Possible predicative role of electrical risk score on transcatheter aortic valve replacement outcomes in older patients. preliminary data

Background:Transcatheter aortic valve replacement (TAVR) is an effective procedure capable to change the natural history of the degenerative aortic valve stenosis. Despite the TAVR, the patients with advanced valve disease and severe myocardial damage (low flow, gradient and ejection fraction)show high mortality level. Aim of this study was toevaluate the predicative power of a noninvasive and inexpensive test obtained by means of a simple standard 12-leads electrocardiogram,known as the Electrical Risk Score (ERS). Methods: ERS was composed by seven simple ECG markers: heart rate (>75 bpm); QRS duration (>110 ms), left ventricular hypertrophy (Sokolow-Lyon criteria), delayed QRS transition zone (≥ V4), frontal QRS-T angle (>90°), long QTBazett (>450 ms for men and >460 in women) or JTBazett(330 ms for men and > 340 ms for women);long T peak to T end interval (Tp-e)( >89 ms). An ERS ≥ 4was considered high risk for all-cause or cardiovascular mortality.We calculated retrospectively the pre-procedure ERS in 40 TAVR patients after one year of follow-up. Results: In the follow up the all-cause and cardiovascular mortality were respectively 25% and 15%.None of survivors reported ERS ≥ 4,moreover, the ERS was the strongest predictor of all-cause (odd ratio 3.73, 95% CI: 1.44-9.66, p<0.05) or cardiovascular (odd ratio 3.95, 95% CI: 1.09-14.27, p<0.05) mortality.ROC curves showed that ERS had the widest significant sensitivity-specificity area under the curve (auc) predicting all-cause (auc: 0.855, p<0.05) or cardiovascular mortality (auc: 0.908, p<0.05). Conclusions:In this pivotal study, ERS resulted an useful tool to stratify the risk of mortality in one-year follow-up TAVR patients. Obviously, it is necessary to confirm these data in large prospective studies

Arrhythmic risk in elderly patients candidates to transcatheter aortic valve replacement. predicative role of repolarization temporal dispersion

Degenerative aortic valve stenosis (AS) is associated to ventricular arrhythmias and sudden cardiac death, as well as mental stress in specific patients. In such a context, substrate, autonomic imbalance as well as repolarization dispersion abnormalities play an undoubted role. Aim of the study was to evaluate the increase of premature ventricular contractions (PVC) and complex ventricular arrhythmias during mental stress in elderly patients candidate to the transcatheter aortic valve replacement (TAVR). In eighty-one elderly patients with AS we calculated several short-period RRand QT-derived variables at rest, during controlled breathing and during mild mental stress, the latter being represented by a mini-mental state evaluation (MMSE). All the myocardial repolarization dispersion markers worsened during mental stress (p &lt; 0.05). Furthermore, during MMSE, low frequency component of the RR variability increased significantly both as absolute power (LFRR) and normalized units (LFRRNU) (p &lt; 0.05) as well as the low-high frequency ratio (LFRR/HFRR) (p &lt; 0.05). Eventually, twenty-four (30%) and twelve (15%) patients increased significantly PVC and, respectively, complex ventricular arrhythmias during the MMSE administration. At multivariate logistic regression analysis, the standard deviation of QTend (QTesd), obtained at rest, was predictive of increased PVC (odd ratio: 1.54, 95% CI 1.14–2.08; p = 0.005) and complex ventricular arrhythmias (odd ratio: 2.31, 95% CI 1.40–3.83; p = 0.001) during MMSE. The QTesd showed the widest sensitive-specificity area under the curve for the increase of PVC (AUC: 0.699, 95% CI: 0.576–0.822, p &lt; 0.05) and complex ventricular arrhythmias (AUC: 0.801, 95% CI: 0.648–0.954, p &lt; 0.05). In elderly with AS ventricular arrhythmias worsened during a simple cognitive assessment, this events being a possible further burden on the outcome of TAVR. QTesd might be useful to identify those patients with the highest risk of ventricular arrhythmias. Whether the TAVR could led to a QTesd reduction and, hence, to a reductionof thearrhythmicburdenin thissettingofpatients isworthytobe investigated

Time- and frequency-domain analysis of repolarization phase during recovery from exercise in healthy subjects

Background/aim: Recently, data from temporal dispersion of myocardial repolarization analysis have gained a capital role in the sudden cardiac death risk stratification. Aim of this study was to evaluate the influence of heart rate, autonomic nervous system and controlled breathing on different myocardial repolarization markers in healthy subjects. Method: Myocardial repolarization dispersion markers from short period (5-minutes) ECG analysis (time and frequency domain) have been obtained in 21 healthy volunteers during these conditions: free breathing (rest); controlled breathing (resp); the first 5-minutes of post-exercise recovery phases (exercisePeak); maximum sympathetic activation, and during the second five minutes of post-exercise recovery phases (exerciseRecovery), intermediate sympathetic activation. Finally, we analyzed the whole repolarization (QTe), the QT peak (QTp) and T peak - T end intervals (Te). Results: During the exercisePeak major part of repolarization variables changed in comparison to the rest and resp conditions. Particularly, QTe, QTp, Te standard deviations (QTeSD, QTpSD, TeSD), variability indexes (QTeVI, QTpVI), normalized variances (QTeVN, QTpVN, TeVN), the ratio between short term QTe, QTp, Te variability RR (STVQTe/RR, STVQTp/RR and STVTe/RR increased. During exerciserecovery QTpSD (p&lt;0.05), QTpVI (p&lt;0.05), QTeVN (p&lt;0.05), QTpVN (p&lt;0.001), TeVN (p&lt;0.05), STVQTe/RR (p&lt;0.05), STVQTp/RR (p&lt;0.001) and STVTe/RR (p&lt;0.001) were significantly higher in comparison with the rest. The slope between QTe (0.24±0.06) or QTp (0.17±0.06) and RR were significantly higher than Te (0.07±0.06, p&lt;0.001). Conclusion: Heart rate and sympathetic activity, obtained during exercise, seem able to influence the time domain markers of myocardial repolarization dispersion in healthy subjects whereas they do not alter any spectral components

Age, gender and drug therapy influences on Tpeak-tend interval and on electrical risk score

Background and objectives: Electrical risk score (ERS) has been proposed as easy, inexpensive test to stratify of sudden cardiac death (SCD) risk in subjects with normal left ventricular function. Potentially, aging, gender and drugs can influence ERS affecting two on six electrical markers, particularly, those based on the repolarization. Aim of this study was to establish aging, gender and drug therapy possible influences on ERS and mortality in elderly patients. Method: 237 consecutive, low SCD risk-outpatients with asymptomatic and treated cardiovascular risk factors were analyzed. Six simple ECG markers composed ERS: heart rate (N75 bpm); left ventricular hypertrophy (Sokolow-Lyon criteria); delayed QRS transition zone (≥V4), frontal QRS-T angle (N90°), long QTBazett; long T peak to T end interval (Tp-e). We obtained ERS in 237 outpatients, grouped according age (b40 ys, ≥40 to b60 ys and ≥60 ys), gender and drug therapy with or without possible influence on the repolarization phase. Results: Two-hundred-thirty-seven patients were grouped respectively in the following age classes: b40 years old; ≥40 to b60 years old and ≥60 years old. ERS (p b 0.05), QTBazett (p b 0.001), Tp-e (p b 0.001) were higher in older subjects independently from gender, drug therapy and cardiovascular comorbidity. After two years we reported a 7.3% of mortality in the older groups; age (deceased versus survivors: 80 ± 4 versus 73 ± 7 years, p b 0.05) and Tp-e (deceased versus survivors: 117 ± 15 versus 93 ± 21 ms, p b 0.05) were significantly lower in survivors,multivariable logistic regression analysis selected only the Tp-e as significant risk factor for totalmortality (odd ratio 1.06, 95% CI: 1.01–1.12, p b 0.05). Conclusion: Aging was associated to the ERS and repolarization phase derangement. Tp-e should be considered a marker of total mortality rather than SCD in the over sixty years old patients

Time‐ and frequency‐domain analysis of repolarization phase during recovery from exercise in healthy subjects

Background/aim: Recently, data from temporal dispersion of myocardial repolarization analysis have gained a capital role in the sudden cardiac death risk stratification. Aim of this study was to evaluate the influence of heart rate, autonomic nervous system and controlled breathing on different myocardial repolarization markers in healthy subjects. Method: Myocardial repolarization dispersion markers from short period (5-minutes) ECG analysis (time and frequency domain) have been obtained in 21 healthy volunteers during these conditions: free breathing (rest); controlled breathing (resp); the first 5-minutes of post-exercise recovery phases (exercisePeak); maximum sympathetic activation, and during the second five minutes of post-exercise recovery phases (exerciseRecovery), intermediate sympathetic activation. Finally, we analyzed the whole repolarization (QTe), the QT peak (QTp) and T peak - T end intervals (Te). Results: During the exercisePeak major part of repolarization variables changed in comparison to the rest and resp conditions. Particularly, QTe, QTp, Te standard deviations (QTeSD, QTpSD, TeSD), variability indexes (QTeVI, QTpVI), normalized variances (QTeVN, QTpVN, TeVN), the ratio between short term QTe, QTp, Te variability RR (STVQTe/RR, STVQTp/RR and STVTe/RR increased. During exerciserecovery QTpSD (p&lt;0.05), QTpVI (p&lt;0.05), QTeVN (p&lt;0.05), QTpVN (p&lt;0.001), TeVN (p&lt;0.05), STVQTe/RR (p&lt;0.05), STVQTp/RR (p&lt;0.001) and STVTe/RR (p&lt;0.001) were significantly higher in comparison with the rest. The slope between QTe (0.24±0.06) or QTp (0.17±0.06) and RR were significantly higher than Te (0.07±0.06, p&lt;0.001). Conclusion: Heart rate and sympathetic activity, obtained during exercise, seem able to influence the time domain markers of myocardial repolarization dispersion in healthy subjects whereas they do not alter any spectral components

Short-period temporal dispersion repolarization markers predict 30-days mortality in decompensated heart failure

Background and Objectives: Electrocardiographic (ECG) markers of the temporal dispersion of the myocardial repolarization phase have been shown able to identify chronic heart failure (CHF) patients at high mortality risk. The present prospective single-center study sought to investigate in a well-characterized cohort of decompensated heart failure (HF) patients the ability of short-term myocardial temporal dispersion ECG variables in predicting the 30-day mortality, as well as their relationship with N-terminal Pro Brain Natriuretic Peptide (NT-proBNP) plasmatic values. Method:One hundred and thirteen subjects (male: 59, 67.8%) with decompensated CHF underwent 5 min of ECG recording, via a mobile phone. We obtained QT end (QTe), QT peak (QTp) and T peak to T end (Te) and calculated the mean, standard deviation (SD), and normalized index (VN). Results: Death occurred for 27 subjects (24%) within 30 days after admission. Most of the repolarization indexes (QTe mean (p &lt; 0.05), QTeSD (p &lt; 0.01), QTpSD (p &lt; 0.05), mean Te (p &lt; 0.05), TeSD (p &lt; 0.001) QTeVN (p &lt; 0.05) and TeVN (p &lt; 0.01)) were significantly higher in those CHF patients with the highest NT proBNP (&gt;75th percentile). In all the ECG data, only TeSD was significantly and positively related to the NT-proBNP levels (r: 0.471; p &lt; 0.001). In the receiver operating characteristic (ROC)analysis, the highest accuracy for 30-day mortality was found for QTeSD (area under curve, AUC: 0.705, p &lt; 0.01) and mean Te (AUC: 0.680, p &lt; 0.01), whereas for the NT-proBNP values higher thanthe 75th percentile, the highest accuracy was found for TeSD (AUC: 0.736, p &lt; 0.001) and QTeSD (AUC: 0.696, p &lt; 0.01). Conclusion: Both mean Te and TeSD could be considered as reliable markers of worsening HF and of 30-day mortality. Although larger and possibly interventional studies are needed to confirm our preliminary finding, these non-invasive and transmissible ECG parameters could be helpful in the remote monitoring of advanced HF patients and, possibly, in their clinical management. (ClinicalTrials.gov number, NCT04127162)

Hospital mortality in decompensated heart failure. a pilot study

Background/aim Heart failure is a leading cause of morbidity and mortality worldwide and it is a major cause of emergency department access for cardiovascular disease patients. Aim of this study was to identify the electrocardiographic (ECG) markers, based on short-term temporal repolarization dispersion, capable to individuate decompensated chronic heart failure (CHF) patients at high mortality risk. Methods We obtained the following variables from an ECG recording, monitored via mobile phone, during 5-minute recordings in decompensated CHF patients: RR, QT end (QTe), QT peak (QTp) and T peak to T end (Te) and we calculated mean, standard deviation (SD) and normalized index (N). Results In-hospital mortality occurred for 25 subjects on 101 studied (25%). Deceased patients showed higher QTeSD (p &lt; 0.01), Te mean (p &lt; 0.01), TeSD (p &lt; 0.05), QTeVN (p &lt; 0.05) than the surviving group. Logistic multivariable analysis evidenced that Te mean was a significant predictor of in-hospital mortality (odd ratio: 0.09, 95% confidence limit: 0.02–0.35, p: 0.001). At multiple regression analysis, TeSD was significantly and positively related only to the NT-pro BNP levels (r: 0.540; p &lt; 0.001). The Te mean (AUC: 0.677 p &lt; 0.01) and TeSD (AUC: 0.647, p: 0.05) showed significant sensitivity/specificity for the event. Conclusions The Te mean and TeSD seem to be a promising noninvasive clinical marker able to identify patients with decompensated CHF at high risk of in-hospital mortality