Skip to main content
NCBI home page
Clinical Cardiology logoLink to Clinical Cardiology
. 2006 Dec 5;27(11):653–659. doi: 10.1002/clc.4960271115

Prognostic value of heterogeneity of ventricular repolarization in survivors of acute myocardial infarction

Velislav N Batchvarov 1,✉, Katerina Hnatkova 1, Jan Poloniecki 1, A John Camm 1, Marek Malik 1
PMCID: PMC6654101  PMID: 15562938

Abstract

Background: The expansion of indications for implantation of cardioverter‐defibrillators (ICD) has enhanced the need for risk stratification of patients post myocardial infarction (MI), while the improved treatment of acute MI has decreased mortality and diminished the prognostic power of traditional risk variables.

Hypothesis: Increased heterogeneity of ventricular repolarization quantified by TCRT (total cosine R‐to‐T, angular difference between spatial QRS and T loops, decreased with increase in repolarization heterogeneity) is an independent predictor of mortality in patients post MI.

Methods: Left ventricular ejection fraction (EF), QRS duration on signal‐averaged ECG, number of ventricular ectopic beats (VE)/h, heart rate variability (HRV) triangular index, heart rate turbulence slope on 24‐h Holter recording, and TCRT were analyzed in 334 survivors of acute MI followed up for 41 ± 20 months.

Results: In multivariate analysis, EF < 35% (relative risk [RR] 2.3, 95% confidence interval [CI] 1.1‐4.7, p = 0.023), VE > 10/h (RR 2.2, CI 1.0‐4.6, p = 0.044), HRV < 20 U (RR 2.2, CI 1.1‐4.5, p = 0.032), and TCRT < −0.896 (RR 4.3, CI 2.2‐8.5, p = 0.00001) were independent predictors of cardiac mortality (11%). Independent predictors of arrhythmic mortality (5%) were VE, HRV, and TCRT (RR 5.8, CI 2.1‐15.6, p = 0.0004). Cardiac and arrhythmic mortality of patients with both EF < 35% and TCRT < −0.896 were > 60 and > 30%, respectively, compared with 17 and 7% in those with only EF < 35% or TCRT < −0.896.

Conclusion: Decreased TCRT, which reflects increased repolarization heterogeneity, is a strong and independent predictor of cardiac and arrhythmic death in patients post MI.

Keywords: risk stratification, myocardial infarction, ventricular repolarization, ventricular gradient, electrocardiogram

Full Text

The Full Text of this article is available as a PDF (74.1 KB).

References

  • 1. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL, Brown MW, Andrews ML, for the Multicenter Automatic Defibrillator Implantation Trial II Investigators : Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002; 346: 877–883 [DOI] [PubMed] [Google Scholar]
  • 2. Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G, for the Multicenter Unsustained Tachycardia Trial Investigators : A randomized study of the prevention of sudden death in patients with coronary artery disease. N Engl J Med 1999; 341: 1882–1890 [DOI] [PubMed] [Google Scholar]
  • 3. Task Force Report : Task Force on Sudden Cardiac Death of the European Society of Cardiology. Eur Heart J 2001; 22: 1374–1450 [DOI] [PubMed] [Google Scholar]
  • 4. Huikuri H, Tapanainen JM, Lindgren K, Raatikainen P, Mäkikallio TH, Juhani Airaksinen KE, Myerburg RJ: Prediction of sudden cardiac death after myocardial infarction in the beta‐blocking era. J Am Coll Cardiol 2003; 42: 652–658 [DOI] [PubMed] [Google Scholar]
  • 5. Wilson FN, Macleod AG, Barker PS: The T deflection of the electrocardiogram. Trans Assoc Amer Physicians 1931; 46: 29–38 [Google Scholar]
  • 6. Wilson FN, Macleod AG, Barker PS, Johnston FD: The determination and the significance of the areas of the ventricular deflections of the electrocardiogram. Am Heart J 1934; 10: 46–61 [Google Scholar]
  • 7. Abildskov JA, Burgess MJ, Millar K, Wyatt R: New data and concepts concerning the ventricular gradient. Chest 1970; 58: 244–248 [DOI] [PubMed] [Google Scholar]
  • 8. Surawicz B: ST‐T abnormalities In Comprehensive Electrocardiology: Theory and Practice in Health and Disease (Eds. Macfarlane PW, Veitch Lawrie TD.), p. 521–524. Oxford: Pergamon Press, 1989. [Google Scholar]
  • 9. Urie PM, Burgess MJ, Lux RL, Wyatt RF, Abildskov JA: The electrocardiographic recognition of cardiac states at high risk of ventricular arrhythmias. An experimental study in dogs. Circ Res 1978; 42: 350–358 [DOI] [PubMed] [Google Scholar]
  • 10. Gettes LS: The T wave: A window on ventricular repolarization? J Cardiovasc Electrophysiol 2001; 12: 1326–1328 [DOI] [PubMed] [Google Scholar]
  • 11. Abildskov JA, Burgess MJ, Urie PM, Lux RL, Wyatt RF: The unidentified information content of the electrocardiogram. Circ Res 1977; 40: 3–7 [DOI] [PubMed] [Google Scholar]
  • 12. Abildskov JA, Evans AK, Lux RL, Burgess MJ: Ventricular recovery properties and QRST deflection area in cardiac electrograms. Am J Physiol 1980; 239: H227–H231 [DOI] [PubMed] [Google Scholar]
  • 13. Kardys I, Kors JA, van der Meer IM, Hofman A, van der Kuip DAM, Witte‐man JCM: Spatial QRS‐T angle predicts cardiac death in a general population. Eur Heart J 2003; 24: 1357–1364 [DOI] [PubMed] [Google Scholar]
  • 14. Acar B, Yi G, Hnatkova K, Malik M: Spatial, temporal and wavefront direction characteristics of 12‐lead T wave morphology. Med Biol Eng Comput 1999; 37: 574–584 [DOI] [PubMed] [Google Scholar]
  • 15. Zabel M, Acar B, Klingenheben T, Franz MR, Hohnloser SH, Malik M: Analysis of 12‐lead T‐wave morphology for risk stratification after myocardial infarction. Circulation 2000; 102: 1252–1257 [DOI] [PubMed] [Google Scholar]
  • 16. Zabel M, Malik M, Hnatkova K, Papademetriou V, Pittaras A, Fletcher RD, Franz MR: Analysis of T‐wave morphology from the 12‐lead electrocardiogram for prediction of long‐term prognosis in male US veterans. Circulation 2002; 105: 1066–1070 [DOI] [PubMed] [Google Scholar]
  • 17. Odemuyiwa O, Malik M, Farrell T, Bashir Y, Poloniecki J, Camm AJ: Comparison of the predictive characteristics of heart rate variability index and left ventricular ejection fraction for all‐cause mortality, arrhythmic events and sudden death after acute myocardial infarction. Am J Cardiol 1991; 68: 434–439 [DOI] [PubMed] [Google Scholar]
  • 18. Schmidt G, Malik M, Barthel P, Schneider R, Ulm K, Rolnitzky L, Camm AJ, Bigger JT, Schömig A: Heart‐rate turbulence after ventricular premature beats as a predictor of mortality after acute myocardial infarction. Lancet 1999; 353: 1390–1396 [DOI] [PubMed] [Google Scholar]
  • 19. Moss AJ: Dead is dead, but can we identify patients at increased risk for sudden cardiac death? J Am Coll Cardiol 2003; 42: 659–660 [DOI] [PubMed] [Google Scholar]
  • 20. ACC Expert Consensus Document : Signal‐averaged electrocardiography. J Am Coll Cardiol 1996; 27: 238–249 [PubMed] [Google Scholar]
  • 21. Hofmann A, Bühler FR, Burckhardt D: High grade ventricular ectopic activity and 5‐year survival in patients with chronic heart disease and in healthy subjects. Cardiology 1983; 70 (suppl 1): 82–87 [DOI] [PubMed] [Google Scholar]
  • 22. Naccarella F, Lepera G, Rolli A: Arrhythmic risk stratification of post‐myocardial infarction patients. Curr Opin Cardiol 2000; 15: 1–6 [DOI] [PubMed] [Google Scholar]
  • 23. Task Force of the European Society of Cardiology and The North American Society of Pacing and Electrophysiology : Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Eur Heart J 1996; 17: 354–381 [PubMed] [Google Scholar]
  • 24. Malik M, Acar B, Gang Yi, Yap YG, Hnatkova K, Camm AJ: QT dispersion does not represent electrocardiographic interlead heterogeneity of ventricular repolarization. J Cardiovasc Electrophysiol 2000; 11: 835–843 [DOI] [PubMed] [Google Scholar]
  • 25. Zabel M, Malik M: Morphological assessment of T wave patterns In Dynamic Electrocardiography (Eds. Malik M, Camm AJ.), p. 350–357. New York: Blackwell Futura, 2004. [Google Scholar]
  • 26. Hartikainen JEK, Malik M, Staunton A, Poloniecki J, Camm AJ: Distinction between arrhythmic and nonarrhythmic death after acute myocardial infarction based on heart rate variability, signal‐averaged electrocardiogram, ventricular arrhythmias and left ventricular ejection fraction. J Am Coll Cardiol 1996; 28: 296–304 [DOI] [PubMed] [Google Scholar]
  • 27. Greenberg H, Case RB, Moss AJ, Brown MW, Carroll ER, Andrews ML: Analysis of Mortality Events in the Multicenter Automatic Defibrillator Implantation Trial (MADIT‐II). J Am Coll Cardiol 2004; 43: 1459–1465 [DOI] [PubMed] [Google Scholar]
  • 28. Available at http://www.sicr.org/scdheft_results_acc_lbcc.pdf
  • 29. Reynolds MR, Josephson ME: MADIT II (Second Multicenter Automated Defibrillator Implantation Trial) debate risk stratification, costs, and public policy. Circulation 2003; 108: 1779–1783 [DOI] [PubMed] [Google Scholar]
  • 30. La Rovere MT, Bigger JT Jr, Marcus FI, Mortara A, Schwartz PJ, for the ATRAMI (Autonomic Tone and Reflexes After Myocardial Infarction) Investigators : Baroreflex sensitivity and heart rate variability in prediction of total cardiac mortality after myocardial infarction. Lancet 1998; 351: 478–484 [DOI] [PubMed] [Google Scholar]
  • 31. La Rovere MT, Pinna GD, Hohnloser SH, Marcus FI, Mortara A, Nohara R, Bigger JT Jr, Camm AJ, Schwartz PJ, on behalf of the Autonomic Tone and Reflexes After Myocardial Infarction (ATRAMI) Investigators : Baroreflex sensitivity and heart rate variability in the identification of patients at risk for life‐threatening arrhythmias. Implications for clinical trials. Circulation 2001; 103: 2072–2077 [DOI] [PubMed] [Google Scholar]
  • 32. Malik M, Camm AJ, Janse MJ, Julian DJ, Frangin GA, Schwartz PJ, on behalf of the EMIAT Investigators: Depressed heart rate variability identifies postinfarction patients who might benefit from prophylactic treatment with amiodarone : A substudy of EMIAT (The European Myocardial Infarct Amiodarone Trial). J Am Coll Cardiol 2000; 35: 1263–1275 [DOI] [PubMed] [Google Scholar]
  • 33. Zareba W, Moss AJ: Noninvasive risk stratification in postinfarction patients with severe left ventricular dysfunction and methodology of the MADIT II noninvasive electrocardiology substudy. J Electrocardiol 2003; 36 (suppl): 101–108 [DOI] [PubMed] [Google Scholar]
  • 34. Kannel WB, Anderson K, McGee D, Degatano L, Stampfer MJ: Non‐specific electrocardiographic abnormality as a predictor of coronary heart disease: The Framingham Study. Am Heart J 1987; 113: 370–376 [DOI] [PubMed] [Google Scholar]
  • 35. Liao Y, Liu K, Dyer A, Schoenberger JA, Shekelle RB, Collette P, Stamler J: Sex differential in the relationship of electrocardiographic ST‐T abnormalities to the risk of coronary disease: 11.5 year follow‐up findings in the Chicago Heart Association Detection Project in Industry. Circulation 1987; 75: 347–352 [DOI] [PubMed] [Google Scholar]
  • 36. Dekker JM, Schouten EG, Klootwijk P, Pool J, Kromhout D: Association between QT interval and coronary heart disease in middle‐aged and elderly men, The Zutphen Study. Circulation 1994; 90: 779–785 [DOI] [PubMed] [Google Scholar]
  • 37. De Bruyne MC, Hoes AW, Kors JA, Hofman A, van Bemmel JH, Grobbee DE: Prolonged QT interval predicts cardiac and all‐cause mortality in the elderly. The Rotterdam Study. Eur Heart J 1999; 20: 278–284 [DOI] [PubMed] [Google Scholar]
  • 38. Kors J, de Bruyne M, Hoes AW, van Herpen G, Hofman A, van Bemmel JH, Grobbee DE: T axis as an indicator of risk of cardiac events in elderly people. Lancet 1998; 352: 601–605 [DOI] [PubMed] [Google Scholar]

Articles from Clinical Cardiology are provided here courtesy of Wiley

RESOURCES