Prognostic value of fragmented QRS on a 12-lead ECG in patients with acute myocardial infarction Luc Lorgis, MD, PhD a, b, * , François Jourda, MD a , Olivier Hachet, MD a , Marianne Zeller, PhD b , Aurelie Gudjoncik, MD a, b , Gilles Dentan, MD c , Karim Stamboul, MD a , Charles Guenancia, MD a , Laurent Mock, MD c , Yves Cottin, MD, PhD a, b , on behalf of the RICO Survey Working Group a Department of Cardiology, University Hospital, Dijon, France b Laboratory of Cardiometabolic Physiopathology and Pharmacology, INSERM U866, University of Burgundy, Dijon, France c Department of Cardiology, clinique de Fontaine, Fontaine les Dijon, France article info Article history: Received 23 January 2013 Received in revised form 15 May 2013 Accepted 16 May 2013 Available online 11 July 2013 Keywords: Fragmented QRS Prognosis Myocardial infarction abstract Objective: To investigate the determinants and the prognostic value of fragmented QRS (fQRS) after AMI. Patients and methods: Prospective cohort of 307 consecutive patients with AMI. Main outcomes measured: MACE (death plus non-fatal recurrent MI), hospitalization for an episode of heart failure, ventricular arrhythmia (VT or VF) at two years follow-up. Results: On the serial 12-lead ECG recorded during the in-hospital stay, 162 (53%) had no fQRS (no fQRS group). 145 (47%) presented an fQRS, which was persistent in 108 (34%) patients (persistent fQRS group) and transient in 37 (12%) patients (transient fQRS group). Patients with a fragmented QRS (transient or persistent) were older, more likely to be hypertensive and less likely to be smokers than were patients without fQRS. By multivariate logistic regression analysis, only hypertension (OR (95% CI): 1.66 (1.00e2.74); p ¼ 0.047) was associated with an fQRS. During a mean follow-up of 846  297 days, there were 82 MACE recorded: 17 patients died from a CV cause (10% event rate) among patients without fQRS, 22 (20% event rate) among patients with persistent fQRS and 3 (8% event rate) among patients with transient fQRS. Similarly, non-fatal recurrent MI occurred more frequently in patients with fQRS (18 (16%) and 10 (27%)) for persistent and transient fQRS, respectively, vs.16 (10%) in the no fQRS group (p ¼ 0.019). However, the occurrence of heart failure symptoms and ventricular arrhythmia was not significantly different (p ¼ 0.162 and p ¼ 0.242, respectively). Survival analysis by the KaplaneMeier method showed a significant difference (log rank p ¼ 0.026) between groups, and only persistent fQRS was associated with decreased survival. In multivariate cox regression analysis, the GRACE score, blood glucose on admission, and B-blockers in the acute phase were independent predictors of MACE at two years. fQRS was not a significant independent predictor of MACE (HR (95% CI): 1.57 (0.95e2.60); p ¼ 0.08). Moreover, fQRS was not a predictor of heart failure or ventricular arrhythmia in univariate analysis. Conclusions: Persistent fQRS on a 12-lead ECG is a marker of decreased survival after AMI, whereas transient fQRS correlates with recurrent MI. Crown Copyright Ó 2013 Published by Elsevier Inc. All rights reserved. Introduction A twelve-lead electrocardiogram is an integral part of the evaluation of acute myocardial infarction (AMI). Fragmented QRS complexes (fQRS), which include various RSR 0 patterns with or without a typical bundle-branch block on routine 12-lead electro- cardiography (ECG) has recently been proposed as a reliable and sensitive tool in this setting. 1e5 An fQRS is defined by the presence of an additional R wave (R 0 ) or notching in the nadir of the S wave, or the presence of >1R 0 (fragmentation) in two contiguous leads. Described by Grant in 1950, fragmentation of the QRS complex on the 12-lead surface ECG has been described in a number of cardiac Abbreviations: AMI, acute myocardial infarction; CAD, coronary artery disease; ECG, electrocardiogram; FQRS, fragmented QRS; LVEF, left ventricular ejection fraction; NON-STEMI, NON-ST segment elevation myocardial infarction; STEMI, ST- segment elevation myocardial infarction. Disclosures: The authors have no potential conflict of interest to disclose in connection with the submitted article. Funding: This work was supported by the University Hospital of Dijon, the Asso- ciation de Cardiologie de Bourgogne, and by grants from the Agence Regionale de Santé (ARS) de Bourgogne, the Conseil Régional de Bourgogne and the Fédération Française de Cardiologie (FFC). * Corresponding author. Service de Cardiologie, Bocage Central CHU Dijon,14 rue Gaffarel, 21079 Dijon Cedex, France. Tel.: þ33 380293536; fax: þ33 380293291. E-mail address: luc.lorgis@chu-dijon.fr (L. Lorgis). Contents lists available at SciVerse ScienceDirect Heart & Lung journal homepage: www.heartandlung.org 0147-9563/$ e see front matter Crown Copyright Ó 2013 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2013.05.005 Heart & Lung 42 (2013) 326e331