健康成年人群和肥厚型心肌病患者碎裂QRS波群的分布规律与特征

目的：比较健康成年人群和肥厚型心肌病患者碎裂QRS波群（fQRS）的检出率、分布规律与特征。方法：前瞻性连续入选1500例无症状的健康体检者,同时回顾性入选经心脏核磁共振检查确诊的肥厚型心肌病患者91例,年龄范围均在18~65岁。记录并分析所有患者的常规12导联心电图。fQRS的定义为至少2个连续导联的QRS波群存在≥2个R波或者R波的波顶或S波的波谷出现顿挫波。结果：健康成人和肥厚型心肌病患者分别有76（5.1%）和19例（20.9%）检出fQRS（P=0.001）,fQRS平均导联数目无明显差异（2.3±0.7 vs 2.1±0.3,P=0.082）。健康成人中86.8%（66/76）的fQRS分布于下壁导联,另外13.2%（10/76）分布于胸前导联,而肥厚型心肌病患者的fQRS主要分布在下壁导联（10/19,52.6%）,其次分布在前壁导联（6/19,31.8%）以及侧壁导联（3/19,15.8%）（与健康成人相比,P<0.001）。与肥厚型心肌病患者的fQRS相比,健康成人的fQRS的平均额面心电轴更偏左（27.9±30.7°vs 45.5±63.0°,P=0.024）。结论：肥厚型心肌病患者fQRS的检出率高于健康成年人群。与肥厚型心肌病患者的fQRS相比,见于健康成人的fQRS的分布范围更加集中,主要分布于下壁导联,而且后者的额面心电轴更加偏左。     

Incidence and Clinical Significance of Ventricular Late Potentials in Idiopathic Dilated Cardiomyopathy Compared to Coronary Artery Disease

Objective: This prospective study was designed to compare incidence and clinical significance of ventricular late potentials between patients with idiopathic dilated cardiomyopathy (IDC) and postinfarct patients (CAD) using exactly the same method of signal-averaged electrocardiography (SAECG) in both patient groups. Methods: Time-domain analysis of SAECG was performed in 120 consecutive patients with IDC, 120 patients with CAD, and 60 healthy controls. Ventricular late potentials were detected in 27 of 120 patients with IDC (23%) compared to 41 of 120 patients with CAD (34%; P < 0.05). Results: Ventricular late potentials were found in 2 of 60 controls (3%). During 15 ± 7 months follow-up, serious arrhythmic events occurred in 17 of 120 patients with IDC (14%) and in 13 of 120 patients with CAD (11%). The sensitivity of ventricular late potentials for future arrhythmic events was 35% for IDC compared to 77% for CAD (P < 0.05). The positive predictive value of late potentials detected by time-domain analysis was 22% for IDC versus 24% for CAD (P = ns). Conclusion: In this selected patient population with IDC and CAD, time-domain analysis of SAECG revealed a lower incidence of ventricular ate potentials in patients with IDC as compared to postinfarct patients. Whereas ventricular late potentials had a high sensitivity but a low positive predictive value for identification of postinfarct patients with serious arrhythmic events during follow-up, both sensitivity and positive predictive value of ventricular late potentials for future serious arrhythmic events were low in the setting of IDC.     

碎裂 QRS 波对心肌梗死患者心血管事件的预测价值

碎裂 QRS 波（fragmented QRS complex,fQRS）作为一项新的无创心脏电生理指标,多见于心肌梗死患者。近年来,学者们发现 fQRS 波也见于非缺血性心肌病、致心律失常性右室发育不良型心肌病、布加综合征等疾病中。fQRS 波对心肌梗死的辅助诊断有帮助,且对心肌梗死患者心源性死亡及主要心血管事件有一定的预测作用。它对血管再通治疗的疗效评估亦有重要意义。本文就 fQRS 波在心肌梗死患者预后判断及危险分层中的作用展开论述。     

Fragmented QRS Is Associated with All‐Cause Mortality and Ventricular Arrhythmias in Patient with Idiopathic Dilated Cardiomyopathy

Background: Several studies have showed that fragmented QRS complexes (f ‐ QRS, defined as different RSR′ patterns) on a routine 12 ‐ lead electrocardiogram were associated with increased mortality and arrhythmic events in patients with coronary artery disease, but relatively little data were available regarding idiopathic dilated cardiomyopathy (IDCM). Objective: The purpose of this study was to evaluate the relationship between fragmentation of QRS and the combined end point of all‐cause mortality and ventricular arrhythmias in patients with IDCM. Methods: One hundred twenty‐eight patients with IDCM and left ventricular dysfunction (ejection fraction, EF ≤ 40%) were analyzed, respectively. According to QRS duration and the existence of f ‐ QRS on 12‐lead electrocardiograph (ECG), the study populations were divided into three groups: (1) the f ‐ QRS group (QRS <120 ms and with fragmented QRS, n = 51), (2) the wide QRS (wQRS) group (QRS ≥ 120 ms, n = 48), and (3) the nonfragmented QRS (non‐fQRS) group (QRS < 120 ms and without f ‐ QRS, n = 29). Results: During a mean follow‐up of 14 ± 5 months, 25 (19.5%) patients had deaths and ventricular arrhythmic events. The combined end point of all‐cause mortality and ventricular tachyarrhythmias was significantly higher in the f ‐ QRS and wQRS groups than the non‐fQRS group (23.5%, 25%, and 3.4%, respectively; P < 0.05 for both). Event‐free was significantly decreased in the f ‐ QRS group versus the non‐fQRS group (P = 0.02). Univaritae regression analysis revealed that f ‐ QRS was a stronger predictor of mortality and arrhythmic events in IDCM patients. Conclusion: f ‐ QRS on 12‐lead ECG has a high predictive value for the combined end point of all‐cause mortality and ventricular tachyarrhythmias in IDCM patients with left ventricular dysfunction. Ann Noninvasive Electrocardiol 2011;16(3):270–275     

碎裂 QRS 波与急性心肌梗死患者预后的关系研究

目的：探讨碎裂 QRS （fragmented QRS，fQRS）波与急性心肌梗死（acute myocardial infarction，AMI）预后的关系。方法入选287例 AMI 患者，根据心电图是否存在 fQRS 波分为fQRS 组和无 fQRS 组，采集相关临床资料。随访1～36个月的心源性死亡和非致死性心脏事件（再梗死、持续室性心动过速、室颤、心源性休克、严重心力衰竭）发生情况，用 Kaplan Meier法和 Cox 比例风险模型比较生存率、发生率和风险度。结果① fQRS 组与无 fQRS 组3年内非致死性心脏事件发生率分别是28．9％和12．2％（χ2＝13．303，P ＝0．000）。在校正了年龄等混杂因素的影响后，fQRS 组患者发生非致死性心脏事件的风险度（HR）为2．642，Wald ＝11．593，P ＝0．001。② fQRS 组1、2、3年累计生存率分别为93．1％、91．4％和88．6％，无 fQRS组1、2、3年累计生存率分别为98．2％、97．0％和95．7％（χ2＝5．276，P ＝0．022）。在调整了患者年龄等因素的作用后，fQRS 组患者发生心源性死亡的 HR 为2．674，Wald ＝4．371，P ＝0．037。结论fQRS 波是评估 AMI 后患者预后的一项新的无创心电指标。     

QT interval dispersion as a predictor of arrhythmic events in congestive heart failure: Importance of aetiology

Aims Identification of patients with congestive heart failure atrisk of sudden death remains problematic and few data are availableon the prognostic implications of QT dispersion. We sought toassess the predictive value of QT dispersion for arrhythmicevents in heart failure secondary to dilated cardiomyopathyor ischaemic heart disease. Methods and Results Twelve-lead ECGs calculated for QT dispersion, 24h Holter ECGsand signal-averaged ECGs were prospectively recorded in 205heart failure patients in sinus rhythm. The 86 patients withischaemic heart disease and the 119 with dilated cardiomyopathywere not significantly different as regards NYHA grades (51vs 49% in grades III–IV), cardiothoracic ratio (57±7vs 57±6%) and ejection fraction (28±8 vs 29±9%).The mean QT dispersion (66±29 vs 65±27ms), thefrequency of non-sustained ventricular tachycardia (37 vs 38%)and ventricular late potentials (41 vs 40%) were not significantlydifferent in patients with ischaemic or dilated cardiomyop-athy.QT dispersion was not significantly related to other arrhythmogenicmarkers. During follow-up (24±16 months), 66 patientsdied, 22 of them died suddenly and seven presented a spontaneoussustained ventricular tachycardia. In patients with dilatedcardiomyopathy, in multivariate analysis, only a QT dispersion>80ms was an independent predictor of sudden death (RR: 4·9,95% CI 1·4–16·8,P<0·02) and arrhythmicevents (RR: 4·5, 95% CI 1·5–13·5,P<0·01).In patients with ischaemic heart disease, no studied parameterwas found significantly related to sudden death or arrhythmicevents. Conclusion: In congestive heart failure, abnormal QT dispersion can identifypatients with dilated cardiomyopathy who are at high risk ofarrhythmic events.     

健康成年人群碎裂QRS波群的检出与意义

目的:研究碎裂QRS波群(fragmented QRS, fQRS)在健康人群中的检出率、分布规律及临床意义.方法:前瞻性入选连续1 000例无症状的健康体检者(年龄18~65岁),采集其静息状态下的常规心电图.fQRS的定义为至少2个连续导联的QRS波群存在≥2个R波或者R波的波顶或S波的波谷出现切迹.通过Logistic多因素分析确定与fQRS检出相关的指标.结果:总计86例(8.6%)检出fQRS,其中男性占69.8%(60/86),平均每例的fQRS导联数目为(2.3±0.5)个.90.7%(78/86)的fQRS分布于下壁导联,另9.3%(8/86)分布于胸前导联.Logistic多因素分析显示,QRS时限偏长及额面心电轴<30°是健康成人常规心电图检出fQRS的独立相关因素.胸前导联呈现fQRS的导联(8例)均包含QRS移行所在导联.结论:①fQRS在健康成年人群中并不罕见,特别是在下壁导联;②健康成年人fQRS的产生似与轻度室内传导延缓和(或)平均心电轴有关.     

Fragmented Left Sided QRS in Absence of Bundle Branch Block: Sign of Left Ventricular Aneurysm

Background: A left ventricular aneurysm (LVA) occurs between 3.5% and 9.4% of all cases of acute myocardial infarction. A fragmented left sided QRS (RSR` pattern or its variant RSr`, rSR`, or rSr`) without evidence of bundle branch block (QRS duration ≤120 ms) on the ECG may be associated with a significant myocardial scar, which is the characteristic of a LVA. We, therefore, postulate that fragmented QRS (RSR` pattern or its variant) in the left sided leads (I, aVL, V₃ to V₆) may be a useful sign of LVA. Methods: ECGs of 110 consecutive patients with LVA documented by left ventricular angiography (30° right anterior oblique view) was compared with 220 patients without LVA (110 patients with and 110 patients without coronary artery disease (CAD)), who were evaluated for CAD by symptoms and signs. Results: The sensitivity of the fragmented QRS for identification of LVA was 50% (55 of 110 patients) and specificity was 94.6% (209 of 220). Within the study population, the positive predictive value of the fragmented QRS for LVA was 83.3% (55 of 66) and the negative predictive value was 79.2% (209 of 264). Based on the range of prevalence of LVA in postmyocardial infarction population (3.5–9.4%) and on observed sensitivity and specificity, the positive predictive value of fragmented QRS for LVA after infarction can be estimated at 29–53% and the negative predictive value can be estimated at 95–98%. Conclusion: The sensitivity of fragmented QRS in left precordial leads for LVA was only 50%, whereas the specificity was 94.5%. It has a relatively low to moderate positive predictive value and high negative predictive value.