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. 2020 Aug;7(4):1817-1829.
doi: 10.1002/ehf2.12746. Epub 2020 May 26.

Diagnostic and prognostic values of the QRS-T angle in patients with suspected acute decompensated heart failure

Romy Sweda  1   2 , Zaid Sabti  3 , Ivo Strebel  3 , Nikola Kozhuharov  3 , Desiree Wussler  3 , Samyut Shrestha  3 , Dayana Flores  3 , Patrick Badertscher  3 , Pedro Lopez-Ayala  3 , Tobias Zimmermann  3 , Eleni Michou  3 , Danielle M Gualandro  3 , Andreas Häberlin  1   2 , Hildegard Tanner  1 , Dagmar I Keller  4 , Albina Nowak  5 , Otmar Pfister  3 , Tobias Breidthardt  3 , Christian Mueller  3 , Tobias Reichlin  1   3
Affiliations

Diagnostic and prognostic values of the QRS-T angle in patients with suspected acute decompensated heart failure

Romy Sweda et al. ESC Heart Fail. 2020 Aug.

Abstract

Aims: The aim of this study was to investigate the diagnostic and prognostic utility of the QRS-T angle, an electrocardiogram (ECG) marker quantifying depolarization-repolarization heterogeneity, in patients with suspected acute decompensated heart failure (ADHF).

Methods and results: We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of ADHF. The QRS-T angle was automatically derived from a standard 12-lead ECG recorded at presentation. The primary diagnostic endpoint was a final adjudicated diagnosis of ADHF. The primary prognostic endpoint was all-cause mortality during 2 years of follow-up. Among the 1915 patients enrolled, those with higher QRS-T angles were older, were more commonly male, and had a higher rate of co-morbidities such as arterial hypertension, coronary artery disease, or chronic kidney disease. ADHF was the final adjudicated diagnosis in 1140 (60%) patients. The QRS-T angle in patients with ADHF was significantly larger than in patients with non-cardiac causes of dyspnoea {median 110° [inter-quartile range (IQR) 46-156°] vs. median 33° [IQR 15-57°], P < 0.001}. The diagnostic accuracy of the QRS-T angle as quantified by the area under the receiver operating characteristic curve (AUC) was 0.75 [95% confidence interval (CI) 0.73-0.77, P < 0.001], which was inferior to N-terminal pro-B-type natriuretic peptide (AUC 0.93, 95% CI 0.92-0.94, P < 0.001), but similar to that of high-sensitivity troponin T (AUC 0.78, 95% CI 0.76-0.80, P = 0.09). The AUC of the QRS-T angle for discrimination between ADHF and non-cardiac dyspnoea remained similarly high in subgroups of patients known to be diagnostically challenging, including patients older than 75 years [0.71 (95% CI 0.67-0.74)], renal failure [0.79 (95% CI 0.71-0.87)], and atrial fibrillation at presentation [0.68 (95% CI 0.60-0.76)]. Mortality rates according to QRS-T angle tertiles were 4%, 6%, and 10% after 30 days (P < 0.001) and 24%, 31%, and 43% after 2 years (P < 0.001). After adjustment for clinical, laboratory, and ECG parameters, the QRS-T angle remained an independent predictor for 2 year mortality with a 4% increase in mortality for every 20° increase in QRS-T angle (P = 0.02).

Conclusions: The QRS-T angle is a readily available and inexpensive marker that can assist in the discrimination between ADHF and non-cardiac causes of acute dyspnoea and may aid in the risk stratification of these patients.

Keywords: Acute dyspnoea; Acute heart failure; ECG; Heart failure; QRS-T angle.

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Conflict of interest statement

T.B. has received research grants from the Swiss National Science Foundation (PASMP3‐134362), the Department of Internal Medicine, University Hospital Basel, Abbott, and Roche as well as speaker honoraria from Roche. C.M. has received research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, the KTI, the University of Basel, Abbott, Alere, AstraZeneca, Beckman Coulter, BG Medicine, Biomerieux, BRAHMS, Critical Diagnostics, Roche, Siemens, Singulex, Sphingotec, and 8sense as well as speaker/consulting honoraria from Abbott, Alere, AstraZeneca, Biomerieux, BMS, Boehringer Ingelheim, BRAHMS, Cardiorentis, Eli Lilly, Novartis, Roche, Sanofi, Siemens, and Singulex. T.R. has received research grants from the Goldschmidt‐Jacobson Foundation, the Swiss National Science Foundation, the Swiss Heart Foundation, the European Union (Eurostars 9799—ALVALE), the Professor Max Cloëtta Foundation, the Cardiovascular Research Foundation Basel, the University of Basel, and the University Hospital Basel, all for work outside the submitted study. He has received speaker/consulting honoraria or travel support from Abbott/SJM, Astra Zeneca, Brahms, Bayer, Biosense‐Webster, Biotronik, Boston‐Scientific, Daiichi Sankyo, Medtronic, Pfizer‐BMS, and Roche, all for work outside the submitted study. He has received support for his institution's fellowship programme from Abbott/SJM, Biosense‐Webster, Biotronik, Boston‐Scientific, and Medtronic for work outside the submitted study. All other authors declare no conflict of interest.

Figures

Figure 1
Figure 1
QRS‐T angle in patients with acute decompensated heart failure versus other causes of acute dyspnoea. QRS‐T angle in patients with ADHF (displayed in red) and non‐cardiac causes of acute dyspnoea (displayed in blue) in the overall population (A), and stratified according to the presence of no, intermediate (RBBB, LVH), and remarkable (LAFB, RBBB+LAFB, LBBB, and NBBB) ECG confounders (B). Mann–Whitney U test used for comparison. Abbreviations: ADHF, acute decompensated heart failure; RBBB, right bundle branch block; LVH, left ventricular hypertrophy; LAFB, left anterior fascicular block; LBBB, left bundle branch block; NBBB, non‐specific bundle branch block.
Figure 2
Figure 2
Prognostic value of the QRS‐T angle with respect to all‐cause mortality. Kaplan–Meier survival estimates according to QRS‐T angle tertiles in the overall population (A), in patients with acute decompensated heart failure (B), and in patients with non‐cardiac cause of acute dyspnoea (C).
Figure 3
Figure 3
Prognostic value of the QRS‐T angle with regard to all‐cause re‐hospitalizations. Cumulative re‐hospitalization risk according to QRS‐T angle tertiles in the overall population (A), in patients with acute decompensated heart failure (B), and in patients with non‐cardiac cause of acute dyspnoea (C).
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