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      Stability of the ECG Features of Complete Right Bundle Branch Block over Time: A Methodological Study for Implementation in Research and Clinical Practice


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          Since research is concentrated to a large extent on patients with left bundle branch block, we aimed at evaluating the hypothesis that measurements of certain intervals and other characteristics of the ECG may change over time in patients with right bundle branch block (RBBB), and to design a model, which could be implemented in research and clinical practice, irrespective of the specific ECG features present. The duration of the QRS complex, QT, QTc, and PR intervals, the frontal QRS axis, the heart rate and the presence of hemiblocks, atrioventricular blocks, and atrial fibrillation were compared in the 1st and last of all available ECGs for each patient. Also, a subgroup of patients who had a ventricular aneurysm (VA) was compared with the remaining patients, with respect to the above variables. This longitudinal analysis included all of the patients with RBBB followed in our Cardiology Clinic. There were no significant changes in the ECG variables from the two ECGs recorded 487.6 ± 410.1 (range 0–1,476) days apart, in the two comparisons carried out in 151 patients with RBBB. Comparison of the above-described ECG intervals and characteristics of patients with RBBB were found to be stable over the time course of the investigation. This methodological study is presented as a model to be used serially and prospectively in research and clinical practice for the follow-up of patients with bundle branch block, VA, dilated cardiomyopathy, congestive heart failure, or those considered for cardiac resynchronization therapy.

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          Most cited references 15

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          Intraventricular conduction delay: a prognostic marker in chronic heart failure.

          Chronic heart failure (CHF) is associated with high mortality, and there are several established clinical and laboratory parameters that predict mortality in CHF. The purpose of this study was (a) to identify the best ECG parameter that predicts mortality, (b) to evaluate the prognostic marker of ECG against well-established indicators of prognosis. Relevant data from 241 CHF patients were analysed retrospectively. Cardiopulmonary exercise testing and radionuclide ventriculogram were also performed where possible. The mean follow-up period was 31 months. On univariate analysis by the Cox proportional Hazard method, intraventricular conduction delay (IVCD) [P<0.0001, hazard ratio 1.017 (1.011-1.024)] and QTc [P<0.0001, hazard ratio 1.012 (1.006-1.017)] were identified as predictors of mortality. On bivariate analysis, IVCD and MVO2 were better predictors when combined together. A model based on multivariate analysis showed that IVCD, MVO2 and left ventricular ejection fraction (LVEF) were the best predictors of mortality. The addition of plasma sodium, age and NYHA class had no added benefit on the predictive power of the model. Further analysis of IVCD and QTc showed that, for different cut-off values, IVCD is better than QTc, and that there is a graded increase in mortality with increasing value of IVCD. We have found that IVCD is an important ECG predictor of prognosis in patients with CHF.
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            Natural history of abnormal conduction and its relation to prognosis in patients with dilated cardiomyopathy.

            To investigate the natural history of disturbances in ventricular activation, atrioventricular conduction, and ventricular cavity size, we retrospectively studied 58 patients from a total of 296 patients with dilated cardiomyopathy seen within 4 years. A total of 309 computerised electrocardiograms (ECGs) and 135 M-mode echocardiograms were analysed. In the majority of the patients, PR interval, QRS duration and QT interval prolonged progressively, though heart rate changed little. Their increase was much more striking in patients who died (n = 10) or had a pacemaker inserted (n = 9), compared to that in the clinically stable patients, though at entry all these values, as well as age and left ventricular cavity size, were similar. There were no significant differences between patients who died and those with a pacemaker inserted, except for QRS axis, which had shifted rightwards in 8 out of 10 who died, but only in 3 of 9 who subsequently had a pacemaker inserted and 14 of the 29 stable patients. A QRS duration over 160 ms was found in 8 out of the 10 patients who died, 6 of 9 who had a pacemaker and only in 5 out of the 39 stable patients (P < 0.001). The sum of PR interval and QRS duration over 375 ms was not found in any stable patient but was present in 6 of the 7 patients who were in sinus rhythm and died (P < 0.001). Left ventricular cavity size also increased with time, but did not correlate significantly with ECG progression, nor did it identify patients who subsequently died. Thus, a combination of increasing PR interval and QRS duration, particularly along with rightwards shift of QRS axis, appears to be a marker of high risk in patients with dilated cardiomyopathy.
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              Incremental changes in QRS duration in serial ECGs over time identify high risk elderly patients with heart failure.

              To investigate the hypothesis that changes in the ECG over time may be an important and readily available marker of prognostic value in patients with heart failure. 112 elderly patients (81 men) with stable heart failure, a mean (SD) age of 73.3 (4.4) years, left ventricular ejection fraction 38 (17)%, and peak oxygen consumption 15.1 (4.7) ml/kg/min had ECG measurements on two occasions a minimum of 12 (5) months apart. During the subsequent follow up period (mean 27 (17) months) 45 patients died. QRS duration (p = 0.001) and heart rate (p = 0.03) at baseline were found by Cox proportional hazard method analysis to predict adverse outcomes in these patients. Of the changes in ECG parameters between the first and second visit, broadening of QRS duration (p = 0.001) predicted mortality. On Kaplan-Meier survival analysis, patients with 20% increase in QRS duration was associated with the worst prognosis. Progressive prolongation of QRS duration correlated closely with deterioration of LV systolic and diastolic function. A single measurement of QRS duration has significant prognostic value in elderly patients with heart failure and the increase in QRS duration over time is an even better predictor of adverse out comes.

                Author and article information

                S. Karger AG
                February 2005
                07 February 2005
                : 103
                : 2
                : 84-88
                Mount Sinai School of Medicine, New York University, New York, N.Y., and Division of Cardiology, Elmhurst Hospital Center, Elmhurst, N.Y., USA
                82468 Cardiology 2005;103:84–88
                © 2005 S. Karger AG, Basel

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                Page count
                Tables: 2, References: 30, Pages: 5
                General Cardiology


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