Clinical Implications of QRS Duration in Patients Hospitalized With Worsening Heart Failure and Reduced Left Ventricular Ejection Fraction

Wang, Norman C.; Maggioni, Aldo P.; Konstam, Marvin A.; Zannad, Faı̈ez; Krasa, Holly B.; Burnett, John C.; Grinfeld, Liliana; Swedberg, Karl; Udelson, James E.; Cook, Thomas D.; Traver, Brian; Zimmer, Christopher; Orlandi, Cesare; Gheorghiade, Mihai

doi:10.1001/jama.299.22.2656

Cited by 179 publications

(133 citation statements)

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“…The percentage of patients with QRSd >120 ms in this cohort with LV dysfunction was 42%. Similarly, a post hoc analysis from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST)showed that 44.6% of patients had a QRSd >120 ms. 22 Overall, the prevalence of a QRSd >120 ms in CHF patients averages 30% (14%-47%). 21 Also, 21% of patients in the current study had a QRSd >150 ms.…”

Section: Comparison To Previous Registries and Reportsmentioning

confidence: 98%

“…[21][22][23] In fact, an inverse relationship between QRSd and EF has been described. 21 Shenkman et al found a progressive decrease in EF as QRSd lengthened above 120 ms. 32 Furthermore, Sandhu and Bahler noted that mean EF decreased from 41% to 29% and 25% as QRSd increased from <100 ms to 120 ms to 149 ms and >150 ms, respectively.…”

Section: Comparison To Previous Registries and Reportsmentioning

confidence: 99%

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QRS Duration Is Associated With Atrial Fibrillation in Patients With Left Ventricular Dysfunction

El‐Chami

Brancato²,

Langberg

et al. 2010

Clinical Cardiology

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Background: QRSduration (QRSd) is associated with higher mortality and morbidity in patients with left ventricular (LV) dysfunction. The association between QRSd and atrial fibrillation (AF) has not been studied in this patient population. Objectives: To investigate the association between QRSd and AF in patients with LV dysfunction. Methods: Data were obtained from the National Registry to Advance Heart Health (ADVANCENT) registry, a prospective multicenter registry of patients with left ventricular ejection fraction (LVEF) ≤40%. A total of 25 268 patients from 106 centers in the United States, were enrolled between June 2003 and November 2004. Demographic and clinical characteristics of patients were collected from interviews and medical records. Results: Mean age was 66.3 ± 13 years, 71.5% were males, and 81.9% were white. A total of 14 452 (57.8%) patients had a QRSd <120 ms, 5304 (21.2%) had a QRSd between 120 and 150 ms, and 5269 (21%) had a QRSd >150 ms. Atrial fibrillation occurred in 20.9%, 27.5%, and 35.5% of patients in the QRS groups, respectively (P < 0.0001). After adjusting for potential AF risk factors (age, gender, race, body mass index, hypertension, diabetes, renal failure, cancer, lung disease, New York Heart Association [NYHA] class, ejection fraction, etiology of cardiomyopathy) and the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and lipid lowering drugs, QRS duration remained independently associated with AF (odds ratio: 1.20, 95% confidence interval: 1.14-1.25). Conclusion:In this large cohort of patients, QRSd was strongly associated with AF and therefore may predict the occurrence of this arrhythmia in patients with LV dysfunction. This association persisted after adjusting for disease severity, comorbid conditions, and the use of medications known to be protective against AF.

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Section: Comparison To Previous Registries and Reportsmentioning

confidence: 98%

Section: Comparison To Previous Registries and Reportsmentioning

confidence: 99%

QRS Duration Is Associated With Atrial Fibrillation in Patients With Left Ventricular Dysfunction

El‐Chami

Brancato²,

Langberg

et al. 2010

Clinical Cardiology

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“…1 Cardiac conduction abnormalities are a strong independent predictor of mortality in CHF patients. 27 Evidence of disturbed His-Purkinje system function like bundle-branch block is common in CHF, predicting increased disease progression and mortality. 28 Dyssynchronous cardiac contraction has important deleterious effects on cardiac function mediated by adverse remodeling related to deleterious changes in cardiac gene expression.…”

Section: Maguy Et Al Purkinje Ion Channel Subunit Remodeling In Chfmentioning

confidence: 99%

Ion Channel Subunit Expression Changes in Cardiac Purkinje Fibers

Maguy

Bouter

Comtois

et al. 2009

Circulation Research

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Abstract-Purkinje fibers (PFs) play key roles in cardiac conduction and arrhythmogenesis. Congestive heart failure (CHF) causes well-characterized atrial and ventricular ion channel subunit expression changes, but effects on PF ion channel subunits are unknown. This study assessed changes in PF ion channel subunit expression (real-time PCR, immunoblot, immunohistochemistry), action potential properties, and conduction in dogs with ventricular tachypacing-induced CHF. CHF downregulated mRNA expression of subunits involved in action potential propagation (Nav1.5, by 56%; connexin [Cx]40, 66%; Cx43, 56%) and repolarization (Kv4.3, 43%, Kv3.4, 46%). No significant changes occurred in KChIP2, KvLQT1, ERG, or Kir3.1/3.4 mRNA. At the protein level, downregulation was seen for Nav1.5 (by 38%), Kv4.3 (42%), Kv3.4 (57%), Kir2.1 (26%), Cx40 (53%), and Cx43 (30%). Cx43 dephosphorylation was indicated by decreased larger molecular mass bands (pan-Cx43 antibody) and a 57% decrease in Ser368-phosphorylated Cx43 (phospho-specific antibody). Immunohistochemistry revealed reduced Cx40, Cx43, and phospho-Cx43 expression at intercalated disks. Action potential changes were consistent with observed decreases in ion channel subunits: CHF decreased phase 1 slope (by 56%), overshoot (by 32%), and phase 0 dV/dt max (by 35%). Impulse propagation was slowed in PF false tendons: conduction velocity decreased significantly from 2.2Ϯ0.1 m/s (control) to 1.5Ϯ0.1 m/s (CHF). His-Purkinje conduction also slowed in vivo, with HV interval increasing from 35.5Ϯ1.2 (control) to 49.3Ϯ3.4 ms (CHF). These results indicate important effects of CHF on PF ion channel subunit expression. Alterations in subunits governing conduction properties may be particularly important, because CHF-induced impairments in Purkinje tissue conduction, which this study is the first to describe, could contribute significantly to dyssynchronous ventricular activation, a major determinant of prognosis in CHF-patients. Key Words: heart failure Ⅲ remodeling Ⅲ ventricular dyssynchrony Ⅲ connexins Ⅲ specialized conducting system C ardiac Purkinje fibers (PFs) play an important role in ensuring rapid and appropriately timed conduction of electric impulses to the ventricles 1 and are an important arrhythmogenic source for a variety of cardiac arrhythmias. [2][3][4][5] Congestive heart failure (CHF) changes ion channel distribution and function, with important electrophysiological consequences, 6 and sudden arrhythmic death contributes importantly to CHF-related mortality. 7 We previously demonstrated discrete CHF-induced remodeling of repolarizing ion current function in canine cardiac PFs. 8 In particular, decreases in transient-outward (I to ) and inward-rectifier (I K1 ) K ϩ currents reduce repolarization reserve and enhance the action potential (AP)-prolonging effects of class III antiarrhythmic agents, potentially accounting for the increased Torsades de Pointes risk conferred by CHF. 9 -11 Virtually no work has been done on CHF-induced remodeling of PF ion channel subunit exp...

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“…According to previous studies, such as HFSS and SHFM, widened QRS duration is a poor prognostic factor. 5,6, 23 On the other hand, widened QRS duration reflects, to some extent, mechanical LV dyssynchrony, which is required for CRT indication and is expected for its efficacy. Our result may be explained by the patient distribution with baseline QRS duration and serum sodium concentration as shown in Figure 3.…”

Section: Hyponatremia In Crt 121mentioning

confidence: 99%

Hyponatremia as a Predictor for Worsening Heart Failure in Patients Receiving Cardiac Resynchronization Therapy

Arao

Fujiwara

Sakakura

et al. 2013

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp hronic heart failure (HF) is associated with poor clinical outcomes. 1 In HF subjects, hyponatremia has been considered as important in terms of poor prognosis and is associated with plasma arginine vasopressin (AVP) secretion. 2-6 Moreover, cardiac resynchronization therapy (CRT) has played an important role in indicated HF subjects refractory to optimal medical therapy. 7-12 However, almost 30% of recipients show non-responsiveness, 7 which occasionally leads to subsequent HF events. In the past few years, various factors and physiological parameters such as electrocardiographic QRS duration, left bundle branch block and ischemic/non-ischemic cause associated with responsiveness/non-responsiveness to CRT have been explored. However, these parameters are indirect predictors for HF events as described above. To our knowledge, few have assessed the factors associated with HF events in patients receiving CRT. We explored the predictors among the baseline measurements, as well as conventional factors, for exacerbation of HF and with the baseline factors associated with responsiveness/non-responsiveness to CRT. Editorial p 47 Methods Study PopulationFrom August 2006 to February 2010, 83 consecutive chronic HF patients with an indication for CRT were eligible according to the guideline of the European Society of Cardiology; that is: New York Heart Association (NYHA) classification III or IV even with optimal medical therapy; left ventricular ejection fraction (LVEF) on echocardiogram <35%; QRS duration on electrocardiogram >120 ms. 8 Among them, a small number of patients with QRS duration <120 ms were included because of clinical necessity. Of the 83 eligible patients, 6 were excluded: 1 elderly bedridden woman who was transferred to other institution for long-term in-hospital rehabilitation, 1 bedridden elderly man with a tracheotomy and advanced lung disease who was similarly transferred for taking rehabilitation, and 4 patients with chronic kidney disease on regular hemodialysis. Background: Various factors associated with worsening heart failure (HF) events have been investigated in HF subjects. The purpose of this study was to identify the predictive factor(s) for worsening HF events after cardiac resynchronization therapy (CRT) among baseline parameters, as well as baseline factors associated with responsiveness or non-responsiveness to CRT. C Methods and Results:Seventy-seven HF patients with an indication for CRT were enrolled. Baseline parameters of blood chemistry, electrocardiogram, echocardiogram and cardiac catheterization before device implantation were measured, and subsequent clinical HF events after CRT were investigated. During the follow-up period (median 601 days), 22 of 77 (29%) recipients had HF events (unscheduled HF hospitalization: 16; use of left ventricular assist system: 1; heart transplantation: 1; cardiac death: 4). In the multivariate Cox proportional hazards model, low serum sodium concen...

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Clinical Implications of QRS Duration in Patients Hospitalized With Worsening Heart Failure and Reduced Left Ventricular Ejection Fraction

Cited by 179 publications

References 43 publications

QRS Duration Is Associated With Atrial Fibrillation in Patients With Left Ventricular Dysfunction

QRS Duration Is Associated With Atrial Fibrillation in Patients With Left Ventricular Dysfunction

Ion Channel Subunit Expression Changes in Cardiac Purkinje Fibers

Hyponatremia as a Predictor for Worsening Heart Failure in Patients Receiving Cardiac Resynchronization Therapy

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