DOI QR코드

DOI QR Code

Fragmented QRS and abnormal creatine kinase-MB are predictors of coronary artery disease in patients with angina and normal electrocardiographys

  • Lee, Jung Joo (Department of Emergency Medicine, Dong-A University College of Medicine) ;
  • Lee, Jae Hoon (Department of Emergency Medicine, Dong-A University College of Medicine) ;
  • Jeong, Jin Woo (Department of Emergency Medicine, Dong-A University College of Medicine) ;
  • Chung, Jun Young (Department of Emergency Medicine, Dong-A University College of Medicine)
  • Received : 2015.04.30
  • Accepted : 2015.07.09
  • Published : 2017.05.01

Abstract

Background/Aims: Patients with symptoms of coronary artery disease (CAD) often display normal tracings or only nonspecific changes on electrocardiography (ECG). The aim of this study was to explore strategic elements of the ECG and other potential factors that are predictive of CAD in this scenario. Methods: This was an observational study of 142 patients with the chief complaint of chest pain, each of whom presented with a normal ECG and was subjected to emergency coronary angiography (CAG). Two population subsets were identified: those patients (n = 97) with no significant stenotic lesions and those (n = 45) with the significant stenotic lesions of CAD. Results: Those patients with normal or nonspecific ECGs and CAD (15.8%) were more likely to have left circumflex artery involvement (20% vs. 7%). In patients with normal ECGs and CAD (vs. normal CAG), male sex (86.7% vs. 68%, p = 0.023), creatine kinase-MB (CK-MB) levels > 10 U/L (13 vs. 10, p = 0.025), and fragmented QRS (fQRS) (38.6% vs. 21.6%, p = 0.042) occurred with greater frequency. In multivariable analysis, the following variables were significant predictors of CAD, given a normal ECG: male sex (odds ratio [OR], 2.593; 95% confidence interval [CI], 1.068 to 5.839); CK-MB (OR, 2.497; 95% CI, 0.955 to 7.039); and W- or M-shaped QRS complex (OR, 2.306; 95% CI 0.988 to 5.382). Conclusions: In our view, male sex, elevated CK-MB (> 10 U/L), and fQRS complexes are suspects for CAD in patients with angina and unremarkable ECGs and should be considered screening tests.

Keywords

Acknowledgement

Supported by : Dong-A University

References

  1. Lee TH, Rouan GW, Weisberg MC, et al. Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Cardiol 1987;60:219-224. https://doi.org/10.1016/0002-9149(87)90217-7
  2. Caceres L, Cooke D, Zalenski R, Rydman R, Lakier JB. Myocardial infarction with an initially normal electrocardiogram: angiographic findings. Clin Cardiol 1995;18:563-568. https://doi.org/10.1002/clc.4960181006
  3. Brush JE Jr, Brand DA, Acampora D, Chalmer B, Wackers FJ. Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction. N Engl J Med 1985;312:1137-1141. https://doi.org/10.1056/NEJM198505023121801
  4. McCullough PA, Ayad O, O'Neill WW, Goldstein JA. Costs and outcomes of patients admitted with chest pain and essentially normal electrocardiograms. Clin Cardiol 1998;21:22-26. https://doi.org/10.1002/clc.4960210105
  5. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163-1170. https://doi.org/10.1056/NEJM200004203421603
  6. Silber SH, Leo PJ, Katapadi M. Serial electrocardiograms for chest pain patients with initial nondiagnostic electrocardiograms: implications for thrombolytic therapy. Acad Emerg Med 1996;3:147-152. https://doi.org/10.1111/j.1553-2712.1996.tb03403.x
  7. Welch RD, Zalenski RJ, Frederick PD, et al. Prognostic value of a normal or nonspecific initial electrocardiogram in acute myocardial infarction. JAMA 2001;286:1977-1984. https://doi.org/10.1001/jama.286.16.1977
  8. Sanchis J, Bodi V, Nunez J, et al. New risk score for patients with acute chest pain, non-ST-segment deviation, and normal troponin concentrations: a comparison with the TIMI risk score. J Am Coll Cardiol 2005;46:443-449. https://doi.org/10.1016/j.jacc.2005.04.037
  9. Dagnone E, Collier C, Pickett W, et al. Chest pain with nondiagnostic electrocardiogram in the emergency department: a randomized controlled trial of two cardiac marker regimens. CMAJ 2000;162:1561-1566.
  10. Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad Emerg Med 2002;9:203-208. https://doi.org/10.1197/aemj.9.3.203
  11. Peels CH, Visser CA, Kupper AJ, Visser FC, Roos JP. Usefulness of two-dimensional echocardiography for immediate detection of myocardial ischemia in the emergency room. Am J Cardiol 1990;65:687-691. https://doi.org/10.1016/0002-9149(90)90143-O
  12. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 2005;294:2623-2629. https://doi.org/10.1001/jama.294.20.2623
  13. Hollander JE, Blomkalns AL, Brogan GX, et al. Standardized reporting guidelines for studies evaluating risk stratification of emergency department patients with potential acute coronary syndromes. Ann Emerg Med 2004;44:589-598. https://doi.org/10.1016/j.annemergmed.2004.08.009
  14. Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SD. Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain. J Am Coll Cardiol 2002;40:251-256. https://doi.org/10.1016/S0735-1097(02)01968-X
  15. Slater DK, Hlatky MA, Mark DB, Harrell FE Jr, Pryor DB, Califf RM. Outcome in suspected acute myocardial infarction with normal or minimally abnormal admission electrocardiographic findings. Am J Cardiol 1987;60:766-770. https://doi.org/10.1016/0002-9149(87)91020-4
  16. Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol 1989;64:1087-1092. https://doi.org/10.1016/0002-9149(89)90857-6
  17. Chua SK, Shyu KG, Cheng JJ, et al. Significance of left circumflex artery-related acute myocardial infarction without ST-T changes. Am J Emerg Med 2010;28:183-188. https://doi.org/10.1016/j.ajem.2008.11.010
  18. Conti A, Poggioni C, Viviani G, et al. Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram. Am J Emerg Med 2012;30:1698-1705. https://doi.org/10.1016/j.ajem.2012.01.022
  19. Jewitt DE, Balcon R, Raftery EB, Oram S. Incidence and management of supraventirucular arrhythmias after acute myocardial infarction. Am Heart J 1969;77:290-293. https://doi.org/10.1016/0002-8703(69)90366-4
  20. Sharkey SW, Berger CR, Brunette DD, Henry TD. Impact of the electrocardiogram on the delivery of thrombolytic therapy for acute myocardial infarction. Am J Cardiol 1994;73:550-553. https://doi.org/10.1016/0002-9149(94)90331-X
  21. Wang TY, Zhang M, Fu Y, et al. Incidence, distribution, and prognostic impact of occluded culprit arteries among patients with non-ST-elevation acute coronary syndromes undergoing diagnostic angiography. Am Heart J 2009;157:716-723. https://doi.org/10.1016/j.ahj.2009.01.004
  22. Ozdemir S, Tan YZ, Colkesen Y, Temiz A, Turker F, Akgoz S. Comparison of fragmented QRS and myocardial perfusion-gated SPECT findings. Nucl Med Commun 2013;34:1107-1115. https://doi.org/10.1097/MNM.0b013e3283653884
  23. Guo R, Li Y, Xu Y, Tang K, Li W. Significance of fragmented QRS complexes for identifying culprit lesions in patients with non-ST-elevation myocardial infarction: a single-center, retrospective analysis of 183 cases. BMC Cardiovasc Disord 2012;12:44. https://doi.org/10.1186/1471-2261-12-44
  24. Take Y, Morita H. Fragmented QRS: what is the meaning? Indian Pacing Electrophysiol J 2012;12:213-225. https://doi.org/10.1016/S0972-6292(16)30544-7
  25. Das MK, Suradi H, Maskoun W, et al. Fragmented wide QRS on a 12-lead ECG: a sign of myocardial scar and poor prognosis. Circ Arrhythm Electrophysiol 2008;1:258-268. https://doi.org/10.1161/CIRCEP.107.763284
  26. Lorgis L, Jourda F, Hachet O, et al. Prognostic value of fragmented QRS on a 12-lead ECG in patients with acute myocardial infarction. Heart Lung 2013;42:326-331. https://doi.org/10.1016/j.hrtlng.2013.05.005
  27. Torigoe K, Tamura A, Kawano Y, Shinozaki K, Kotoku M, Kadota J. The number of leads with fragmented QRS is independently associated with cardiac death or hospitalization for heart failure in patients with prior myocardial infarction. J Cardiol 2012;59:36-41. https://doi.org/10.1016/j.jjcc.2011.09.003
  28. Aslani A, Tavoosi A, Emkanjoo Z. Diffuse fragmented QRS as an index of extensive myocardial scar. Indian Pacing Electrophysiol J 2010;10:67-68.
  29. Boineau JP. Diagnosis of multiple infarcts from complex electrocardiograms during normal rhythm, left bundle-branch block, and ventricular pacing. J Electrocardiol 2011;44:605-610. https://doi.org/10.1016/j.jelectrocard.2011.07.020
  30. Wang DD, Buerkel DM, Corbett JR, Gurm HS. Fragmented QRS complex has poor sensitivity in detecting myocardial scar. Ann Noninvasive Electrocardiol 2010;15:308-314. https://doi.org/10.1111/j.1542-474X.2010.00385.x
  31. Ahn MS, Kim JB, Yoo BS, et al. Fragmented QRS complexes are not hallmarks of myocardial injury as detected by cardiac magnetic resonance imaging in patients with acute myocardial infarction. Int J Cardiol 2013;168:2008-2013. https://doi.org/10.1016/j.ijcard.2012.12.086
  32. MacAlpin RN. The fragmented QRS: does it really indicate a ventricular abnormality? J Cardiovasc Med (Hagerstown) 2010;11:801-809. https://doi.org/10.2459/JCM.0b013e32833b9816
  33. Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med 2000;342:1187-1195. https://doi.org/10.1056/NEJM200004203421607
  34. Goldberger AL. Goldberger's Clinical Electrocardiography. 8th ed. Philadelphia: Elsevier, 2012.
  35. Lekakis J, Katsoyanni K, Trichopoulos D, Tsitouris G. Qversus non-Q-wave myocardial infarction: clinical characteristics and 6-month prognosis. Clin Cardiol 1984;7:283-288. https://doi.org/10.1002/clc.4960070506
  36. Juul-Moller S. Corrected QT-interval during one year follow-up after an acute myocardial infarction. Eur Heart J 1986;7:299-304. https://doi.org/10.1093/oxfordjournals.eurheartj.a062067
  37. Choi WS, Lee JH, Park SH, et al. Prognostic value of standard electrocardiographic parameters for predicting major adverse cardiac events after acute myocardial infarction. Ann Noninvasive Electrocardiol 2011;16:56-63. https://doi.org/10.1111/j.1542-474X.2010.00409.x
  38. Das MK, Khan B, Jacob S, Kumar A, Mahenthiran J. Significance of a fragmented QRS complex versus a Q wave in patients with coronary artery disease. Circulation 2006;113:2495-2501. https://doi.org/10.1161/CIRCULATIONAHA.105.595892
  39. Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118:397-409. https://doi.org/10.1161/CIRCULATIONAHA.106.677625

Cited by

  1. Abdominal Pain as an Initial Manifestation of Paroxysmal Supraventricular Tachycardia in Children vol.29, pp.2, 2019, https://doi.org/10.5812/ijp.80065
  2. Use of Anti-angiogenic Drugs Potentially Associated With an Increase on Serum AST, LDH, CK, and CK-MB Activities in Patients With Cancer: A Retrospective Study vol.8, pp.None, 2021, https://doi.org/10.3389/fcvm.2021.755191
  3. Repeated use of SSRIs potentially associated with an increase on serum CK and CK-MB in patients with major depressive disorder: a retrospective study vol.11, pp.1, 2021, https://doi.org/10.1038/s41598-021-92807-7