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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 131-135

Fragmented QRS complex in acute coronary syndrome, does it have significance in the emergency room? A study from Egypt


Department of Cardiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Web Publication3-Dec-2019

Correspondence Address:
Dr. Ibtesam Ibrahim El-Dosouky
Department of Cardiology, Faculty of Medicine, Zagazig University, Zagazig 44519
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_41_19

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  Abstract 


Background: Fragmented QRS (fQRS) is derived from regional myocardial fibrosis/scar and ischemia, which cause heterogeneous myocardial electrical activation. We aimed to detect if the presence of fQRS can predict the presence of coronary artery disease (CAD) and to which extent in Egyptian patients with acute coronary syndrome (ACS). Materials and Methods: Seventy-four patients with ACS were divided into two groups according to the presence of fQRS in the initial and follow-up electrocardiography (ECG), they underwent clinical examination, full history for CAD risks, echocardiographic study, cardiac enzymes, lipid profile estimation, and coronary angiographic study. Results: FQRS, when compared with pathological Q wave and ST-segment depression for diagnosis CAD; it has higher sensitivity (49.0% vs. 36.7% and 17.3%) for left anterior descending artery (LAD), (66.7% vs. 14.3% and 9.5%) for left circumflex (LCX), (67.5% vs. 27.5% and 12.5%) for right coronary artery (RCA), more specific (92.00% vs. 78.2% and 80%) for LAD, higher positive predictive value (45% vs. 39.2% and 35.9%) for LAD, (77% vs. 50% and 22%) for LCX, (90% vs. 73.3% and 38.5%) for RCA, more accuracy (63.5% vs. 51.4% and 41.9%) for LAD, (85.1% vs. 71.6% and 64.8%) for LCX, and (78.4% vs. 55.4% and 41.9%) for RCA with a statistically significant differences (P < 0.05). Conclusions: Presence of fQRS in ECG is a good, simple, applicable positive test to predict the presence of significant CAD in the Egyptian patients with ACS in the emergency room, even in those without enzyme elevation but have “fQRS.”

Keywords: Acute coronary syndrome, diagnosis of acute coronary syndrome in the emergency room, fragmented QRS, significant coronary lesions


How to cite this article:
El-Dosouky II, Abomandour HG. Fragmented QRS complex in acute coronary syndrome, does it have significance in the emergency room? A study from Egypt. J Indian coll cardiol 2019;9:131-5

How to cite this URL:
El-Dosouky II, Abomandour HG. Fragmented QRS complex in acute coronary syndrome, does it have significance in the emergency room? A study from Egypt. J Indian coll cardiol [serial online] 2019 [cited 2019 Dec 7];9:131-5. Available from: http://www.joicc.org/text.asp?2019/9/3/131/272175




  Introduction Top


Coronary artery disease (CAD) can lead to acute coronary syndrome (ACS), which describes any condition characterized by signs and symptoms of sudden myocardial ischemia, from unstable angina, and non-ST-segment elevation myocardial infraction (STEMI) to STEMI.[1]

Fragmented QRS (fQRS) was defined by an additional R wave (R') or notching within the QRS complex. fQRS on a 12-lead electrocardiography (ECG) was originally defined as narrow QRS complex duration (<120 ms). fQRS improved identification of prior myocardial infarction in patients who are being evaluated for CAD. The usefulness of fQRS for the diagnosis and prediction of prognosis has expanded to patients with ischemic and nonischemic cardiomyopathy (CMP) and patients with primary electrical diseases.[2]

It was demonstrated that fQRS is associated with increased morbidity and mortality and also is a predictor of adverse cardiac events in patients with ACS,[3] idiopathic-dilated CMP,[4] and decompensated heart failure.[5] Theoretically, fQRS is generally agreed to be derived from regional myocardial fibrosis/scar and ischemia, which cause heterogeneous myocardial electrical activation.[6]

We aimed to detect if the presence of fQRS complex in patient with ACS can predict the presence of coronary artery lesion and to which extent in Egyptian patients with ACS.


  Materials and Methods Top


This cross-sectional study included 74 patients who presented to the Damietta Cardiology Center and Cardiology Department, Zagazig University Hospital with ACS. ACS was defined as new-onset or worsening chest pain occurring at rest or with minimal exertion and not improved by nitroglycerin and or rest.

Diagnosis of ACS:[7],[8],[9]

  1. Typical chest pain >20 min or atypical chest pain with suggestion of ACS
  2. ECG finding as (ST-segment deviation >1 mm, inverted T wave, hyperacute T wave in two or more contagious leads, and new-onset left bundle branch block [LBBB]) (Ischemic evidence)
  3. Positive cardiac enzymes (troponin I and creatine kinase-MB [CKMB])
  4. Past history of typical ischemic chest pain or symptoms suggestive of myocardial ischemia with evidences of ischemia as ECG either resting or stress ECG, coronary angiography with coronary lesions, history of thrombolytic therapy and admission to CCU.


Patients with nonischemic or atypical chest pain, previous cardiac revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting), left bundle branch block (LBBB or right BBB), any degree of heart block or pacing and patients with any structural heart diseases that may carry fQRS as mitral stenosis, tetralogy of Fallot, and Brugada syndrome were excluded from the study.

Approval was obtained from the Ethical Committee of the Zagazig University Cardiology department after approval of the Institutional Review Board, Zagazig University (IRB-ZU), Egypt. After giving written informed consent, all participants were subjected to the following:

1. Full history taking with special emphasis on age, gender, and risk factors of ischemic heart disease, thorough physical examination, and body mass index (BMI) was used to gauge obesity, which is equal to weight/height2 (in kg/m2)

2. Laboratory investigations:

  1. Cardiac troponin T and troponin I are highly specific for myocardial damage. Troponin T measurement (Roche diagnostics, detection limit 0.1 ng/ml) was done on admission and 6-8 h later if the first set was negative, values > 0.1 ng/ml was considered positive.
  2. CPK-total and CK-MB enzyme were measured, samples obtained within 6-h postadmission and each 12 h for 48 h.
  3. Lipid profile (total cholesterol and triglyceride levels) within 24 h from admission.
  4. Resting 12 lead ECG:


Standard 12-lead ECG was analyzed paying special attention for detection of electrocardiographic criteria of ST-segment elevation acute myocardial infarction and whether or not pathological q waves, ST-T wave changes, or recent LBBB.

Baseline ECG was used for evaluation of ischemia and for exclusion. Serial ECG was used every 6 h for detection of fQRS.

  • ECG criteria to diagnose ischemia:


    1. ST depression >0.5 mm in 2 contiguous leads
    2. ST elevation >1 mm in 2 contiguous leads
    3. New LBBB (Third universal definition of myocardial infarction)[10]
    4. Hyperacute (T) wave
    5. Pathological Q wave
    6. Normal ECG (no ST deviation).


According to the site of affection:[11] Septal (V1, V2), anterior (V3, V4), anterosetpal (V1, V2, V3, V4), anterolateral (V3, V4, V5, V6, I, aVL), inferior (II, III, aVF), lateral (I, aVL, V5, V6), posterior (usually with inferior or lateral can be isolated (V7, V8, V9), and RV (V1R to V4R). In patients with inferior STEMI (II, III, aVF), the right side ECG was done to screen for (RV) infarction.

ECG recording that was used to detect fQRS was not a specific setting and was the same as routine 12-lead ECG recording: High-pass filter: 0.05–20 Hz (usually 0.15 Hz), low-pass filter: 100–150 Hz, AC filter: 50 or 60 Hz, paper speed: 25–50 mm/s (usually 25 mm/sec), and voltage: 1 mm/mV.[12]

The RSR' pattern includes various morphologies of the QRS complex with or without the Q wave. It was defined by the presence of an additional R wave or notching in the nadir of the S wave or the presence of 2 R (fragmentation) in two contiguous leads with a QRS duration <120 ms.

The resting 12-lead ECG was analyzed by two independent readers blinded to the patient clinical data.

4. Echocardiography:

Comprehensive M-mode, two-dimensional, and Doppler echocardiographic assessment was performed for all patients, using VIVID System 5 machine by two cardiologists, using the same equipment and recorded on computer discs.

Patients were examined in the supine or left lateral position, to obtain left parasternal long-axis, short-axis, apical four-, apical five-, and apical two-chamber views according to the recommendation of the American Society of Echocardiography.[13]

The following measurements were stressed upon and were selected for analysis:

  • Systolic function parameters: Left ventricular end-diastolic dimension, left ventricular end-systolic dimension, fractional shortening, and ejection fraction (EF). It is calculated from the formula: EF = EDV − ESV/EDV × 100%, where EDV “End Diastolic Volume” = (EDV).[13]
  • Wall motion abnormalities:


Left ventricular segmental wall motion was analyzed according to the 16-segment model of the American Society of Echocardiography and graded as follows:

Normal = 1, Hypokinetic = 2, Akinetic = 3, Dyskinetic = 4, Aneurysmal = 5.

Wall motion score index was obtained by dividing the sum of individual visualized segments score by the number of visualized segments.[14]

5. Coronary angiography:

Invasive coronary angiography was done either immediately or after the patient condition had been stabilized according to the plan by a professional experienced cardiologist.

Left and right guiding catheters introduced through the sheath in right femoral artery (trans-femoral approach). Injection of the dye in the left guiding catheter to visualize the left main coronary artery and its branches. Injection of dye in the right guiding catheter to visualize the RCA (right coronary artery). Visualization of the left main coronary artery and its branches (left anterior descending artery [LAD], left circumflex artery [LCx], and ramus if present). Then evaluation and assessment of the severity of lesion, if present. Then visualization of the right coronary artery (RCA) and evaluation and assessment of the severity of lesions if present.

We use the visual method for evaluation and assessment of the coronary arteries.

The results of coronary angiography were classified finally into:

  1. Normal coronary angiography
  2. Nonsignificant CAD (<70% stenosis in the epicardial vessel and <50% in the left main coronary artery)
  3. Significant one-vessel disease (>70% stenosis in 1 major epicardial vessel)
  4. Significant two vessels disease (>70% stenosis in 2 major epicardial vessels)
  5. Significant three vessels disease (>70% stenosis in all 3 major vessels).[15]


According to the presence of fQRS in ECG, the patients were divided into two groups:

  • Group I included (52) patients with fQRS.
  • Group II included (22) patients without fQRS.


Statistical analysis

All data were analyzed using SPSS software Statistical Package for Social Sciences Version 10 (SPSS, Inc. Chicago, IL, USA). Results were presented as mean value ± standard deviation for continuous variables and as frequency (%) for categorical variables. Data were tested for normality using the Kolmogorov–Smirnov test. Means were compared for significant difference using paired t-test, Mann–Whitney test, and ANOVA test. Sensitivity, specificity, positive predictive value, and negative predictive values were calculated.


  Results Top


[Table 1] showed the demographic and clinical characters of the studied groups. There were statistically nonsignificant differences between groups regarding age, gender, BMI, history of smoking, presence of hypertension, diabetes mellitus, dyslipidemia, family history of CAD, and heart rate (P > 0.05), while systolic blood pressure was higher in Group II 140.17 ± 10.39 compared to Group I 130.00 ± 10.49 mmHg with a statistically significant difference between groups (P = 0.0028), Group II had higher diastolic blood pressure 87.95 ± 6.76 compared to Group I 80.95 ± 6.25 mmHg with a statistically significant difference between groups (P = 0.0019).
Table 1: Demographic, clinical, and laboratory data of the studied groups

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[Table 1], [Table 2], [Table 3] showed that there were no significant differences between groups regarding troponin, CKMB, CK total, electrocardiographic findings, echocardiographic findings, and angiographic findings (P > 0.05).
Table 2: Electrocardiographic and echocardiographic findings of the study groups

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Table 3: Angiographic findings

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The presence of fQRS for the diagnosis of left anterior artery (LAD) lesions compared to the presence of pathological Q wave and ischemic ST-segment depression was more sensitive (49.0% vs. 36.7% and 17.3%), respectively (P< 0.001), more specific (92.00% vs. 78.2% and 80%), respectively (P = 0.03), showed higher positive predictive value (45% vs. 39.2% and 35.9%), respectively (P = 0.05), and more accuracy (63.5% vs. 51.4% and 41.9%), respectively (P = 0.03).

For the diagnosis of LCX artery lesions, presence of fQRS compared to the presence of pathological Q wave and ischemic ST-segment depression was more sensitive (66.7% vs. 14.3% and 9.5%), respectively (P< 0.001), carry more positive predictive value (77% vs. 50% and 22%), respectively (P< 0.001), and more accuracy (85.1% vs. 71.6% and 64.8%), respectively (P< 0.001).

For the diagnosis of RCA lesions, the presence of fQRS compared to the presence of pathological Q wave and ischemic ST-segment depression was more sensitive (67.5% vs. 27.5% and 12.5%), had higher positive predictive value (90% vs. 73.3% and 38.5%), more negative predictive value (70.5% vs. 58% and 42.6%) (P = 0.003), and more accuracy (78.4% vs. 55.4% and 41.9%), respectively (P< 0.001). The specificity of fQRS (91.2%) is more than pathological Q waves (90.9%) (P = 0.02).


  Discussion Top


Systolic and diastolic blood pressures were higher in patients with fQRS in agreement with Çetin et al.[16]

Çetin et al.[16] found significant differences between the two groups in all ischemic changes in ECG, but we found that it was true for ST-segment depression only, perhaps due their selection of patients with STEMI only.

In our study, there were no differences between groups regarding the angiographic findings, in agreement with Guo et al.[17] and Ari et al.,[18] except for 70%–90% stenosis. Guo et al.[17] found a difference when compared the groups in the three-vessel disease.

When we compare our results to the previous studies, we found that a lot of studies were marched on the same approaches, as they compared between the incidence of fQRS and the ischemic changes in ECG for detection of CAD. Das et al.[19],[20] study compared between fQRS with pathological Q and ST-segment depression, it showed that fQRS is more sensitive (51% vs. 28% and 21%) compared with pathological Q and ST-segment depression, respectively; while the specificity (96% vs. 99% and 80%) compared with them. Ari et al., 2011,[18] showed that the presence of fQRS had the upper hand on detection of pathological Q of diagnosis of culprit lesion as the study showed that the sensitivity of fQRS was equal to sensitivity of pathological Q (77% vs. 77%), while fQRS was more specific (67% vs. 36%).

Study limitations

Our study was limited by the small sample size.


  Conclusion Top


We concluded that the presence of fQRS in ECG is a good, simple, applicable positive test to predict the presence of significant CAD in the Egyptian patient with ACS in the emergency room to decide whether to be conscious and prepare the patients for PCI or not, even in those without enzyme elevation but carry an ECG with “fQRS.”

Recommendations

Our study recommended identifying fQRS in patients with ACS, as it is a promising and simple noninvasive modality of investigation. It may be of immense help in evaluating CAD patients, but it needs to be energetically promoted in routine clinical practice, where it is a neglected entity at present and studying the accuracy of fQRS complexes to identify culprit lesions in a large sample size.

Acknowledgment

we would like to thank all patients and colleges in the cardiology department who helped us to complete this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Das MK, Suradi H, Maskoun W, Michael MA, Shen C, Peng J, et al. Fragmented wide QRS on a 12-lead ECG: A sign of myocardial scar and poor prognosis. Circ Arrhythm Electrophysiol 2008;1:258-68.  Back to cited text no. 12
    
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Çetin M, Kocaman SA, Erdoǧan T, Durakoǧlugil ME, Çiçek Y, Bozok Ş, et al. Fragmented QRS may predict postoperative atrial fibrillation in patients undergoing isolated coronary artery bypass graft surgery. Anadolu Kardiyol Derg 2012;12:576-83.  Back to cited text no. 16
    
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Guo R, Li Y, Xu Y, Tang K, Li W. Significance of fragmented QRS complexes for identifying culprit lesions in patients with non-ST-elevation myocardial infarction: A single-center, retrospective analysis of 183 cases. BMC Cardiovasc Disord 2012;12:44.  Back to cited text no. 17
    
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Das MK, Michael MA, Suradi H, Peng J, Sinha A, Shen C, et al. Usefulness of fragmented QRS on a 12-lead electrocardiogram in acute coronary syndrome for predicting mortality. Am J Cardiol 2009;104:1631-7.  Back to cited text no. 20
    



 
 
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