STATE-OF-THE-ART PAPER
Significance of QRS Complex Duration in Patients With Heart Failure
Amir Kashani, MS, MD* and
S. Serge Barold, MD, FACC ,*
* Section of Cardiology, Yale University School of Medicine, New Haven, Connecticut
Division of Cardiology, University of South Florida College of Medicine, Tampa, Florida
Manuscript received November 1, 2004;
revised manuscript received December 26, 2004,
accepted January 12, 2005.
* Reprint requests and correspondence: Dr. S. Serge Barold, 5806 Mariner’s Watch Drive, Tampa, Florida 33615. (Email: ssbarold{at}aol.com).
Prolongation of QRS ( 120 ms) occurs in 14% to 47% of heart failure (HF) patients. Left bundle branch block is far more common than right bundle branch block. Left-sided intraventricular conduction delay is associated with more advanced myocardial disease, worse left ventricular (LV) function, poorer prognosis, and a higher all-cause mortality rate compared with narrow QRS complex. It also predisposes heart failure patients to an increased risk of ventricular tachyarrhythmias, but the incidence of cardiac or sudden death remains unclear because of limited observations. A progressive increase in QRS duration worsens the prognosis. No electrocardiographic measure is specific enough to provide subgroup risk categorization for excluding or selecting HF patients for prophylactic implantable cardioverter-defibrillator (ICD) therapy. In ICD patients with HF, a wide underlying QRS complex more than doubles the cardiac mortality compared with a narrow QRS complex. There is a high incidence of an elevated defibrillation threshold at the time of ICD implantation in patients with QRS 200 ms. Mechanical LV dyssynchrony potentially treatable by ventricular resynchronization occurs in about 70% of HF patients with left-sided intraventricular conduction delay, a fact that would explain the lack of therapeutic response in about 30% of patients subjected to ventricular resynchronization according to standard criteria relying on QRS duration. The duration of the basal QRS complex does not reliably predict the clinical response to ventricular resynchronization, and QRS narrowing after cardiac resynchronization therapy does not correlate with hemodynamic and clinical improvement. Mechanical LV dyssynchrony is best shown by evolving echocardiographic techniques (predominantly tissue Doppler imaging) currently in the process of standardization.
|
Abbreviations and Acronyms
| | CI = confidence interval | | CRT = cardiac resynchronization therapy | | ECG = electrocardiogram | | HF = heart failure | | HR = hazard ratio | | ICD = implantable cardioverter-defibrillator | | LBBB = left bundle branch block | | LV = left ventricle/ventricular | | LVEF = left ventricular ejection fraction | | NYHA = New York Heart Association | | RBBB = right bundle branch block | | VT = ventricular tachycardia |
|
This article has been cited by other articles:
|
|
|
|
 
H. Nakamura, T. Mine, T. Kanemori, M. Ohyanagi, and T. Masuyama
Effect of right ventricular pacing site on QRS Width
Asian Cardiovasc Thorac Ann,
October 1, 2011;
19(5):
339 - 345.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. L. Aro, O. Anttonen, J. T. Tikkanen, M. J. Junttila, T. Kerola, H. A. Rissanen, A. Reunanen, and H. V. Huikuri
Intraventricular Conduction Delay in a Standard 12-Lead Electrocardiogram as a Predictor of Mortality in the General Population
Circ Arrhythm Electrophysiol,
October 1, 2011;
4(5):
704 - 710.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Cohen, J. P. Saul, A. S. Batra, R. Friedman, and J. Janousek
Acute Cardiac Resynchronization Therapy for the Failing Left, Right, or Single Ventricle After Repaired Congenital Heart Disease
World Journal for Pediatric and Congenital Heart Surgery,
July 1, 2011;
2(3):
424 - 429.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. M. Cubbon, C. P. Gale, L. C. Kearney, C. B. Schechter, W. P. Brooksby, J. Nolan, K. A. A. Fox, A. Rajwani, W. Baig, D. Groves, et al.
Changing Characteristics and Mode of Death Associated With Chronic Heart Failure Caused by Left Ventricular Systolic Dysfunction: A Study Across Therapeutic Eras
Circ Heart Fail,
July 1, 2011;
4(4):
396 - 403.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. W. X. Foley, K. Patel, N. Irwin, J. E. Sanderson, M. P. Frenneaux, R. E. A. Smith, B. Stegemann, and F. Leyva
Cardiac resynchronisation therapy in patients with heart failure and a normal QRS duration: the RESPOND study
Heart,
July 1, 2011;
97(13):
1041 - 1047.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Arshad, A. J. Moss, E. Foster, L. Padeletti, A. Barsheshet, I. Goldenberg, H. Greenberg, W. J. Hall, S. McNitt, W. Zareba, et al.
Cardiac Resynchronization Therapy Is More Effective in Women Than in Men: The MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) Trial
J. Am. Coll. Cardiol.,
February 15, 2011;
57(7):
813 - 820.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. A. Castel, S. Magnani, L. Mont, E. Roig, D. Tamborero, F. Mendez-Zurita, J. F. Femenia, J. M. Tolosana, F. Perez-Villa, and J. Brugada
Survival in New York Heart Association class IV heart failure patients treated with cardiac resynchronization therapy compared with patients on optimal pharmacological treatment
Europace,
August 1, 2010;
12(8):
1136 - 1140.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G.-Y. Cho, H.-K. Kim, Y.-J. Kim, D.-J. Choi, D.-W. Sohn, B.-H. Oh, and Y.-B. Park
Electrical and mechanical dyssynchrony for prediction of cardiac events in patients with systolic heart failure
Heart,
July 1, 2010;
96(13):
1029 - 1032.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Thireau, F. Aimond, D. Poisson, B. Zhang, P. Bruneval, V. Eder, S. Richard, and D. Babuty
New Insights into Sexual Dimorphism during Progression of Heart Failure and Rhythm Disorders
Endocrinology,
April 1, 2010;
151(4):
1837 - 1845.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. B. Kronborg, J. C. Nielsen, and P. T. Mortensen
Electrocardiographic patterns and long-term clinical outcome in cardiac resynchronization therapy
Europace,
February 1, 2010;
12(2):
216 - 222.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. S. Hazari, N. Haykal-Coates, D. W. Winsett, D. L. Costa, and A. K. Farraj
A Single Exposure to Particulate or Gaseous Air Pollution Increases the Risk of Aconitine-Induced Cardiac Arrhythmia in Hypertensive Rats
Toxicol. Sci.,
December 1, 2009;
112(2):
532 - 542.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Steffel and D. Hurlimann
Current practice of cardiac resynchronization therapy (CRT) in the real world: insights from the European CRT survey
Eur. Heart J.,
October 2, 2009;
30(20):
2433 - 2435.
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. A. Popescu, C. C. Beladan, A. Calin, D. Muraru, D. Deleanu, M. Rosca, and C. Ginghina
Left ventricular remodelling and torsional dynamics in dilated cardiomyopathy: reversed apical rotation as a marker of disease severity
Eur J Heart Fail,
October 1, 2009;
11(10):
945 - 951.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Sonne, L. Sugeng, M. Takeuchi, L. Weinert, R. Childers, N. Watanabe, K. Yoshida, V. Mor-Avi, and R. M. Lang
Real-Time 3-Dimensional Echocardiographic Assessment of Left Ventricular Dyssynchrony: Pitfalls in Patients With Dilated Cardiomyopathy
J. Am. Coll. Cardiol. Img.,
July 1, 2009;
2(7):
802 - 812.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Gervais, C. Leclercq, A. Shankar, S. Jacobs, H. Eiskjaer, A. Johannessen, N. Freemantle, J. G.F. Cleland, L. Tavazzi, C. Daubert, et al.
Surface electrocardiogram to predict outcome in candidates for cardiac resynchronization therapy: a sub-analysis of the CARE-HF trial
Eur J Heart Fail,
July 1, 2009;
11(7):
699 - 705.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Boriani, M. Bertini, I. Diemberger, M. Biffi, and C. Martignani
The QRS interval in patients treated with resynchronization therapy: which value?
Eur J Heart Fail,
July 1, 2009;
11(7):
635 - 637.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Donal, L. H. Lund, C. Linde, M. Edner, S. Lafitte, H. Persson, F. Bauer, J. Ohrvik, P.-V. Ennezat, C. Hage, et al.
Rationale and design of the Karolinska-Rennes (KaRen) prospective study of dyssynchrony in heart failure with preserved ejection fraction
Eur J Heart Fail,
February 1, 2009;
11(2):
198 - 204.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Bordachar, X. Iriart, J. Chabaneix, F. Sacher, S. Lafitte, P. Jais, M. Haissaguerre, J. Clementy, P. Dos Santos, and J.-B. Thambo
Presence of ventricular dyssynchrony and haemodynamic impact of right ventricular pacing in adults with repaired Tetralogy of Fallot and right bundle branch block
Europace,
August 1, 2008;
10(8):
967 - 971.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Abraham and T. P. Abraham
Is echocardiographic assessment of dyssynchrony useful to select candidates for cardiac resynchronization therapy?: Echocardiography Is Useful Before Cardiac Resynchronization Therapy if QRS Duration Is Available
Circ Cardiovasc Imaging,
July 1, 2008;
1(1):
79 - 85.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. L. Clark, K. Goode, and J. G.F. Cleland
The prevalence and incidence of left bundle branch block in ambulant patients with chronic heart failure
Eur J Heart Fail,
July 1, 2008;
10(7):
696 - 702.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. B. Bleeker, S. A. Mollema, E. R. Holman, N. Van De Veire, C. Ypenburg, E. E. van der Wall, M. J. Schalij, J. J. Bax, and E. Boersma
Response to Letter Regarding Article, "Left Ventricular Dyssynchrony Is Mandatory for Response to Cardiac Resynchronization Therapy"
Circulation,
March 18, 2008;
117(11):
e197 - e197.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Pu and W. T Abraham
Resynchronisation therapy in heart failure: searching for predictors
Heart,
January 1, 2008;
94(1):
4 - 5.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. C. Myles, C. E. Jackson, I. Tsorlalis, M. C. Petrie, J. J. V. McMurray, and S. M. Cobbe
Is Microvolt T-Wave Alternans the Answer to Risk Stratification in Heart Failure?
Circulation,
December 18, 2007;
116(25):
2984 - 2991.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Lim, C. Bars, L. Mitchell-Heggs, C. Roiron, N. Elbaz, B. Hamdaoui, N. Lellouche, J.-L. Dubois-Rande, and P. Gueret
Importance of contractile reserve for CRT
Europace,
September 1, 2007;
9(9):
739 - 743.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. L. Fosbol, M. Seibaek, B. Brendorp, D. V. Moller, M. Ersboll, C. Torp-Pedersen, L. Kober, and for the Danish Investigations and Arrhythmia ON Do
Differential prognostic importance of QRS duration in heart failure and acute myocardial infarction associated with left ventricular dysfunction
Eur J Heart Fail,
August 1, 2007;
9(8):
814 - 819.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Fischer, R. Dechend, A. Gapelyuk, E. Shagdarsuren, K. Gruner, A. Gruner, P. Gratze, F. Qadri, M. Wellner, A. Fiebeler, et al.
Angiotensin II-induced sudden arrhythmic death and electrical remodeling
Am J Physiol Heart Circ Physiol,
August 1, 2007;
293(2):
H1242 - H1253.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. D. Burkhardt and B. L. Wilkoff
Interventional Electrophysiology and Cardiac Resynchronization Therapy: Delivering Electrical Therapies for Heart Failure
Circulation,
April 24, 2007;
115(16):
2208 - 2220.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. P. Badano, O. Gaddi, C. Peraldo, G. Lupi, M. Sitges, F. Parthenakis, S. Molteni, M. R. Pagliuca, B. Sassone, P. Di Stefano, et al.
Left ventricular electromechanical delay in patients with heart failure and normal QRS duration and in patients with right and left bundle branch block
Europace,
January 1, 2007;
9(1):
41 - 47.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C.-M. Yu, Y.-S. Chan, Q. Zhang, G. W.K. Yip, C.-K. Chan, L. C.C. Kum, L. Wu, A. P.-W. Lee, Y.-Y. Lam, and J. W.-H. Fung
Benefits of Cardiac Resynchronization Therapy for Heart Failure Patients With Narrow QRS Complexes and Coexisting Systolic Asynchrony by Echocardiography
J. Am. Coll. Cardiol.,
December 5, 2006;
48(11):
2251 - 2257.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. B. Bleeker, E. R. Holman, P. Steendijk, E. Boersma, E. E. van der Wall, M. J. Schalij, and J. J. Bax
Cardiac Resynchronization Therapy in Patients With a Narrow QRS Complex
J. Am. Coll. Cardiol.,
December 5, 2006;
48(11):
2243 - 2250.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Stern
Electrocardiogram: Still the Cardiologist's Best Friend
Circulation,
May 16, 2006;
113(19):
e753 - e756.
[Full Text]
[PDF]
|
|
|
|
|
|
|
O.-A. Breithardt and G. Breithardt
Quest for the Best Candidate: How Much Imaging Do We Need Before Prescribing Cardiac Resynchronization Therapy?
Circulation,
February 21, 2006;
113(7):
926 - 928.
[Full Text]
[PDF]
|
|
|
|
