Relationship of fragmented QRS with prognostic markers and long-term major adverse cardiac events in patients undergoing coronary artery bypass graft surgery.

BACKGROUND: Fragmented QRS (fQRS) complex is associated with increased sudden cardiac death, recurrent cardiovascular events, morbidity and mortality. However, the prognostic role of fQRS has not been comprehensively studied in patients undergoing coronary artery bypass graft (CABG) surgery. In this study, we planned to investigate the relationship of fQRS with prognostic markers and long-term major adverse cardiovascular events (MACEs) following isolated CABG surgery. METHODS: Two hundred and thirteen patients who underwent CABG surgery at our institution were enrolled consecutively. MACE was defined as cardiac death, recurrent myocardial infarction, decompensated heart failure and re-hospitalization. The patients were followed up for a mean duration of 26 ±â€Š10 months for MACE. RESULTS: Patients with fQRS had a higher rate of Q wave on ECG (30 vs. 10%, P < 0.001), more prolonged QRS time (99 ±â€Š11 vs. 88 ±â€Š13 ms, P < 0.001), higher EUROSCORE (4.0 ±â€Š1.9 vs. 2.7 ±â€Š1.5, P < 0.001) and lower left ventricular ejection fraction (44 ±â€Š12 vs. 56 ±â€Š12, P < 0.001) in comparison with patients with non-fQRS. In addition, patients with fQRS had increased short-term and long-term MACE (17 vs. 4%, P = 0.002; 23 vs. 6%, P < 0.001, respectively) after discharge. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of fQRS for predicting MACE were 67, 71, 23, 94 and 70%, respectively. fQRS [odds ratio (OR) 3.110, 95% confidence interval (CI) 1.157-8.362, P = 0.025] and prolonged QRS duration (>100 ms) (OR 3.898, 95% CI 1.463-10.39, P = 0.007) were the only independent predictors of long-term MACE in multivariate logistic regression analysis. However, QRS duration had a better association with MACE than the presence of fQRS. CONCLUSION: fQRS and prolonged QRS duration may have an additional value in predicting cardiac status and long-term prognosis. Fragmentations on admission ECG and prolonged QRS duration may be useful for identifying patients with higher long-term risk who will need more intense treatment and close follow-up after CABG surgery.

The effect of irritable bowel syndrome on carotid intima-media thickness, pulse wave velocity, and heart rate variability.

OBJECTIVE: Irritable bowel syndrome (IBS), a subgroup of functional somatic disorders, may be associated with autonomic dysfunction (AD). Heart rate variability (HRV), a measure of autonomic dysfunction, may predict survival. The aim of this study was to investigate the effect of IBS on HRV parameters, carotid intima-media thickness (CIMT) and carotid-femoral pulse wave velocity (cf-PWV) as surrogates of AD, subclinical atherosclerosis and arterial stiffness, respectively. METHODS: Our study was cross-sectional and observational. Thirty consecutive patients with IBS and 30 control participants underwent 24-hour Holter monitoring, cf-PWV assessment and CIMT measurement. The diagnosis of IBS was based on Rome III criteria. There were 24 patients with IBS-Constipation (80%), 4 patients with IBS-Diarrhea (13.3%), and 2 patients with IBS-Mixed (6.7%) in IBS group. Student t-test and χ2 test were utilized in order to compare continuous and categorical variables between two groups, respectively. RESULTS: Biochemical parameters did not differ between groups except for slightly increased creatinine in patients with IBS. cf-PWV and CIMT values were similar between groups. SDNN index and RMSSD were significantly impaired in patients with IBS compared to controls. Frequency analyses revealed lower LF, HF, and VLF in subjects with IBS. CONCLUSION: We demonstrated decreased parasympathetic modulation in patients with constipation predominant IBS. However, we could not demonstrate any changes in vascular structure and functions measured by carotid intima-media thickness and pulse wave velocity. Our results do not support accelerated atherosclerosis in IBS population.

Heart Rate Acceleration and Recovery Indices are Not Related to the Development of Ventricular Premature Beats During Exercise Test.

BACKGROUND: Changes in heart rate (HR) during exercise and recovery from exercise are mediated by the balance between sympathetic and vagal activity. HR acceleration (HRA) and recovery (HRR) are important measures of cardiac autonomic dysfunction and directly correlated with sympathetic and parasympathetic activity. It is not known if the autonomic nervous system related to ventricular arrhythmias during exercise. The purpose was to evaluate the HRA and HRR in patients with and without premature ventricular complex (PVC) during exercise, and to examine the factors that might affect HRA and HRR. METHODS: The records of consecutive patients undergoing routine exercise test were reviewed. The characteristics and the HRA and HRR were compared between patients with and without PVC during exercise. RESULTS: A total of 232 patients (145 men) were recruited; 156 (103 men) developed PVCs during the exercise. Max HR was significantly lower in men with PVCs than in those without, which were not mirrored in women. There was no difference in HRA and HRR between the patients with and without exercise-induced PVCs in both genders. Compared to the men with PVCs, women had higher body mass index, shorter total exercise time, and higher HRA indices after the 3 and 6 minutes exercise. In patients with PVCs, the HRA and HRR indices were similar regardless of the presence of coronary artery disease and the phase of exercise test where PVC developed. CONCLUSIONS: Although exercise performance may be different between the genders, the HRA or HRR indices were not related to the development of PVC during exercise in both genders. KEY WORDS: Exercise-induced arrhythmias; Heart rate acceleration; Heart rate recovery.

Increased YKL-40 levels in patients with isolated coronary artery ectasia: an observational study.

OBJECTIVE: YKL-40, a new biomarker of localized inflammation, is secreted by macrophages within the atherosclerotic plaques. Coronary artery ectasia (CAE) is a clinical entity with unclear etiopathogenesis. Some studies have revealed that CAE may be a form of atherosclerosis that has more localized and intense inflammatory properties than atherosclerosis. The goal of this study was to investigate YKL-40 and C-reactive protein (CRP) levels in patients with isolated CAE compared to patients with normal coronary arteries (NCA) and coronary artery disease (CAD). METHODS: Our study has an observational and cross-sectional design. Forty-nine patients with isolated CAE (mean age: 60±10 years), 30 age-and gender-matched control participants with NCA (30 patients, mean age: 58±12 years) and 30 patients with CAD (mean age: 61±10 years), were included in the study. The relationship between YKL-40, CRP levels and the presence of CAE was investigated. Univariate and multiple logistic regression analysis were used for analysis of independent variables to predict CAE. RESULTS: Serum YKL-40 levels were significantly different among study groups (NCA: 110±53 µg/L, CAE: 144±68 and CAD: 180±117, p=0.005). CAD group and CAE group had significantly higher YKL-40 levels than NCA group (p=0.004 and p=0.015, respectively). CRP was not significantly different between three groups. In addition, there were no any statistically significant differences, with respect to age, gender, the presence of hypertension or diabetes mellitus, and the smoking status (p>0.05). Logistic regression analysis revealed only YKL-40 level as the determinant of CAE (OR: 1.010, 95% CI: 1.001-1.019, p=0.027). CONCLUSION: YKL-40 levels in patients with isolated CAE compared to patients with NCA were found significantly high and only YKL-40 level was established as the determinant of CAE. We believe that further studies are needed to clarify the possible causative roles of YKL-40 in patients with isolated CAE.

Effect of epicardial adipose tissue on diastolic functions and left atrial dimension in untreated hypertensive patients with normal systolic function.

BACKGROUND: Adipose tissue is the source of many adipokines affecting the cardiovascular system either locally or systemically. Although hypertension is one of the most important factors in diastolic dysfunction (DD), the exact cause of this relationship is unknown. There is no specific study in the current literature regarding the association of epicardial adipose tissue (EAT) with left ventricular DD in patients with essential hypertension. METHODS: The present study was cross-sectional and observational, including 127 patients with untreated hypertension who underwent a complete transthoracic echocardiographic examination as well as measurements of EAT and diastolic parameters. RESULTS: EAT was significantly correlated with left atrial dimension, DD parameters, and left ventricular (LV) mass as well as age and blood pressure measurements. EAT was also correlated with Framingham risk score (p<0.001). Age and EAT were significantly increased in patients with high grades of DD compared to those with low values (p<0.001 and p=0.001, respectively). Linear regression analyses revealed EAT as an independent predictor of all DD parameters. The area under the curve values of EAT were similar to age and higher than those of LV mass and mean BP for both the presence of DD and grade two DD. CONCLUSION: Based on our findings, increased EAT may be associated with diastolic dysfunction and left atrial dilatation due to local or systemic effects in untreated hypertensive patients. This relationship is independent of and stronger than abdominal obesity, implicating the clinical importance of measuring EAT thickness.

Increased pulse wave velocity and carotid intima-media thickness in patients with carpal tunnel syndrome.

INTRODUCTION: Carpal tunnel syndrome (CTS) is associated with cardiovascular risk factors. The aim of our study was to determine whether carotid intima-media thickness (CIMT) and carotid-femoral pulse wave velocity (cf-PWV), as surrogates of cardiovascular disease and arterial stiffness, are increased in patients with carpal tunnel syndrome. METHODS: Forty patients with CTS and 40 gender- and age-matched controls underwent cf-PWV assessment, CIMT measurement, and nerve conduction study. RESULTS: CIMT and cf-PWV were increased significantly in patients with CTS. They correlated positively with median sensory and motor nerve distal latency. Whereas both CIMT and PWV related to CTS, only CIMT independently predicted CTS. CONCLUSIONS: There is both increased pulse wave velocity and CIMT and a positive correlation between these parameters and median nerve sensory distal latency in patients with CTS. CTS appears to be associated with arterial stiffness and atherosclerotic burden, but the underlying mechanisms require further study.

The independent relationship of epicardial adipose tissue with carotid intima-media thickness and endothelial functions: the association of pulse wave velocity with the active facilitated arterial conduction concept.

BACKGROUND: Hypertension, identifiable by elevated blood pressure (BP), is a heterogeneous multifactorial disorder. Epicardial adipose tissue (EAT), a special fat depot that is related to visceral fat rather than total adiposity, shares the same microcirculation with myocardial tissue and coronary vessels. Recent studies have identified EAT as an active organ, which secretes several mediators, called adipokines, affecting the vascular system. The aim of this study was to evaluate the potential association between EAT and BP, endothelial function, carotid intima-media thickness (CIMT), and pulse wave velocity (PWV) independent of conventional and novel metabolic risk factors in patients with previously untreated hypertension. PATIENTS AND METHODS: Our study, which has a cross-sectional design, included 107 consecutive untreated hypertensive patients. Vascular status and functions were evaluated using CIMT, PWV, and flow-mediated dilation (FMD) of the brachial artery. The values of BP were obtained both by the traditional auscultatory method using a sphygmomanometer in an office and by ambulatory BP measurement. RESULTS: When we stratified the patients into three groups according to increased EAT values, CIMT (P<0.001), presence of carotid plaque (P=0.026), and BP values (P=0.001) were increased in the higher tertile compared with the lower tertile. FMD of the brachial artery decreased significantly with increasing EAT thickness (P<0.001). There was a significant, strong, and negative association between CIMT and FMD (r=-0.604, P<0.001). CIMT correlated positively to age (r=0.404, P<0.001), EAT (r=0.517, P<0.001), office systolic BP (r=0.241, P=0.016), ambulatory systolic BP (r=0.419, P<0.001), and diastolic BP (r=0.360, P=0.002). FMD correlated negatively to age (r=-0.390, P<0.001), EAT (r=-0.495, P<0.001), ambulatory systolic (r=-0.338, P=0.006), and diastolic BP (r=-0.281, P=0.024). Multivariate linear regression analyses, carried out to identify predictors of CIMT and FMD, showed only age, EAT, and mean ambulatory BP as independent predictors of both CIMT and FMD. CONCLUSION: Our study showed that EAT is an independent factor of adverse changes in CIMT, FMD, and PWV. Future studies, investigating the vascular influence of EAT at the molecular level, may provide therapeutic options to prevent its adverse vascular interactions.

Premature hair whitening is an independent predictor of carotid intima-media thickness in young and middle-aged men.

OBJECTIVE: Premature graying or whitening of the hair may possibly represent premature atherosclerotic changes as a surrogate marker of different host responses to cardiovascular risk factors (CVRFs). This study was undertaken to test whether carotid artery intima-media thickness (CIMT) as a validated surrogate marker of the severity and extent of coronary artery disease (CAD) is higher in subjects with prominent signs of hair whitening, independent of chronological age and other CVRFs. METHODS: The current study was conducted in young and middle-aged patients (<55 years age) without a history of cardiovascular disease. Two hundred and two eligible patients consecutively admitted to our outpatient clinic for CVRF management were included. A gray/white-hair scale was used to determine the percentage of hair whitening. RESULTS: In the groups determined according to the degree of hair whitening, age (p<0.001), waist circumference (p=0.011), the presence of hypertension (p=0.003), the uric acid levels (p=0.008), the C - reactive protein levels (p=0.002) and CIMT (p<0.001) were significantly different. When we performed multivariate analyses to determine the independent predictors of CIMT and hair whitening, CIMT was found to be related to age, waist circumference, the levels of uric acid, bilirubin and gamma-glutamyl transpeptidase, the presence of a family history of CAD and hair whitening, while hair whitening was found to be related to age, hypertension, the bilirubin level and CIMT. CONCLUSION: Our findings suggest that premature hair whitening intensity is independently related to CIMT. In cumulative assessments of CVRFs on the human body, the presence of premature hair whitening may be useful in identifying individuals with an increased risk of cardiovascular disease.

Increased carotid and brachial intima-media thickness is related to diffuse coronary involvement rather than focal lesions.

We evaluated whether an increased carotid intima-media thickness (cIMT) and brachial artery IMT (bIMT) are related to diffuse coronary involvement rather than focal lesions. Patients (n = 88) with at least 1 significant lesion of the main epicardial coronary arteries (≥50%) were included in the present study. We used a novel score based on length and mean narrowing of all lesions in order to predict diffuse coronary involvement. Both cIMT and bIMT were higher in patients with long coronary lesion than focal lesion (P < .001). The patients with long coronary lesion had a higher rate of total coronary involvement than patients with focal lesion (P < .001). The cIMT had a higher correlation with total atherosclerotic burden in the coronary vasculature (r = .495, P < .001) and the longest lesion length (r = .489, P < .001) than cardiovascular risk factor score (r = .453, P < .001 and r = .324, P = .012, respectively). These findings may be valuable for clarifying the prognostic value of IMT measurements.

Non-dipping pattern in untreated hypertensive patients is related to increased pulse wave velocity independent of raised nocturnal blood pressure.

BACKGROUND: Non-dipper pattern, characterized by diminished nocturnal decline in blood pressure (BP), is associated with an increase in cardiovascular events. Carotid-femoral pulse wave velocity (CF-PWV) has been accepted as the gold standard measurement of arterial stiffness. CF-PWV is a well-recognized predictor of an adverse cardiovascular outcome with higher predictive value than classical cardiovascular risk factors. In this study, we investigated the association between PWV as the surrogate of arterial stiffness and non-dipper pattern in untreated hypertensive patients. METHODS: The present study was cross-sectional and observational. Hypertensive patients were diagnosed according to ambulatory BP measurements (mean BP ≥ 130/80 mmHg). Eighty-four hypertensive patients, consulted for initial evaluation of hypertension, were enrolled. CF-PWV as the indicator of arterial stiffness was measured by a validated tonometry system (SphygmoCor). Patients with the history of any cardiovascular disease were excluded from the study. RESULTS: Fifty-six patients had non-dipper pattern and 28 patients had dipper pattern in the study. Baseline characteristics were not significantly different between the two groups, except the CF-PWV (non-dipper vs dipper; 8.91 ± 2.53 vs 7.66 ± 1.08 m/s, p = 0.002), female gender (55% vs 32%, p = 0.045) and nocturnal BP measurements (for mean BP; 106 ± 11 vs 92 ± 8 mmHg, p < 0.001). Multiple logistic regression analysis including age, gender, BP and PWV measurements, revealed female gender (odds ratio, OR = 5.112, 95% confidence interval, CI 1.282-20.4, p = 0.021), nocturnal mean BP (OR = 1.243, 95% CI 1.107-1.396, p < 0.001) and CF-PWV (OR = 1.992, 95% CI 1.240-3.198, p = 0.004) as the independent predictors of non-dipper hypertensive pattern. CONCLUSION: Our results suggest that diminished nocturnal decline in BP is independently associated with PWV and nocturnal BP rather than daytime BP. Non-dipper pattern, mainly related to increased PWV and impaired modulation of vascular smooth muscle tone during the night, may justify an increased cardiovascular risk in these patients.

Increased circulating soluble CD40 levels in patients with slow coronary flow phenomenon: an observational study.

OBJECTIVE: Slow coronary flow (SCF) is an angiographic finding characterized with delayed opacification of epicardial coronary arteries without obstructive coronary disease. CD40/CD40 ligand (CD40L) signaling seems closely related to atherosclerosis due to increased inflammation and prothrombotic state. We investigated whether soluble CD40 (sCD40), an indirect marker of CD40/CD40L dyad, is related to SCF. METHODS: The present study was cross-sectional and observational, consisting of seventy individuals who underwent coronary angiography with suspicion of CAD and had angiographically normal coronary arteries of varying coronary flow rates. The relationship between sCD40, C-reactive protein (CRP) and SCF phenomenon was investigated. Fifty patients with isolated SCF (mean age: 56±10 years) and 20 age- and gender-matched control participants with normal coronary flow (NCF) and normal coronary arteries (NCA), (mean age: 55±10 years) were included in the study. We used logistic regression analysis to determine the predictors of SCF. RESULTS: The clinical characteristics were not statistically significant different between SCF and NCA group. Serum CRP levels were also similar between two groups. Serum sCD40 level was significantly higher in the SCF group compared to control group (74±31 vs. 59±16 pg/mL, p=0.014). In multiple regression analyses, mean coronary diameter strongly (OR: 7.358, 95% CI: 1.990-27.20, p=0.003) and sCD40 (OR: 1.044, 95% CI: 1.006-1.084, p=0.023) weakly predicted SCF. CONCLUSION: This study revealed, significantly increased serum sCD40 levels in patients with SCF. Although we cannot conclude the underlying pathological process of SCF, we believe that these findings may be pivotal for further studies searching the specific roles of CD40/CD40L signaling on SCF phenomenon in coronary vasculature.

Absence and Resolution of Fragmented QRS Predict Reversible Myocardial Ischemia With Higher Probability of ST Segment Resolution in Patients With ST Segment Elevation Myocardial Infarction.

BACKGROUND AND OBJECTIVES: Fragmented QRS complexes (fQRS) are associated with increased morbidity and mortality. The causative relationship between fQRS and cardiac fibrosis has been shown, but whether the presence and the number of fQRS on admission of electrocardiogram (ECG) predicts ST segment resolution in patients undergoing primary percutaneous coronary intervention (p-PCI) has not been investigated until now. SUBJECTS AND METHODS: This study included one hundred and eighty-four consecutive patients with ST elevation myocardial infarction (STEMI) who underwent p-PCI. The presence or absence of fQRS on pre and post-PCI ECG and their relation with myocardial infarction and reperfusion parameters were investigated. RESULTS: Patients with fQRS on admission of ECG or newly developed fQRS after p-PCI had increased inflammatory markers, higher cardiac enzyme levels, increased pain to balloon time, prolonged QRS time, more extended coronary involvement and more frequent Q waves on ECG in comparison to patients with absence or resolved fQRS. The presence and higher number of fQRS on admission or post-PCI ECGs were significantly related with low percent of ST resolution and myocardial reperfusion parameters. The area under the receiver operating characteristics curve values for the presence and number of fQRS to detect Thrombolysis in Myocardial Infarction Blush Grade 0 and 1, were 0.682 and 0.703. CONCLUSION: In our study, fQRS was significantly related to infarction and myocardial reperfusion parameters before and after p-PCI. Successful myocardial reperfusion by p-PCI caused the reduction in number of fQRS and QRS time with higher ST resolution. fQRS may be useful in identifying the patients at higher cardiac risk with increased ischemic jeopardized or infarcted myocardium, and persistent or newly developed fQRS may predict low percent of ST segment resolution in patients undergoing p-PCI.

Increased epicardial adipose tissue in patients with slow coronary flow phenomenon.

BACKGROUND: Slow coronary flow (SCF) is an angiographic finding characterised by delayed opacification of epicardial coronary arteries without obstructive coronary disease. Epicardial adipose tissue (EAT), localised beneath the visceral pericardium, is a metabolically active endocrine and paracrine organ with possible interactions within the heart. EAT and low-grade inflammation play major roles in the atherosclerotic vascular processes and may be important in other coronary pathologies such as SCF. AIM: To investigate whether EAT and C-reactive protein (CRP) are increased in patients with isolated SCF compared to normal subjects. METHODS: The present study was cross-sectional and observational, consisting of 66 individuals who underwent coronary angiography with a suspicion of coronary artery disease and who had angiographically normal coronary arteries of varying coronary flow rates. The relationship between EAT, CRP and SCF phenomenon was investigated. Thirty-three patients with isolated SCF (mean age: 56 ± 10 years) and 33 age- and gender-matched control participants with normal coronary flow (NCF), but without SCF, (mean age: 55 ± 10 years) were included in the study. RESULTS: EAT thickness was significantly increased in the SCF group compared to the NCF group (7.1 ± 2.7 vs. 4.7 ± 1.9 mm, p < 0.001). Body mass index (BMI, p < 0.001) and the percentage of isolated SCF (p = 0.002) were significantly higher in patients with increased EAT thickness. CRP was not related to SCF. When we performed multiple logistic regression analysis, only increased EAT thickness was related to the presence of SCF (OR 1.720, 95% CI 1.175-2.516, p = 0.005) independent of BMI and CRP. CONCLUSIONS: This study revealed, for the first time, a significant increase in EAT thickness in patients with SCF compared to NCF. We believe that further studies are needed to clarify the role of adipose tissue in patients with SCF.

Independent determinants of ascending aortic dilatation in hypertensive patients: smoking, endothelial dysfunction, and increased epicardial adipose tissue.

BACKGROUND: Ascending aortic aneurysm is an uncommon condition with lethal consequences. Lately, epicardial adipose tissue (EAT) is acknowledged as an organ with important effects on the vascular system. In this study, we aimed to investigate whether EAT, cardiovascular risk factors, and vascular structure and functions are independently related to ascending aortic dilatation. METHODS AND RESULTS: Vascular structure and functions were determined by carotid intima-media thickness, pulse wave velocity, and brachial artery flow-mediated dilation. Study parameters were compared between 46 patients with a dilated ascending aorta (diameter ≥ 37 mm) and 58 individuals with a normal aortic diameter of <37 mm. Ascending aortic diameter significantly correlated with age (r=0.420, P<0.001), waist circumference (r=0.235, P=0.032), EAT (r=0.507, P<0.001), mean carotid intima-media thickness (r=0.354, P<0.001), flow-mediated dilation (r=-0.513, P<0.001), and diastolic blood pressure (r=0.365, P<0.001). Although C-reactive protein was related to BMI (r=0.485, P<0.001), waist circumference (r=0.368, P=0.001), and EAT (r=0.315, P=0.003), it was not correlated with ascending aortic diameter (r=0.092, P=0.403). Linear regression analysis revealed EAT thickness (ß: 0.483, P<0.001), smoking (ß: 0.366, P=0.002), and flow-mediated dilation (ß: -0.332, P=0.007) as the determinants of ascending aortic dilatation. CONCLUSION: On the basis of our findings, smoking, endothelial dysfunction, and increased EAT may be suggested as risk factors for ascending aortic dilation due to local or systemic effects in hypertensive patients.

The independent relationship of systemic inflammation with fragmented QRS complexes in patients with acute coronary syndromes.

BACKGROUND AND OBJECTIVES: QRS complex fragmentations are frequently seen on routine electrocardiograms with narrow or wide QRS complex. Fragmented QRS complex (fQRS) is associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events. In this study, we aimed to interrogate the relationship of systemic inflammation with the presence of fQRS in patients with acute coronary syndromes (ACS). SUBJECTS AND METHODS: Two-hundred and twenty eligible patients with ACS that underwent coronary angiography were enrolled consecutively in this study. Patients with significant organic valve disease and those with any QRS morphology that had a QRS duration ≥120 ms as well as patients with permanent pacemakers were excluded from this study. RESULTS: Patients with fQRS were of a higher age (p=0.02), had increased C-reactive protein (CRP) levels (p<0.001), prolonged QRS time (p<0.001), extent of coronary artery disease (CAD) (p<0.001), creatine kinase-MB (CK-MB) levels (p=0.006) and Q wave on admission electrocardiography (p<0.001) in comparison to patients with non-fragmented QRS. When we performed multiple logistic regression analysis, fQRS was found to be related to increased CRP levels {odds ratio (OR): 1.2, 95% confidence interval (CI): 1.045-1.316, p=0.007}, QRS duration (OR: 1.1, 95% CI: 1.033-1.098, p<0.001), extent of CAD (OR: 1.5, 95% CI: 1.023-2.144, p=0.037), Q wave (OR: 2.2, 95% CI: 1.084-4.598, p=0.03) and CK-MB levels (OR: 1.0, 95% CI: 1.001-1.037, p=0.04) independently. CONCLUSION: In our study, we found that fQRS was independently related to increased CRP. Fragmented QRS that may result as an end effect of inflammation at cellular level can represent increased cardiac risk by different causative mechanisms in patients with ACS.

The importance of fragmented QRS complexes in prediction of myocardial infarction and reperfusion parameters in patients undergoing primary percutaneous coronary intervention.

OBJECTIVES: The QRS complex fragmentations (fQRS) frequently seen on admission electrocardiograms (ECGs) with narrow or wide QRS complex are associated with increased morbidity and mortality. The causative relationship between fQRS and cardiac fibrosis is known, but the relation of fragmented QRS before and after primary percutaneous coronary intervention (p-PCI) with myocardial infarction and reperfusion parameters has not been studied until now. STUDY DESIGN: The study included 184 consecutive patients with ST elevation myocardial infarction (STEMI) who underwent p-PCI. Presence or absence of fQRS on pre- and post-PCI ECGs and its change following PCI were investigated. In addition, independent predictors of fQRS were also investigated. Patients with significant organic valve disease and patients having any QRS morphology with QRS duration ?120 ms as well as patients with permanent pacemakers were excluded from the study. RESULTS: Patients with fQRS on admission ECG had higher leukocyte counts (p=0.001), higher CK-MB (p=0.001) and troponin levels (p=0.005), increased pain to balloon time (p=0.004), higher Killip score (p<0.001), prolonged QRS time (p<0.001), higher Gensini score (p<0.001) and more frequent Q waves on ECG (p<0.001) in comparison to patients with non-fragmented QRS. In addition, these patients usually had an infarction of anterior territory related to a lesion in proximal LAD and wider jeopardized myocardium (p<0.001). fQRS was significantly related to infarction and myocardial reperfusion parameters before and after p-PCI. In the setting of STEMI, absence of fQRS on admission ECG predicted increased ST resolution, higher reduction in QRS duration, and better myocardial reperfusion. CONCLUSION: FQRS may be useful in identifying patients at higher cardiac risk with larger areas of ischemic jeopardized or necrotic myocardium.

Fragmented QRS may predict postoperative atrial fibrillation in patients undergoing isolated coronary artery bypass graft surgery.

OBJECTIVE: Fragmented QRS complexes (fQRS) are defined as various RSR' patterns in 2 contiguous leads corresponding to a major coronary artery territory. Although the reason of association between fQRS and cardiac events was documented as cardiac fibrosis, the predictive role of fQRS was not studied for postoperative atrial fibrillation (POAF) which is a frequent and serious complication in patients undergoing isolated coronary artery bypass graft (CABG) surgery. Therefore, this issue was investigated in the present study. METHODS: The current study has a prospective observational design. Two hundred and seventy two eligible patients who underwent isolated CABG surgery were enrolled consecutively. The patients were divided in two groups with post-op atrial fibrillation (AF) and non-AF. The occurrence of new-onset AF following CABG and the relationship with fQRS were searched. The logistic regression analysis was used to determine independent predictors for POAF. The sensitivity and specificity of study variables in predicting POAF were calculated using a receiver-operating characteristic curve (ROC). RESULTS: POAF occurred in 62 of 272 patients (22.8%). Patients with POAF were generally older (p<0.001) and female (p=0.006), with preexisting hypertension (p=0.008), lower hemoglobin levels (p=0.011), chronic obstructive lung disease (p=0.003), prolonged QRS time (p=0.004), and higher EUROSCORE (p<0.001) compared to non-AF patients. Patients with POAF had lower left ventricular ejection fraction (p<0.001) and high fQRS rate (p<0.001), but similar left atrial size (LA, p=NS). Interestingly, LA size was significantly enlarged in patients with fQRS (3.8±0.6 vs. 4.1±0.5 cm, p=0.002). In addition, the patients with POAF had prolonged stay in the cardiac surgery intensive-care unit (p<0.001) and extended in-hospital care (p=0.001). New-onset POAF was significantly related to the presence and number of fQRS. In the logistic regression analysis, only age (OR: 1.044, 95% CI: 1.008-1.082, p=0.016), female gender (OR: 2.347, 95% CI: 1.079-5.106, p=0.031), the presence and number of fQRS (OR: 6.020, 95% CI: 3.152-11.5 and OR: 1.522, 95% CI: 1.282-1.807, both of, p<0.001) were independent predictors of POAF. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and the diagnostic accuracy (DA) of presence of fQRS on pre-op electrocardiogram to predict POAF were 66%, 76%, 45%, 88% and 74%, respectively. The area under ROC was found as 0.733 (p<0.001, 95% CI: 0.657-0.810). CONCLUSION: In our study, we found that new-onset POAF was independently related to the presence and number of fQRS in patients undergoing CABG surgery. In addition, fQRS on pre-op surface ECG had high predictive values for new-onset POAF.

The independent relationship between systemic inflammation and fragmented QRS complexes in patients with stable angina pectoris.

BACKGROUND: QRS complex fragmentations can frequently be seen on routine ECG with narrow or wide QRS complex. Fragmented QRS complexes (fQRS) are defined as various RSR' patterns (≥ 1 R' or notching of S wave or R wave) in two contiguous leads corresponding to a major coronary artery territory. In previous studies, fQRS has been associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events. The causative relationship between fQRS and cardiac fibrosis has been shown, but it has not been extensively studied whether there are different mechanisms for the development of fQRS AIM: To interrogate the relationship between systemic inflammation and the presence of fQRS in patients with stable angina pectoris. METHODS: A total of 353 eligible patients who underwent coronary angiography with a suspicion of coronary artery disease (CAD) at our institution between April 2010 and December 2010 were enrolled consecutively. All patients had angina pectoris or angina equivalent symptoms with either a positive treadmill test or myocardial perfusion study. Patients with recent acute coronary syndrome either with or without ST-segment elevation, significant organic valve disease, and patients having any QRS morphology with QRS duration ≥ 120 ms, as well as patients with permanent pacemakers, were excluded from the study. RESULTS: Patients with fQRS had older age (p = 0.01), higher C-reactive protein (CRP) (p 〈 0.001), longer QRS time (p 〈 0.001) and more severe CAD (p 〈 0.001) compared to patients with non-fragmented QRS. When we performed multiple logistic regression analysis, we found that the fragmentations in QRS complexes were positively related with increased CRP (OR: 3.8, 95% CI 1.573.9.278, p = 0.003), and QRS duration (OR: 1.1, 95% CI 1.008.1.101, p = 0.019) and negatively related with left ventricular ejection fraction [%] (OR: 1.0, 95% CI 0.914.0.992, p = 0.020). CONCLUSIONS: In our study, we found that fQRS was independently related with increased CRP and QRS duration as well as left ventricular systolic dysfunction. Fragmented QRS, which may come about as an end effect of inflammation at cellular level, can represent increased cardiac risk by different causative mechanisms in patients with stable CAD. In addition, fragmentations on ECG may be useful for identifying patients who should be investigated and treated for their increased inflammatory status and possible chronic infections.

Increased pulse wave velocity in patients with panic disorder: independent vascular influence of panic disorder on arterial stiffness.

OBJECTIVE: Acute and chronic mental stress and many psychiatric disorders have been accepted as a cause of cardiovascular disease. Panic disorder, a subtype of anxiety disorder, has been associated with increased risk of fatal myocardial infarction and sudden cardiac death in epidemiological studies. Carotid-femoral pulse wave velocity (CF-PWV) is currently the gold standard measurement of arterial stiffness. CF-PWV is a well-recognized predictor of an adverse cardiovascular outcome with higher predictive value than classical cardiovascular risk factors. The aim of our study is to measure PWV as the surrogate of arterial stiffness and vascular involvement in patients with panic disorder. METHODS: Forty-two patients with PD, and 30 control participants were included in the study. Patients with hypertension, diabetes mellitus, or the history of any cardiovascular disease were excluded from study. RESULTS: Baseline characteristics were not significantly different between the two groups, except carotid-femoral pulse wave velocity (PD vs. control; 7.51±2.02 vs. 6.24±1.09 m/s, p=0.001), heart rate, and smoking status. Additionally, CF-PWV positively correlated with age (r=0.250, p=0.034), heart rate (r=0.284, p=0.017), systolic and diastolic blood pressure (r=0.393, p=0.001 and r=0.286, p=0.015, respectively) significantly. However, only the presence of panic disorder was independently related to PWV (ßeta: 0.317, p=0.011) in the multivariate analysis including age, heart rate, smoking status and blood pressure measurements. CONCLUSION: Increased pulse wave velocity in patients with panic disorder may justify the associated risk as documented in previous studies, and may be useful in identifying the patients with higher risk of future cardiovascular complications.