Fatih KARDAŞ, Gökay TAYLAN, Çağlar KAYA, İlhan KURULTAK

Fragmente QRS'nin Varlığı Hemodiyaliz Hastalarında Ventriküler Aritmi ile İlişkili Olabilir

Giriş: Fragmente QRS (fQRS), 12-derivasyon elektrokardiyografide (EKG) görülebilen bir depolarizasyon kusurudur. Miyokardiyal fibrotik skarın, QRS'de parçalanma ve ventriküler geç potansiyellere neden olarak yapısal ve elektrofizyolojik değişiklik sonucu ventriküler aritmilerin oluşumunda rol oynadığı belirlenmiştir. Hemodiyaliz (HD) hastalarında aritmi riski artmıştır. Düzenli EKG izleme ve fQRS' lerin varlığı HD hastalarında ventriküler aritmilerlerin erken teşhisinde yardımcı olabilir. Bu çalışmanın amacı HD hastalarında fQRS' lerin varlığı ile ventriküler aritmi arasındaki ilişkiyi araştırmaktır. Yöntemler: Bu vaka-kontrol çalışmasında, fQRS saptanan 22 HD hastası ile fQRS saptanmamış 72 HD hastası karşılaştırıldı. İki grubun EKG parametreleri ve EKG-Holter sonuçları, çok değişkenli analiz yoluyla ventriküler aritmiler sıklığı açısından karşılaştırıldı. P değeri <0,05 istatistiksel olarak anlamlı kabul edildi. Bulgular: Her iki grubun EKG-Holter verileri kıyaslandığında, ventriküler erken vuru (VEV) sıklığının ve süreksiz ventriküler taşikardi (NSVT) gözlenen olguların sayısının fQRS (+) grupta arttığı istatistiksel anlamlı görüldü (p <0,001, p: 0,01). Ek olarak, EKG parametrelerinden düzeltilmiş QT intervali (QTc), QTc dispersionu (QTcd) ve repolarizasyonun transmural dispersiyonu (TDR)’ nun fQRS (+) grubunda uzadığı ve istatistiksel olarak anlamlı olduğu saptandı (p <0,001, p: 0,003, p: 0,019). Sonuç: FQRS grubundaki VEV ve NSVT sıklığı, kontrol grubundan anlamlı olarak yüksekti. FQRS' lerin varlığı hemodiyaliz hastalarında ventriküler aritmileri tahmin etmek için kullanılabilir.

Anahtar Kelimeler:

Elektrokardiyografi, fragmente QRS, hemodiyaliz, ventriküler aritmi

Presence of Fragmented QRS may be Associated with Ventricular Arrhythmias in Hemodialysis Patients

Introduction: Fragmented QRS (fQRS) is a depolarization defect that can be seen in a 12-derivation electrocardiography (ECG). It has been determined that myocardial fibrotic scar plays a role in the formation of ventricular arrhythmias by causing structural and electrophysiological changes that cause fragmentation and ventricular late potentials in QRS. Arrhythmia risk is increased in hemodialysis (HD) patients. Regular ECG monitoring and the presence of fQRS can help in the early diagnosis of ventricular arrhythmias in HD patients. The aim of this study is to investigate the relationship between the presence of fQRS and ventricular arrhythmia in HD patients. Methods: In this case-control study, 22 HD patients with fQRS and 72 HD patients without fQRS were compared. The ECG parameters and ECG-holter results of the two groups were compared in terms of the frequency of ventricular arrhythmias by multivariate analysis. A p value <0.05 was considered statistically significant. Results: The compared to ECG-holter data of the both groups, it was statistically detected that the frequency of ventricular premature contraction (VPC) and the number of cases observed in non-susteined ventricular tachycardia (NSVT) increased in the group with fQRS (+) (p <0.001, p:0.01). In addition, it was observed that corrected QT (QTc), dispersion of QTc (QTcd) and transmural dispersion of repolarization (TDR) were extended from ECG parameters in the fQRS (+) group and were statistically significant (p <0.001, p:0.003, p:0.019). Conclusion: The frequency of VPC and NSVT in the fQRS group was significantly higher than in the control group. The presence of fQRS may be used to predict ventricular arrhythmias in HD patients.

Keywords:

Electrocardiography, fragmented QRS, hemodialysis, ventricular arrhythmias,

PDF

___

1. Hesketh, C. C., Knoll, G. A., Molnar, A. O., Tsampalieros, A., Zimmerman, D. L. Vitamin D and kidney transplant outcomes: a protocol for a systematic review and meta-analysis. Systematic reviews, 2014;3(1):1-5.
2. Veitenhansl, M., Stegner, K., Hierl, F. X., et al. 40th EASD Annual Meeting of the European Association for the Study of Diabetes. Diabetologia, 2004;47:1-464.
3. Cheung, A. K., Sarnak, M. J., Yan, G., et al. Cardiac diseases in maintenance hemodialysis patients: results of the HEMO Study. Kidney international, 2004;65(6):2380-89.
4. Turakhia, M. P., Blankestijn, P. J., Carrero, J. J., et al. Chronic kidney disease and arrhythmias: conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference. European heart journal, 2018;39(24):2314-25.
5. Akpolat,f T., Utaş, C. Renal transplantasyon ve hasta seçimi. Hemodiyaliz hekimi el kitabı, 2011.
6. Becker, L., Eisenberg, M., Fahrenbruch, C., Cobb, L. Cardiac arrest in medical and dental practices: implications for automated external defibrillators. Archives of internal medicine, 2001;161(12):1509-12.
7. Pietrasik, G., Goldenberg, I., Zdzienicka, J., Moss, A. J., Zareba, W. Prognostic significance of fragmented QRS complex for predicting the risk of recurrent cardiac events in patients with Q-wave myocardial infarction. The American journal of cardiology, 2007;100(4):583-86.
8. Morita, H., Kusano, K. F., Miura, D., et al. Fragmented QRS as a marker of conduction abnormality and a predictor of prognosis of Brugada syndrome. Circulation, 2008;118(17):1697.
9. Wang, D. D., Buerkel, D. M., Corbett, J. R., Gurm, H. S. Fragmented QRS complex has poor sensitivity in detecting myocardial scar. Annals of Noninvasive Electrocardiology, 2010;15(4):308-14.
10. Das, M. K., Maskoun, W., Shen, C., et al. Fragmented QRS on twelve-lead electrocardiogram predicts arrhythmic events in patients with ischemic and nonischemic cardiomyopathy. Heart rhythm, 2010;71:74-80.
11. Peters, S., Trümmel, M., Koehler, B. QRS fragmentation in standard ECG as a diagnostic marker of arrhythmogenic right ventricular dysplasia–cardiomyopathy. Heart Rhythm, 2008;5(10):1417-21.
12. Das, M. K., Suradi, H., Maskoun, W., et al. Fragmented wide QRS on a 12-lead ECG: a sign of myocardial scar and poor prognosis. Circulation: Arrhythmia and Electrophysiology, 2008;1(4):258-68.
13. Sha, J., Zhang, S., Tang, M., Chen, K., Zhao, X., Wang, F. Fragmented QRS is associated with all‐cause mortality and ventricular arrhythmias in patient with idiopathic dilated cardiomyopathy. Annals of Noninvasive Electrocardiology, 2011;16(3):270-75.
14. Carey, M. G., Luisi Jr, A. J., Baldwa, S., et al. The Selvester QRS Score is more accurate than Q waves and fragmented QRS complexes using the Mason-Likar configuration in estimating infarct volume in patients with ischemic cardiomyopathy. Journal of electrocardiology, 2010;43(4):318-25.
15. T. Abdelrahman, "QRS Fragmentation as a Prognostic Test in Acute Coronary Syndrome," World Journal of Cardiovascular Surgery, 2013;3(2):42-51.
16. Das, M. K., Khan, B., Jacob, S., Kumar, A., Mahenthiran, J. Significance of a fragmented QRS complex versus a Q wave in patients with coronary artery disease. Circulation, 2006;113(21):2495-2501.
17. American Diabetes Association. Glycemic targets: standards of medical care in diabetes-2021. Diabetes Care, 2021;44(1):73-84.
18. Al-Khatib, S. M., Stevenson, W. G., Ackerman, M. J., et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 2018;72(14):91-220.
19. Hastalığı, S. G. K. B. Yetmezliği: Tanımı, Evreleri ve Epidemiyolojisi. Türkiye Klinikleri J Int Med Sci, 2007;3(38):1-7.
20. Tonelli, M., Wiebe, N., Culleton, B., et al. Chronic kidney disease and mortality risk: a systematic review. Journal of the American Society of Nephrology, 2006;17(7):2034-47.
21. Qureshi, A. R., Alvestrand, A., Divino-Filho, J. C., et al. Inflammation, malnutrition, and cardiac disease as predictors of mortality in hemodialysis patients. Journal of the American Society of Nephrology, 2002;13(1):28-36.
22. Genovesi, S., Pogliani, D., Faini, A., et al. Prevalence of atrial fibrillation and associated factors in a population of long-term hemodialysis patients. American journal of kidney diseases, 2005;46(5):897-902.
23. Homsi, M., Alsayed, L., Safadi, A., Das, M. K., Mahenthiran, J. Fragmented QRS complexes on a 12-lead ECG as a marker of non-coronary artery disease related myocardial disease by gadolinium delayed enhancement cardiac magnetic resonance imaging. Journal of Cardiovascular Magnetic Resonance, 2009;11(1):1-316.
24. Park, S. J., On, Y. K., Kim, J. S., et al. Relation of fragmented QRS complex to right ventricular fibrosis detected by late gadolinium enhancement cardiac magnetic resonance in adults with repaired tetralogy of fallot. The American journal of cardiology, 2012;109(1):110-15.
25. Basaran, Y., Tigen, K., Karaahmet, T., et al. Fragmented QRS complexes are associated with cardiac fibrosis and significant intraventricular systolic dyssynchrony in nonischemic dilated cardiomyopathy patients with a narrow QRS interval. Echocardiography, 2011;28(1):62-68.
26. Damar H. İ., Kardiyak sendrom x hastalarında fragmente qrs sıklığı, Tıpta uzmanlık tezi, Tokat , Gaziosmanpaşa Üniversitesi Tıp Fakültesi, 2014;26-27.
27. Winkelmayer, W. C., Patrick, A. R., Liu, J., Brookhart, M. A., Setoguchi, S. The increasing prevalence of atrial fibrillation among hemodialysis patients. Journal of the American Society of Nephrology, 2011;22(2):349-57.
28. Yildirir, A., Aksoyek, S., Calguneri, M., et al. QT dispersion as a predictor of arrhythmic events in patients with ankylosing spondylitis. Rheumatology, 2000;39(8):875-79.
29. Castro Hevia, J., Antzelevitch, C., Tornés Bárzaga, F., et al. Tpeak-Tend and Tpeak-Tend dispersion as risk factors for ventricular tachycardia/ventricular fibrillation in patients with the Brugada syndrome. Journal of the American College of Cardiology, 2006;47(9):1828-34.
30. Bekar, L., Kalçık, M., Kilci, H., et al. Presence of fragmented QRS may be associated with complex ventricular arrhythmias in patients with essential hypertension. Journal of electrocardiology, 2019;55:20-25.
31. Sheldon, S. H., Gard, J. J., Asirvatham, S. J. Premature ventricular contractions and non-sustained ventricular tachycardia: association with sudden cardiac death, risk stratification, and management strategies. Indian pacing and electrophysiology journal, 2010;10(8):357.