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ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 4  |  Page : 193-197

Value of QRS distortion and ST-segment shift in acute coronary syndrome patients in relation to gensini score


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

Date of Web Publication11-Mar-2020

Correspondence Address:
Dr. Wael Ali Khalil
Department of Cardiology, Faculty of Medicine, Zagazig University, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_6_18

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  Abstract 


Background: Terminal QRS complex distortion on admission electrocardiography (ECG) has been used to estimate the final infarct size and the prognosis after acute coronary syndrome (ACS); however, it is not sure whether the QRS distortion is more reliable for predicting the severity of coronary artery lesions or not. The Aim of the Work: The aim is to analyze the admission ECG in ACS based on abnormality observed in the terminal QRS complex distortion and ST-segment and its relation to coronary artery lesion severity. Patients and Methods: We included 150 patients presented with ACS. Patients were divided according to the presenting ECG in two major groups, 120 patients presented with ST-segment elevation myocardial infarction (STEMI) who were classified into two groups according the presence or absence of the QRS distortion: 42 patients with +ve QRS distortion (Group I) and 78 patients with −ve QRS distortion (Group II), and 30 patients presented with non-ST-segment elevation (NSTE)-ACS who were also further classified according the magnitude of ST shift by millimeter into three groups. All patients underwent primary percutaneous coronary intervention, and Gensini score defined the severity of coronary artery lesions. Results: In this study, in STEMI patients groups, we observed that QRS distortion on admission, ECG has a significant relationship with high Gensini score values, whereas in NSTE-ACS patients, we demonstrated no significant difference between the extents of ST-segment shift and Gensini score values. Conclusion: QRS distortion has a significant value in predicting severe coronary artery lesions in STEMI patients while the extent of ST-segment shift has no benefits in predicting the severity of coronary artery lesion in NSTE-ACS patients.

Keywords: Acute coronary syndrome, QRS distortion, ST-segment shift


How to cite this article:
Khalil WA, Saad A, Elzaky M, Sofan M. Value of QRS distortion and ST-segment shift in acute coronary syndrome patients in relation to gensini score. J Indian coll cardiol 2019;9:193-7

How to cite this URL:
Khalil WA, Saad A, Elzaky M, Sofan M. Value of QRS distortion and ST-segment shift in acute coronary syndrome patients in relation to gensini score. J Indian coll cardiol [serial online] 2019 [cited 2020 Sep 23];9:193-7. Available from: http://www.joicc.org/text.asp?2019/9/4/193/280352




  Introduction Top


Electrocardiography (ECG) has both diagnostic and prognostic evaluations of ST-segment elevation myocardial infarction (STEMI) patients. Early risk assessment is essential in the management of patients with STEMI. In the previous studies, the presenting electrocardiographic parameters are necessary to predict successful reperfusion in STEMI patients at admission.[1],[2] One of these parameters is terminal QRS distortion,[3] which has the worst prognosis,[4] less benefit from thrombolysis,[5] less benefit from primary percutaneous coronary intervention (PCI),[6] higher mortality, larger infarcts, and less myocardial salvage.[7] The Gensini score can assess the severity of coronary artery disease (CAD), and it was associated with short and long term major adverse cardiac events.[8] Thus, identifying patients with higher Gensini score is crucial in both predicting adverse cardiovascular events and choosing the most appropriate treatment modalities to prevent procedure failure. We hypothesized that increased cardiovascular events in STEMI patients with QRS distortion and ST-segment shift in non-ST-segment elevation (NSTE)-MI patients on the admission electrocardiogram might be due to the higher prevalence of complex and severe coronary lesions. Therefore, we investigated the relationship between QRS distortion and ST-segment shift with the extent and complexity of CAD assessed using the Gensini score in patients with the acute coronary syndrome (ACS) who underwent primary PCI.

The aim of the work

The aim of this study is to analyze the admission ECG in ACS based on abnormality observed in the terminal portion of the QRS complex and ST-segment shift and its relation to coronary artery lesion severity as assessed using the Gensini score.


  Patients and Methods Top


This study included 150 patients with ACS admitted to the Coronary Care Unit.

Inclusion criteria

  1. ST-segment elevation or depression ≥1 mm in two contiguous leads
  2. Patients presented <12 h of evolution at admission
  3. Analyzable 12-lead ECG taken before revascularization.


Exclusion criteria

  1. Left bundle branch block
  2. Pacemaker rhythm
  3. Patients need mechanical ventilation at the time of admission.


All patients were subjected to all of the following:

  1. Full history was taking: As regards age, gender, risk factors, and the time between the onset of symptoms to the first medical contact
  2. Laboratory analysis for both Troponin T level, routine laboratory profile (CBC, kidney function tests, and lipid profile) were done
  3. Twelve-lead surface ECG at admission was done for all patients:


Patients were divided according to the presenting ECG into two major groups:

  • Patients presented with STEMI who were classified into two subgroups:


  1. Group I with distortion of terminal QRS (+ve QRS), defined as: Pattern A-J point at <50% of the R wave amplitude in leads with QR configuration [Figure 1], or Pattern B-Absence of the S waves, in leads with Rs configuration in two consecutive leads (leads V1 through V3) [Figure 2]
  2. Group II without QRS distortion (−ve QRS).


  3. b. Patients presented with NSTE-ACS who were classified according to the magnitude of ST depression by millimeter into three subgroups, Group I (STD = 0.5–1.5 mm), Group II (STD = 2–2.5 mm), and Group III (STD ≥ 3 mm).

  4. Echocardiography was performed in the first 24 h of admission with the estimation of left ventricular ejection fraction
  5. Coronary angiogram: Multiple views were obtained in all patients and angiograms were read by experienced interventional cardiologists, who were blinded to all clinical and electrocardiographic data. The anatomic extent and the severity of coronary artery lesions are defined using the Gensini system score.
Figure 1: The J point is above 50% of the R-wave amplitude in leads II, III, and aVF (Pattern A)

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Figure 2: The J point is clearly above 50% of the height of the R wave in V2 – V5. (Pattern B)

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Statistical analysis

The significance of distortion of the terminal part of QRS complex concerning Gensini score as a parameter of the severity of CAD in STEMI patients was defined using the Mann–Whitney U-test, whereas Kruskal–Wallis test was used to assess the ST shift concerning Gensini score in NSTE-ACS patients. A value of P < 0.05 was considered statistically significant in all statistical analyses.


  Results Top


This study included 150 patients with ACS admitted to the Coronary Care Unit. Patient's age ranged from 44 to 76 years, with a mean ± standard deviation (SD) (60 ± 7), 102 patients were males (68%). Eighty-six patients were hypertensive (57.3%), 78 were diabetic (52%), 70 patients were obese (46.7%), 80 patients had a current history of smoking (53.3%), and 60 patients had a family history of CAD (41.3%), troponin T levels ranged from 0.001 to 7.4 with a mean ± SD (2.839 ± 1.73). Patients were divided according to the presenting ECG to two major groups, 120 patients presented with STEMI who were randomized into two subgroups: 42 patients with +ve QRS distortion (Group I) and 78 patients with −ve QRS distortion (Group II), and 30 patients presented with NSTE-ACS who were also further classified according the magnitude of ST shift by millimeter into three groups.

In patients presented by ST-segment elevation myocardial infarction

There was a statistically significant increase in age, the presence of the history of hypertension, diabetes mellitus, and family history of CAD in Group I (QRS +ve) as compared to that of Group II (QRS −ve) (P< 0.001, <0.001, <0.001, and 0.002), respectively [Table 1].
Table 1: Baseline clinical characteristics in ST-segment elevation myocardial infarction patients according to QRS distortion

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There was a statistically significant increase in troponin T levels and the significant decrease in ejection fraction by echocardiography in Group I as compared to Group II (P< 0.001) [Table 2].
Table 2: Laboratory and radiological characteristics in ST-segment elevation myocardial infarction patients according to QRS distortion

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There was a statistically significant increase in Gensini Scores in coronary angiography in Group I (QRS +ve) as compared to Group II (QRS −ve). Gensini Scores ranged from 44 to 96 in patients with +ve QRS distortion with mean ± SD (79.43 ± 14.92), and ranged from 8 to 80 in patients with −ve QRS distortion in ECG with a mean ± SD (34.82 ± 20.21) (95% confidence intervals: 74.78–84.08, P < 0.001) [Figure 3] and [Table 3], [Table 4].
Figure 3: Receiver operating characteristic curve for QRS distortion patients

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Table 3: Difference in Gensini score values between+ve and –ve QRS groups

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Table 4: Area under the receiver operating characteristic curve for QRS distortion pati

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In patients presented by non-ST-segment elevation-acute coronary syndrome

There was a statistically significant increase in male gender and the presence of family history of CAD in Group III as compared to other groups (P = 0.01, 0.033) [Table 5].
Table 5: Baseline clinical and laboratory characteristics according to ST shift

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There was a statistically significant increase in troponin T levels in Group III as compared to other groups (P = 0.034).

There was a statistically nonsignificant increase in Gensini scores in coronary angiography between the three groups as compared to each other. Gensini score ranged from 8 to 48 with mean ± SD (25.33 ± 16.47) in Group I, and from 8 to 60 with mean ± SD (29.67 ± 19.833) in Group II, and from 22 to 42 with mean ± SD (32.00 ± 8.944) in Group III (P = 0.767) [Figure 4] and [Table 6].
Figure 4: Gensini score in relation to ST shift in non-ST-segment elevation-acute coronary syndrome patients according to amplitude of ST depression by mm

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Table 6: Gensini score in NSTE-acute coronary syndrome patients

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  Discussion Top


The ECG during acute myocardial ischemia is of diagnostic, therapeutic, and prognostic significance. There is a need to determine the subgroups of patients having anatomically severe coronary lesions based on ECG interpretation.[9] The Gensini score can assess the severity of CAD, and short term and long term major adverse cardiac events.[8] The classification of patients presenting with (STEMI) according to QRS distortion was initially described by Birnbaum et al.[4] whose found a correlation between distortion of QRS and prognosis in patients with STEMI. They have also shown this association in large groups of patients who received either thrombolytic therapy or primary angioplasty.[10] In this study, we used “Gensini score” as a scoring system to assess the severity of coronary artery lesions. As regards the demographic data and risk factors in our study, we observed that the elderly and diabetic patients are at higher risk for developing QRS distortion in STEMI patients. It was in agreement with previously published data by García-Rubira et al., Postma et al., and Bakirci et al.[10],[11],[12] They represent a high-risk population with less capability for new collateral vessels development.[13] In our study, we also observed that hypertension and family history of CAD in +ve QRS distortion group is significantly high as compared to −ve QRS group and that was in disagreement with previous studies by Postma et al. and Bakirci et al.[11],[12] The troponin T levels in a group with +ve QRS distortion is significantly high as compared to the group with −ve QRS and that was in disagreement with data obtained from a previous study by Bakirci et al.[12] In our study, there was significant low ejection fraction by echocardiography in the group with +ve QRS distortion as compared to the group with −ve QRS and that was matching with a previous study by García-Rubira et al.[10] In our study, we observed that QRS distortion on admission ECG is a significant predictor of high Gensini score in patients with STEMI who underwent primary PCI. Hence, QRS distortion has a significant value in predicting severe coronary artery lesions in coronary angiography in STEMI patients and also, it is essential in determining the most appropriate treatment modalities and predicting adverse cardiovascular events. The FRISC II ECG substudy analyzed the severity of coronary artery lesions in NSTE-ACS regarding the presence or absence of ST depression. There were considerable differences between the ECG subgroups regarding the extent of CAD. In the group with ST depression, there were significantly more patients with three-vessel or left main disease, 45% compared with 22% if no ST-segment depression was present (P< 0.001). Almost 20% of the patients without ST-segment depression on admission had no significant stenosis compared with fewer than 10% if ST-segment depression was present.[14] The prognostic impact of the ST-segment depression during an episode of ACS was proven in large trials published in 1997 by Cannon et al. At 1 year follow-up in the TIMI registry, death or MI occurred in 11% of patients with 1 mm or more ST-segment deviation, compared with 6.8% of patients with new, isolated T-wave inversion and 8.2% of patients with no ECG changes (P< 0.001) when comparing ST with no ST-segment deviation).[15] Patients with only 0.5-mm ST-segment deviation showed a death or MI rate by 1 year of 16.3%, compared with 14.9%, 9.7%, and 6.1% in patients with ≥ 2 mm, ≥1 mm, or no ST-segment deviation, respectively (P< 0.001). Furthermore, Canadian ACS Registry demonstrated no significant independent risk gradient between the extent of STD and 1-year mortality after adjustment for selected patients presenting with NSTE-ACS.[16] Other findings contribute further to the understanding of quantitative analysis of STD by confirming its null incremental prognostic value beyond a validated comprehensive risk stratification strategy.[17] In agreement with previously mentioned studies, in our study, there was a statistically nonsignificant increase in Gensini scores in coronary angiography between different groups of patients with ST-segment depression in admission ECG, as well, the extent of STD has no prognostic value in predicting the severity of coronary artery lesion in patients presenting with NSTE-ACS.


  Conclusion Top


QRS distortion has a significant value in predicting severe coronary artery lesions in STEMI patients, while the extent of ST-segment shift has no benefits in predicting the severity of coronary artery lesion in NSTE-ACS patients.

Recommendations

QRS distortion is essential in determining the severity of coronary artery lesions and establishes the most appropriate treatment modalities.

Limitations of the study

This study was limited by the variability in image analysis and cutoff point of QRS distortion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sejersten M, Ripa RS, Maynard C, Wagner GS, Andersen HR, Grande P, et al. Usefulness of quantitative baseline ST-segment elevation for predicting outcomes after primary coronary angioplasty or fibrinolysis (results from the DANAMI-2 trial). Am J Cardiol 2006;97:611-6.  Back to cited text no. 1
    
2.
Wong CK, French JK, Aylward PE, Frey MJ, Adgey AA, White HD, et al. Usefulness of the presenting electrocardiogram in predicting successful reperfusion with streptokinase in acute myocardial infarction. Am J Cardiol 1999;83:164-8.  Back to cited text no. 2
    
3.
Sclarovsky S, Mager A, Kusniec J, Rechavia E, Sagie A, Bassevich R, et al. Electrocardiographic classification of acute myocardial ischemia. Isr J Med Sci 1990;26:525-31.  Back to cited text no. 3
    
4.
Birnbaum Y, Herz I, Sclarovsky S, Zlotikamien B, Chetrit A, Olmer L, et al. Prognostic significance of the admission electrocardiogram in acute myocardial infarction. J Am Coll Cardiol 1996;27:1128-32.  Back to cited text no. 4
    
5.
Birnbaum Y, Maynard C, Wolfe S, Mager A, Strasberg B, Rechavia E, et al. Terminal QRS distortion on admission is better than ST-segment measurements in predicting final infarct size and assessing the potential effect of thrombolytic therapy in anterior wall acute myocardial infarction. Am J Cardiol 1999;84:530-4.  Back to cited text no. 5
    
6.
Billgren T, Maynard C, Christian TF, Rahman MA, Saeed M, Hammill SC, et al. Grade 3 ischemia on the admission electrocardiogram predicts rapid progression of necrosis over time and less myocardial salvage by primary angioplasty. J Electrocardiol 2005;38:187-94.  Back to cited text no. 6
    
7.
Birnbaum Y, Mahaffey KW, Criger DA, Gates KB, Barbash GI, Barbagelata A, et al. Grade III ischemia on presentation with acute myocardial infarction predicts rapid progression of necrosis and less myocardial salvage with thrombolysis. Cardiology 2002;97:166-74.  Back to cited text no. 7
    
8.
Huang G, Zhao JL, Du H, Lan XB, Yin YH. Coronary score adds prognostic information for patients with acute coronary syndrome. Circ J 2010;74:490-5.  Back to cited text no. 8
    
9.
Hennings JR, Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med 2012;30:994-1000.  Back to cited text no. 9
    
10.
García-Rubira JC, Núnez-Gil I, García-Borbolla R, Lennie V, Manzano MC, Cobos MA, et al. Distortion of the QRS in elderly patients with myocardial infarction. Cardiol J 2009;16:418-25.  Back to cited text no. 10
    
11.
Postma S, Heestermans T, Ten Berg JW, van Werkum JW, Suryapranata H, Birnbaum Y, et al. Predictors and outcome of grade 3 ischemia in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. J Electrocardiol 2011;44:516-22.  Back to cited text no. 11
    
12.
Bakirci EM, Kalkan K, Hamur H, Buyuklu M, Cetin M, Degirmenci H, et al. Terminal QRS distortion and severity of coronary artery disease in ST-elevation myocardial infarction. Herz 2015;40:521-7.  Back to cited text no. 12
    
13.
Ringborn M. Distortion of the terminal QRS complex in patients with ST-elevation myocardial infarction. J Electrocardiol 2011;44:523-4.  Back to cited text no. 13
    
14.
Diderholm E, Andrén B, Frostfeldt G, Genberg M, Jernberg T, Lagerqvist B, et al. ST depression in ECG at entry indicates severe coronary lesions and large benefits of an early invasive treatment strategy in unstable coronary artery disease; the FRISC II ECG substudy. The fast revascularisation during InStability in coronary artery disease. Eur Heart J 2002;23:41-9.  Back to cited text no. 14
    
15.
Cannon CP, McCabe CH, Stone PH, Rogers WJ, Schactman M, Thompson BW, et al. The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: Results of the TIMI III registry ECG ancillary study. Thrombolysis in myocardial ischemia. J Am Coll Cardiol 1997;30:133-40.  Back to cited text no. 15
    
16.
Yan AT, Yan RT, Tan M, Chow CM, Fitchett DH, Georgescu AA, et al. ST-segment depression in non-ST elevation acute coronary syndromes: Quantitative analysis may not provide incremental prognostic value beyond comprehensive risk stratification. Am Heart J 2006;152:270-6.  Back to cited text no. 16
    
17.
Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: Prospective multinational observational study (GRACE). BMJ 2006;333:1091.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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