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in contiguous leads&#44; corresponding to a major coronary artery territory&#46; A search then began to establish these signs as risk markers in coronary patients&#44; in order to confirm the relationship between fQRS and cardiac events&#46; The relationship was investigated in acute coronary syndromes &#40;ST- and non-ST-elevation MI and unstable angina&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> after primary percutaneous coronary intervention&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> and following MI as a predictor of sudden death or heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The risk of arrhythmic events in patients with fQRS has also been investigated in various other conditions&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> including ischemic and non-ischemic cardiomyopathy&#44; Brugada syndrome&#44; acquired long QT syndrome and arrhythmogenic right ventricular dysplasia&#44; as well as for screening of cardiac involvement in diseases such as rheumatoid arthritis&#44; fibromyalgia and sarcoidosis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Taken together&#44; these studies suggest that fQRS may be associated with myocardial fibrosis and hence with prognosis&#44; thus functioning as a possible risk marker in different populations&#46; However&#44; these associations have not been definitively proven and published studies show that the sensitivity of this sign varies considerably&#46; For example&#44; in studies on stable coronary disease or MI&#44; fQRS seem to be reasonably good predictors of cardiac events&#44; but not of mortality&#44; while in non-ischemic cardiomyopathy they appear to be related to the degree of fibrosis and dyssynchrony&#44; and in patients with left ventricular dysfunction no association has been shown between fQRS and arrhythmic events&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study by Eyuboglu et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> appears to be of some clinical interest&#46; It assumes that the presence of fQRS is a risk marker in patients with ischemic heart disease and seeks to identify subpopulations with more severe disease among those undergoing a first diagnostic coronary angiography by analyzing the relationship between disease severity and the ECG leads &#40;anterior or inferior&#41; in which these complexes are observed&#46; Disease severity in the two groups is assessed by means of an internationally used angiographic measure of the complexity of coronary artery disease&#44; the SYNTAX score&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In accordance with the study hypothesis&#44; differences were found&#58; it was concluded that coronary disease was more severe when fQRS were detected in the anterior rather than the inferior leads&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Although the scope of the study was limited&#44; we consider that it is of some interest&#44; particularly in its potential to contribute to improved stratification of patients about to undergo coronary angiography&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Besides the limitations pointed out by the authors&#44; such as the relatively small study population and the lack of data about coronary hemodynamics and microvascular dysfunction&#44; it should also be noted that the relationship between fQRS and coronary disease severity is taken as proved&#44; which is not in line with the available evidence&#46; This assumption is mainly based on retrospective studies&#44; but it conflicts with the results of at least two trials cited in the review by Pietrasik and Zar&#281;ba&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> which found no association between this sign and mortality or arrhythmic events&#44; and the authors concluded that fQRS were not useful for risk stratification in ischemic heart disease&#46; The present study could have helped clarify the situation if it had included a third arm of patients from the same cohort who did not present fQRS&#44; to be compared with the other two groups&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the systematic review of fQRS mentioned above&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> the authors point out some of the controversial aspects concerning the value of this finding&#44; including the fact that its sensitivity and predictive ability vary with different study populations&#44; persistent doubts as to whether it really can identify myocardial scarring in coronary patients&#44; its inability to predict mortality or arrhythmic events in these patients&#44; and the fact that it has not been shown to predict response to ventricular resynchronization&#46; However&#44; Pietrasik and Zar&#281;ba believe that the main factor limiting the use of fQRS is the subjective nature of how they are defined and that there is a need for a more objective assessment of inhomogeneity in ventricular activation&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">One point that could have been dealt with more thoroughly in the study by Eyuboglu et al&#46; is the relationship between the localization of fQRS and the coronary territories affected&#46; As the authors had access to details of each patient&#39;s coronary lesions&#44; they could have sought to relate them to the leads in which the fragmented pattern were detected&#44; which would help to identify the coronary territories with more significant lesions before coronary angiography&#46; Das et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> deduced from the leads in which fQRS were observed which segments of the myocardium &#40;anterior&#44; lateral&#44; or inferior&#41; were scarred and which vascular territories were affected &#40;anterior descending&#44; circumflex&#44; or right coronary&#41;&#46; In the present study&#44; group 2 had fQRS in the anterior leads&#44; associated with the territories of the anterior descending and circumflex arteries&#44; which may explain the greater severity of coronary disease in this group&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Finally&#44; it should be pointed out that the endpoints in this study are only surrogates for more clinically important outcomes such as mortality or hospitalization&#46; We hope that the authors&#8217; investigation will continue and that some light can be shed on these questions&#44; which will help to increase our understanding of the ability of fQRS to predict cardiovascular events&#44; and thus to improve risk stratification in coronary patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Stratification of patients for coronary angiography: Fragmented QRS complexes – a marker of severity?
Estratificação de doentes para angiografia coronária: QRS fragmentado – um marcador de gravidade?
Daniel Bonhorst
Instituto Português do Ritmo Cardíaco, Porto Salvo, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The possibility that particular alterations on a standard electrocardiogram &#40;ECG&#41; can reveal the existence of areas of myocardial fibrosis could be of clinical interest&#44; not only for non-invasive detection of obstructive coronary disease&#44; but also as an easily accessible risk marker that can be assessed without the need for more complex and costly exams&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The presence of pathological Q waves on the ECG has long been used in clinical practice to identify scarring from previous transmural myocardial infarction &#40;MI&#41;&#46; However&#44; this sign has low sensitivity&#44; since it may not initially appear &#40;non-Q-wave MI&#41; or may sooner or later disappear&#44; and so the absence of Q waves does not exclude the possibility of fibrous scarring of the myocardium&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">There have therefore been efforts for many years to discover alterations in the morphology of the QRS complex that can reliably identify the presence of myocardial scarring&#46; Examples include the investigation by Flowers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> in the 1960s of high-frequency components of the QRS&#44; which the authors discovered to be more common in patients with previous MI&#44; a finding subsequently confirmed by Das et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> in single-photon emission computed tomography studies of myocardial perfusion demonstrating that fragmented QRS complexes &#40;fQRS&#41; on the 12-lead ECG were a marker of previous MI&#44; with significantly superior sensitivity and comparable negative predictive value to Q waves&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Various clinical trials confirmed the potential value of fQRS&#44; defined by Das et al&#46; as the presence of an additional R wave &#40;R&#8242;&#41; or notching in the nadir of the S wave&#44; or the presence of more than one R&#8242; in contiguous leads&#44; corresponding to a major coronary artery territory&#46; A search then began to establish these signs as risk markers in coronary patients&#44; in order to confirm the relationship between fQRS and cardiac events&#46; The relationship was investigated in acute coronary syndromes &#40;ST- and non-ST-elevation MI and unstable angina&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> after primary percutaneous coronary intervention&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> and following MI as a predictor of sudden death or heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The risk of arrhythmic events in patients with fQRS has also been investigated in various other conditions&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> including ischemic and non-ischemic cardiomyopathy&#44; Brugada syndrome&#44; acquired long QT syndrome and arrhythmogenic right ventricular dysplasia&#44; as well as for screening of cardiac involvement in diseases such as rheumatoid arthritis&#44; fibromyalgia and sarcoidosis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Taken together&#44; these studies suggest that fQRS may be associated with myocardial fibrosis and hence with prognosis&#44; thus functioning as a possible risk marker in different populations&#46; However&#44; these associations have not been definitively proven and published studies show that the sensitivity of this sign varies considerably&#46; For example&#44; in studies on stable coronary disease or MI&#44; fQRS seem to be reasonably good predictors of cardiac events&#44; but not of mortality&#44; while in non-ischemic cardiomyopathy they appear to be related to the degree of fibrosis and dyssynchrony&#44; and in patients with left ventricular dysfunction no association has been shown between fQRS and arrhythmic events&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study by Eyuboglu et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> appears to be of some clinical interest&#46; It assumes that the presence of fQRS is a risk marker in patients with ischemic heart disease and seeks to identify subpopulations with more severe disease among those undergoing a first diagnostic coronary angiography by analyzing the relationship between disease severity and the ECG leads &#40;anterior or inferior&#41; in which these complexes are observed&#46; Disease severity in the two groups is assessed by means of an internationally used angiographic measure of the complexity of coronary artery disease&#44; the SYNTAX score&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In accordance with the study hypothesis&#44; differences were found&#58; it was concluded that coronary disease was more severe when fQRS were detected in the anterior rather than the inferior leads&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Although the scope of the study was limited&#44; we consider that it is of some interest&#44; particularly in its potential to contribute to improved stratification of patients about to undergo coronary angiography&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Besides the limitations pointed out by the authors&#44; such as the relatively small study population and the lack of data about coronary hemodynamics and microvascular dysfunction&#44; it should also be noted that the relationship between fQRS and coronary disease severity is taken as proved&#44; which is not in line with the available evidence&#46; This assumption is mainly based on retrospective studies&#44; but it conflicts with the results of at least two trials cited in the review by Pietrasik and Zar&#281;ba&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> which found no association between this sign and mortality or arrhythmic events&#44; and the authors concluded that fQRS were not useful for risk stratification in ischemic heart disease&#46; The present study could have helped clarify the situation if it had included a third arm of patients from the same cohort who did not present fQRS&#44; to be compared with the other two groups&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the systematic review of fQRS mentioned above&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> the authors point out some of the controversial aspects concerning the value of this finding&#44; including the fact that its sensitivity and predictive ability vary with different study populations&#44; persistent doubts as to whether it really can identify myocardial scarring in coronary patients&#44; its inability to predict mortality or arrhythmic events in these patients&#44; and the fact that it has not been shown to predict response to ventricular resynchronization&#46; However&#44; Pietrasik and Zar&#281;ba believe that the main factor limiting the use of fQRS is the subjective nature of how they are defined and that there is a need for a more objective assessment of inhomogeneity in ventricular activation&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">One point that could have been dealt with more thoroughly in the study by Eyuboglu et al&#46; is the relationship between the localization of fQRS and the coronary territories affected&#46; As the authors had access to details of each patient&#39;s coronary lesions&#44; they could have sought to relate them to the leads in which the fragmented pattern were detected&#44; which would help to identify the coronary territories with more significant lesions before coronary angiography&#46; Das et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> deduced from the leads in which fQRS were observed which segments of the myocardium &#40;anterior&#44; lateral&#44; or inferior&#41; were scarred and which vascular territories were affected &#40;anterior descending&#44; circumflex&#44; or right coronary&#41;&#46; In the present study&#44; group 2 had fQRS in the anterior leads&#44; associated with the territories of the anterior descending and circumflex arteries&#44; which may explain the greater severity of coronary disease in this group&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Finally&#44; it should be pointed out that the endpoints in this study are only surrogates for more clinically important outcomes such as mortality or hospitalization&#46; We hope that the authors&#8217; investigation will continue and that some light can be shed on these questions&#44; which will help to increase our understanding of the ability of fQRS to predict cardiovascular events&#44; and thus to improve risk stratification in coronary patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Article information
ISSN: 21742049
Original language: English
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Revista Portuguesa de Cardiologia (English edition)
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