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Multicenter Study
. 2017 Oct 21;38(40):3017-3025.
doi: 10.1093/eurheartj/ehx331.

Electrical risk score beyond the left ventricular ejection fraction: prediction of sudden cardiac death in the Oregon Sudden Unexpected Death Study and the Atherosclerosis Risk in Communities Study

Aapo L Aro  1   2 , Kyndaron Reinier  3 , Carmen Rusinaru  3 , Audrey Uy-Evanado  3 , Navid Darouian  3 , Derek Phan  3 , Wendy J Mack  4 , Jonathan Jui  5 , Elsayed Z Soliman  6 , Larisa G Tereshchenko  5 , Sumeet S Chugh  3
Affiliations
Multicenter Study

Electrical risk score beyond the left ventricular ejection fraction: prediction of sudden cardiac death in the Oregon Sudden Unexpected Death Study and the Atherosclerosis Risk in Communities Study

Aapo L Aro et al. Eur Heart J. .

Abstract

Aims: There is an urgent need to extend sudden cardiac death (SCD) risk stratification beyond the left ventricular ejection fraction (LVEF). We evaluated whether a cumulative electrocardiogram (ECG) risk score would improve identification of individuals at high risk of SCD.

Methods and results: In the community-based Oregon Sudden Unexpected Death Study (catchment population ∼1 million), 522 SCD cases with archived 12-lead ECG available (65.3 ± 14.5 years, 66% male) were compared with 736 geographical controls to assess the incremental value of multiple ECG parameters in SCD prediction. Heart rate, LV hypertrophy, QRS transition zone, QRS-T angle, QTc, and Tpeak-to-Tend interval remained significant in the final model, which was externally validated in the Atherosclerosis Risk in Communities (ARIC) Study. Sixteen percent of cases and 3% of controls had ≥4 abnormal ECG markers. After adjusting for clinical factors and LVEF, increasing ECG risk score was associated with progressively greater odds of SCD. Overall, subjects with ≥4 ECG abnormalities had an odds ratio (OR) of 21.2 for SCD [95% confidence interval (CI) 9.4-47.7; P < 0.001]. In the LVEF >35% subgroup, the OR was 26.1 (95% CI 9.9-68.5; P < 0.001). The ECG risk score increased the C-statistic from 0.625 to 0.753 (P < 0.001), with net reclassification improvement of 0.319 (P < 0.001). In the ARIC cohort validation, risk of SCD associated with ≥4 ECG abnormalities remained significant after multivariable adjustment (hazard ratio 4.84; 95% CI 2.34-9.99; P < 0.001; C-statistic improvement 0.759-0.774; P = 0.019).

Conclusion: This novel cumulative ECG risk score was independently associated with SCD and was particularly effective for LVEF >35% where risk stratification is currently unavailable. These findings warrant further evaluation in prospective clinical investigations.

Keywords: Death; Electrocardiography; Left ventricular ejection fraction; Prevention; Risk stratification; Sudden cardiac.

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Figures

Figure 1
Figure 1
Prevalence of electrocardiogram (ECG) abnormalities in the Oregon SUDS, and risk of sudden cardiac death (SCD) associated with the ECG risk score. (A) Distribution of ECG abnormalities between SCD cases and controls. ECG parameters included in the model were elevated resting heart rate, ECG left ventricular hypertrophy, delayed QRS transition, QRS-T angle >90°, prolonged QTc, and prolonged TpTe. (B) Cumulative risk of SCD associated with the presence of multiple ECG abnormalities. Model adjusted for age, sex, hypertension, diabetes, and left ventricular function.
Figure 2
Figure 2
Incidence of sudden cardiac death (SCD) in the ARIC cohort. Observed cumulative incidence of SCD associated with the presence of multiple electrocardiogram (ECG) abnormalities in the ARIC validation cohort during the mean follow-up of 14 years.
Summarizing Figure
Summarizing Figure
Components of the multi-marker, cumulative electrocardiographic risk score for prediction of sudden cardiac death.
See this image and copyright information in PMC

Comment in

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