exhibited increased QTc intervals in both 12-lead ECG recordings and in 24-hour Holter recordings. In addition, they had increased indexes of ventricular repolarization heterogeneity such as QT dispersion, and T peak-to-end/QT ratios. Furthermore, TM patients had decreased indexes of heart rate variability while the heart rate recovery after exercise was significantly attenuated compared to controls. Also, they had increased P wave and QRS duration while the QRS fragmentation was very prevalent. Finally, premature atrial extrasystoles and paroxysmal atrial fibrillation episodes were more frequent in TM patients.
TM patients with preserved left ventricular systolic function have several ECG abnormalities including alterations in ventricular depolarization and repolarization. Also, cardiac autonomic dysfunction is evident in 24-hour ECG monitoring as well as in the recovery phase after exercise testing. The prognostic value of specific arrhythmic risk indexes in this setting remains to be elucidated.
The clinical correlates and prognostic impact of QRS prolongation in patients with dilated cardiomyopathy: A single-center cohort study
2014, International Journal of Cardiology
Impact of new-onset persistent left bundle branch block on late clinical outcomes in patients undergoing transcatheter aortic valve implantation with a balloon-expandable valve
2014, JACC: Cardiovascular Interventions
Citation Excerpt :
These differences between studies may partially explain the controversial results regarding the clinical impact of new LBBB after TAVI, but this will need to be further evaluated in future studies. A high risk of AVB has been observed in patients and individuals without overt cardiac disease in the presence of LBBB (27,28). Previous studies including a relatively small number of patients showed a higher rate of PPI at follow-up among those patients in whom a new LBBB developed after either SAVR or TAVI (2,11,29).
The aim of this study was to determine the impact of new-onset persistent left bundle branch block (NOP-LBBB) on late outcomes after transcatheter aortic valve implantation (TAVI).
The impact of NOP-LBBB after TAVI remains controversial.
A total of 668 consecutive patients who underwent TAVI with a balloon-expandable valve without pre-existing LBBB or permanent pacemaker implantation (PPI) were included. Electrocardiograms were obtained at baseline, immediately after the procedure, and daily until hospital discharge. Patients were followed at 1, 6, and 12 months and yearly thereafter.
New-onset LBBB occurred in 128 patients (19.2%) immediately after TAVI and persisted at hospital discharge in 79 patients (11.8%). At a median follow-up of 13 months (range 3 to 27 months), there were no differences in mortality rate between the NOP-LBBB and no NOP-LBBB groups (27.8% vs. 28.4%; adjusted-hazard ratio: 0.87 [95% confidence interval (CI): 0.55 to 1.37]; p = 0.54). There were no differences between groups regarding cardiovascular mortality (p = 0.82), sudden death (p = 0.87), rehospitalizations for all causes (p = 0.11), or heart failure (p = 0.55). NOP-LBBB was the only factor associated with an increased rate of PPI during the follow-up period (13.9% vs. 3.0%; hazard ratio: 4.29 [95% CI: 2.03 to 9.07], p < 0.001. NOP-LBBB was also associated with a lack of left ventricular ejection fraction improvement and poorer New York Heart Association functional class at follow-up (p < 0.02 for both).
NOP-LBBB occurred in ∼1 of 10 patients who had undergone TAVI with a balloon-expandable valve. NOP-LBBB was associated with a higher rate of PPI, a lack of improvement in left ventricular ejection fraction, and a poorer functional status, but did not increase the risk of global or cardiovascular mortality or rehospitalizations at 1-year follow-up.
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2014, Cardiac Electrophysiology: From Cell to Bedside: Sixth Edition
The evaluation and management of drug effects on cardiac conduction (PR and QRS Intervals) in clinical development
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Citation Excerpt :
In the absence of underlying heart disease, the presence of rate-dependent bundle-branch block does not necessarily indicate an impaired prognosis.29 However, a recent prospective study has suggested that QRS duration independently predicts risk of sudden cardiac death, with a 2.5-fold elevated risk in subjects with a QRS >110 ms compared with those with a QRS <96 ms.30 Additionally, QRS prolongation in CV patients may portend a worsened outcome.31,32 Pathologic causes of bundle-branch block include ischemic heart disease, hypertrophy, endocarditis, myocarditis, cardiomyopathy, congenital defects, massive pulmonary embolus, age-dependent degenerative changes, or drug effect (eg, sodium channel blockers).
Recent advances in electrocardiographic monitoring and waveform analysis have significantly improved the ability to detect drug-induced changes in cardiac repolarization manifested as changes in the QT/corrected QT interval. These advances have also improved the ability to detect drug-induced changes in cardiac conduction. This White Paper summarizes current opinion, reached by consensus among experts at the Cardiac Safety Research Consortium, on the assessment of electrocardiogram-based safety measurements of the PR and QRS intervals, representing atrioventricular and ventricular conduction, respectively, during drug development.

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: This work was supported by the Framingham Heart Study of the National Heart, Lung, and Blood Institute, Bethesda, Maryland (Contract Number N01-HC-25195).

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Arrhythmias and conduction disturbanceRelation of QRS Width in Healthy Persons to Risk of Future Permanent Pacemaker Implantation

Section snippets

Methods

Results

Discussion

Am Heart J

Prog Cardiovasc Dis

Am J Med

Prog Cardiovasc Dis

Int J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Heart Rhythm

J Electrocardiol

A clinicopathological study on 25 cases of complete left bundle branch block

Jpn Heart J

Arrhythmias and conduction disturbance
Relation of QRS Width in Healthy Persons to Risk of Future Permanent Pacemaker Implantation