QRS fragmentation and the risk of sudden cardiac death in MADIT II.
BACKGROUND
QRS fragmentation (fQRS) has been reported as a useful ECG parameter in predicting mortality in high-risk postinfarction patients. Its prognostic value for sudden cardiac death (SCD) and ventricular arrhythmias in ischemic cardiomyopathy (ICM) remains unknown.


METHODS
MADIT II enrollment 12-lead ECGs were analyzed for fQRS defined as RSR' patterns (≥1 R' or notching of S or R wave) in patients with a normal QRS duration and >2 notches on the R or S wave in patients with abnormal QRS duration, present in 2 contiguous leads. Exclusion criteria included a paced rhythm and an uninterpretable or incomplete ECG. Study endpoints included SCD, SCD or appropriate implantable cardioverter defibrillator (ICD) shock, and total mortality (TM).


RESULTS
Of the 1,232 ECGs reviewed, 1,040 were of suitable quality for fQRS analysis. QRS fragmentation was found in 33% of patients in any leads, in 10% of patients in anterior leads, in 8% of patients in lateral leads and in 21% of patients in inferior leads. Anterior and lateral location of QRS fragmentation was not associated with follow-up events. Inferior location of fQRS was found to be predictive of SCD/ICD shock (hazard ratio [HR] 1.46, P = 0.032), SCD (HR 2.05, P = 0.007), and TM (HR 1.44, P = 0.036). This association was driven primarily by the increase in events found in LBBB patients: SCD/ICD shock (HR 2.05, P = 0.046), SCD (HR 4.24, P = 0.002), and TM (HR 2.82, P = 0.001).


CONCLUSIONS
Fragmented QRS, especially identified in inferior leads, is predictive of SCD, SCD or appropriate ICD shock, and all-cause mortality in patients with ICM. Identifying inferior fQRS in patients with LBBB is of particular prognostic significance and should reinforce the use of ICD therapy in this high-risk group.
Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA. andrew_brenyo@urmc.rochester.edu
Andrew
A
Brenyo
Grzegorz
G
Pietrasik
Alon
A
Barsheshet
David T
DT
Huang
Bronislava
B
Polonsky
Scott
S
McNitt
Arthur J
AJ
Moss
Wojciech
W
Zareba
D000368:Aged; D000369:Aged, 80 and over; D016757:Death, Sudden, Cardiac / Q000453:epidemiology*; D017147:Defibrillators, Implantable; D004562:Electrocardiography / Q000706:statistics & numerical data*; D005260:Female; D005858:Germany / Q000453:epidemiology; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality* / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality* / Q000517:prevention & control*; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D015996:Survival Rate; D016896:Treatment Outcome