Electrocardiographic Z-axis QRS-T voltage-time-integral in patients with typical right bundle branch block - Correlation with echocardiographic right ventricular size and function

Abstract

Background: Right bundle branch block (RBBB) can be benign or associated with right ventricular (RV) functional and structural abnormalities. Our aim was to evaluate QRS-T voltage-time-integral (VTI) compared to QRS duration and lead V1 R' as markers for RV abnormalities.

Methods: We included adults with an ECG demonstrating RBBB and echocardiogram obtained within 3 months of each other, between 2010 and 2020. VTI_QRS and VTI_QRST were obtained for 12 standard ECG leads, reconstructed vectorcardiographic X, Y, Z leads and root-mean-squared (3D) ECG. Age, sex and BSA-adjusted linear regressions were used to assess associations of QRS duration, amplitudes, VTIs and lead V1 R' duration/VTI with echocardiographic tricuspid annular plane systolic excursion (TAPSE), RV tissue Doppler imaging S', basal and mid diameter, and systolic pressure (RVSP).

Results: Among 782 patients (33% women, age 71 ± 14 years) with RBBB, R' duration in lead V1 was modestly associated with RV S', RV diameters and RVSP (all p ≤ 0.03). QRS duration was more strongly associated with RV diameters (both p < 0.0001). Amplitude_QRS-Z was modestly correlated with all 5 RV echocardiographic variables (all p ≤ 0.02). VTI_R'-V1 was more strongly associated with TAPSE, RV S' and RVSP (all p ≤ 0.0003). VTI_QRS-Z and VTI_QRST-Z were among the strongest correlates of the 5 RV variables (all p < 0.0001). VTI_QRST-Z.√BSA cutoff of ≥62 μVsm had sensitivity 62.7% and specificity 65.7% for predicting ≥3 of 5 abnormal RV variables (AUC 0.66; men 0.71, women 0.60).

Conclusion: In patients with RBBB, VTI_QRST-Z is a stronger predictor of RV dysfunction and adverse remodeling than QRS duration and lead V1 R'.

Keywords: ECG; QRS amplitude; QRS area; QRS duration; QRS-T voltage-time-integral; Right bundle branch block; Right ventricular failure; Right ventricular hypertrophy.