ECG, ECG Changes in Acute Heart Failure.

3. Presenter: Dr Hasan Mahmud Iqbal

37. In this prospective cohort, they found that there is a high prevalence of
ECG abnormalities, with a normal ECG seen only in 7.5% of patients.
This is higher than previously reported in studies of AHF, which report a
normal ECG prevalence of 2%.
Discrepancies between previous studies and the present study can be
partly explained by the timing of the ECG capture.While the present
study used the first available ECG, with the majority captured from EMS
or the ED, previous studies have relied on the latest ECG before to the
patient’s death or ECGs collected up to 15 days following admission.

40. .
The present study adds to the evidence that sinus rhythm appears to be
protective in both the short and long-term in patients with AHF, and
consistent with studies of chronic HF.
Our findings suggest that patients with HF who exhibit a widened QRS
are at a higher risk of death or readmission. Patients with a broad QRS
have been observed to have a higher rate of left ventricular dyssynchrony
and a reduced left ventricular ejection fraction, and a higher rate of
morbidity and mortality.

41. In the EHFS II (EuroHeart Failure Survey II) study, a statistically significant
shorter QRS duration was observed among survivors at 1 year (100 ms )
compared with non-survivors (110 ms )
This is supported by the findings of AHEAD (Acute Heart Failure Database)
registry, which found that an increased QRS duration was independently
associated with increased inhospital mortality and long-term mortality.
This is also seen in data from the KorHF (Korean Heart Failure) registry, where
the presence of both a widened QRS (>120 ms) and a prolonged PR interval
(>200 ms) was independently associated with in-hospital death, post-discharge
death and rehospitalization.

42. Discussion Cont…..
The prevalence and effect of bundle branch blocks on morbidity and
mortality is inconsistent in the AHF setting.The prevalence of LBBB among
patients with HF has been reported as ranging from 8% to 31%, with
variable effects of mortality.
Prevalence of RBBB is more consistently reported as ranging from 7% to
14%, also with variable effects on mortality. While univariate analysis
demonstrated a statistically significant association between the presence
of RBBB and poor outcomes, when entered into a multivariate regression
model it was found not to be an independent predictor of mortality.

43. Data from the present study would suggest that the presence of LBBB or
RBBB should not be used as a prognostic marker. Mueller et al. while the presence
of a LBBB may indicate left ventricular disease, it does not add any additional
prognostic information because the majority of patients with AHF already have
advanced left ventricular dysfunction.
This would lead us to believe that the prognostic ability of ECG
characteristics may be influenced by left ventricular ejection fraction.
This is supported by the study of Lund et al., which demonstrates that a
widened QRS was only predictive of mortality in subgroups of higher ejection
fractions.

44. Discussion Contd….
The prevalence of atrial fibrillation in the present study was 36%, which
is comparable to other studies that report a prevalence ranging between
22% and 37%.
The present study suggests that while atrial fibrillation is associated
with rehospitalization, it is not an independent predictor of mortality.
In the chronic HF population a meta-analysis of 53 969 patients
demonstrated that the presence of atrial fibrillation was associated with
increased mortality in both observational studies and clinical trials, which is
supported by data from the large CHARM (Candesartan in Heart failure -
Assessment of moRtality and Morbidity) study.

52. Summery:
The present study demonstrates that the presence of
a normal ECG and sinus rhythm in patients with HF is
associated with increased survival, while the presence of
a widened QRS, and paced rhythm are associated with
decreased survival.
When used in conjunction with data from a clinical
examination and laboratory results, identification of
these characteristics may allow clinicians to risk stratify
patients with HF and appropriately adjust their
management.

54. ThankYou All