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J Am Coll Cardiol, 2005; 46:2183-2192, doi:10.1016/j.jacc.2005.01.071
© 2005 by the American College of Cardiology Foundation
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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{dagger},*

* Section of Cardiology, Yale University School of Medicine, New Haven, Connecticut
{dagger} 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




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