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ECG as a risk stratification tool in patients with wearable cardioverter-defibrillator

Published:August 16, 2022DOI:https://doi.org/10.1016/j.jjcc.2022.08.001

      Highlights

      • The wearable cardioverter defibrillator is safe and effective in patients with elevated risk for fatal arrhythmias.
      • Tp-e and QTc are independent electrocardiographic (ECG) predictors of adverse events in these patients.
      • ECG can serve as an additional risk stratification tool in this high-risk subgroup.

      Abstract

      Background

      The wearable cardioverter defibrillator (WCD) is increasingly used in patients at elevated risk for ventricular arrhythmias but not fulfilling the indications for an implantable cardioverter defibrillator (ICD). Currently, there is an insufficient risk prediction of fatal arrhythmias in patients at risk. In this study, we assessed the prognostic role of baseline electrocardiogram (ECG) in WCD patients.

      Methods

      WCD patients from diverse clinical institutions in Germany (n = 227) were retrospectively enrolled and investigated for the incidences of death or ventricular arrhythmias during WCD wearing. In addition, the widely accepted ECG predictors of adverse outcome were analyzed in patients with arrhythmic events.

      Results

      Life-threatening arrhythmias occurred in 22 (9.7 %) patients, mostly in subjects with ischemic heart disease (15 of 22). There was no difference in baseline left ventricular ejection fraction (LVEF) in subjects with and without arrhythmic events (31.3 ± 7.9 % vs. 32.6 ± 8.3 %; p = 0,24). Patients with arrhythmia exhibited significantly longer QRS duration (109.5 ± 23.1 ms vs. 100.6 ± 22.3 ms, p = 0,04), Tpeak-Tend (Tp-e) (103.1 ± 15.6 ms vs. 93.2 ± 19.2 ms, p = 0,01) and QTc (475.0 ± 60.0 ms vs. 429.6 ± 59.4 ms, p < 0,001) intervals. In contrast, no significant differences were found for incidences of fragmented QRS (27.3 % vs. 24 %, p = 0.79) and inverted/biphasic T-waves (16.6 % vs. 22.7 %, p = 0,55). In multivariate regression analysis both Tp-e (HR 1.03; 95 % CI 1.001–1.057; p = 0.02) and QTc (HR 1.02; 95 % CI 1.006–1.026; p < 0.001) were identified as independent predictors of ventricular arrhythmias.
      After WCD use, the prophylactic ICD was indicated in 76 patients (33 %) with uneventful clinical course but persistent LVEF ≤35 %. The ECG analysis in these subjects did not reveal any relevant changes in arrhythmogenesis markers.

      Conclusions

      ECG repolarization markers Tp-e and QTc are associated with malignant arrhythmias in WCD patients and may be used - in addition to other established risk markers - to identify appropriate patients for ICD implantation.

      Graphical abstract

      Keywords

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