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CLINICAL RESEARCH: ECHOCARDIOGRAPHY AND HEART FAILURE

Electrocardiography and Doppler echocardiography for risk stratification in patients with chronic heart failure

Incremental prognostic value of QRS duration and a restrictive mitral filling pattern

Christian Bruch, MD^_*,_*, Michael Gotzmann^_*, Jörg Stypmann, MD^_*, Frauke Wenzelburger, MD, Markus Rothenburger, MD, Matthias Grude, MD^_*, Hans H. Scheld, MD, FESC, FETCS, Lars Eckardt, MD, Günter Breithardt, MD, FESC, FACC^_* and Thomas Wichter, MD, FESC^_*

^_* Department of Cardiology and Angiology, University Hospital of Münster, Münster, Germany
Department of Thoracic and Cardiovascular Surgery, University Hospital of Münster, Münster, Germany
Department of Electrophysiology, University Hospital of Münster, Münster, Germany

Manuscript received October 30, 2004; revised manuscript received December 8, 2004, accepted December 21, 2004.

^_* Reprint requests and correspondence: Dr. Christian Bruch, Universitätsklinikum Münster, Medizinische Klinik und Poliklinik C (Kardiologie und Angiologie), Albert-Schweitzer-Str. 33, D-48129 Münster, Germany (Email: bruchc{at}uni-muenster.de).

OBJECTIVES: This prospective study tested whether Doppler echocardiographic variables add incremental value to QRS duration in determining the prognosis of patients with chronic heart failure (CHF) and systolic dysfunction.

BACKGROUND: Diastolic dysfunction frequently is observed in patients with CHF, but its prognostic impact relative to that of QRS duration is unknown.

METHODS: A total of 193 patients with CHF and an ejection fraction <45% were enrolled prospectively. Echo measurements included left ventricular dimensions/volumes, ejection fraction, mitral early/late diastolic velocity ratio, deceleration time, and tissue Doppler mitral annular velocities. The mitral filling pattern was classified as either restrictive (RFP) or nonrestrictive. A cardiac event (cardiac death or urgent cardiac transplantation) was defined as combined study end point.

RESULTS: During a follow-up of 385 ± 270 days, 24 patients suffered an event (cardiac death, n = 21; urgent transplantation, n = 3). The RFP, QRS duration, left ventricular systolic diameter, and mitral annular early diastolic velocity were independent predictors of an event. In patients with QRS duration >144 ms, the outcome was markedly poorer in the presence of RFPs as compared with their absence. Similarly, despite a QRS duration 144 ms, the outcome was worse in the presence of a RFP. A risk-stratification model based on the three strongest independent predictors separated groups into those with good prognosis and those with high, intermediate, and low event-free survival rates.

CONCLUSIONS: In subjects with CHF and systolic dysfunction, transmitral flow patterns add incremental value to QRS duration in determining the prognosis.

Abbreviations and Acronyms   A = peak late diastolic mitral filling velocity   A' = peak late diastolic mitral annular velocity   CHF = chronic heart failure   DT = deceleration time   E = peak early diastolic mitral filling velocity   E' = peak early diastolic mitral annular velocity   ECG = electrocardiography   LVEF = left ventricular ejection fraction   RFP = restrictive filling pattern   S' = peak systolic mitral annular velocity   TDI = tissue Doppler imaging

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