Clinical Symptoms of Atrial Fibrillation Clinical Symptoms of Atrial Fibrillation in Different Ranges of QRS Durationin Different Ranges of QRS Duration

Burda I.Yu., Yabluchansky N.I.Medical Clinics ChairNational University of Karazin (Kharkov, Ukraine)

Reasons to InvestigateReasons to Investigate

Atrial fibrillation (AF) is the most frequent arrhythmia and Atrial fibrillation (AF) is the most frequent arrhythmia and generates 1/3 of all hospitalizations by arrhythmic cause. generates 1/3 of all hospitalizations by arrhythmic cause. The incidence of AF increases with age and varies between The incidence of AF increases with age and varies between less than 1% in people older than 60 years and almost 10% less than 1% in people older than 60 years and almost 10% in all people older than 80 years.in all people older than 80 years.AF is associated to an increase in risk of stroke, heart AF is associated to an increase in risk of stroke, heart failure (HF), and total mortality.failure (HF), and total mortality.Both QRS shortening and prolongation cause myocardial Both QRS shortening and prolongation cause myocardial electric instability, intra- and interventricular asynchrony, electric instability, intra- and interventricular asynchrony, intracardiac hemodynamic disorders, a decrease in cardiac intracardiac hemodynamic disorders, a decrease in cardiac ejection effectiveness, being as well, an independent ejection effectiveness, being as well, an independent predictor of mortality. predictor of mortality. Up to this date, there are no studies conducted to prove the Up to this date, there are no studies conducted to prove the relationship between the clinical symptoms of AF and QRS relationship between the clinical symptoms of AF and QRS duration.duration.

Objective of the InvestigationObjective of the Investigation

To study the relationship between QRS To study the relationship between QRS duration and the clinical symptoms of AF, duration and the clinical symptoms of AF, to improve the quality of the diagnosis and to improve the quality of the diagnosis and the management of this arrhythmia.the management of this arrhythmia.

Investigated PopulationInvestigated Population

Patients selected for the studyPatients selected for the study

98 98 patients patients (67 (67 male male and and 31 31 femalefemale)), ages between 45 and , ages between 45 and 87 years old with AF duration 87 years old with AF duration 6±56±5 years yearsForm of AFForm of AF– chronicchronic – 65 – 65 – persistentpersistent – 27 – 27– paroxysmal paroxysmal – 6 – 6

High blood pressure High blood pressure – 89 – 89 patientspatientsCoronary heart diseaseCoronary heart disease – 63 – 63 patientspatientsCombination of hypertension and CHD Combination of hypertension and CHD –– 32 32 patientspatients

Investigated PopulationInvestigated PopulationClassification of the characteristics of patientsClassification of the characteristics of patients

SexSex - - malemale - - femalefemale

Age: Age: –– adults adults ((45-60 years old men, 45-55 years old women45-60 years old men, 45-55 years old women)) - - older older adults adults ((61-74 years old men, 56-74 years old women61-74 years old men, 56-74 years old women)) - - elderlyelderly ( (75-87 years old men and women75-87 years old men and women))

Characteristics of AFCharacteristics of AFTime of evolution Time of evolution ((up to 10 years or more than 10 yearsup to 10 years or more than 10 years))– formform ( (chronic, chronic, persistent, paroxysmalpersistent, paroxysmal))– classification by HR (bpm) – bradycardia (less than 60), normal (60-90) and classification by HR (bpm) – bradycardia (less than 60), normal (60-90) and

tachycardia (more than 90)tachycardia (more than 90)Degree of HF Degree of HF ((FC FC І-ІІІІ-ІІІ))LV ejection fraction (EF) LV ejection fraction (EF) (20-43%, 44-66% (20-43%, 44-66% and and 67-88%)67-88%)Stable chronic angina Stable chronic angina ((FC FC І-ІІІІ-ІІІ))Systolic and diastolic pressure: normal BP – below 140/90 mm.Hg.Systolic and diastolic pressure: normal BP – below 140/90 mm.Hg.

- - mild HBP mild HBP ((systolic systolic 140-159 140-159 mm.Hg. , diastolic mm.Hg. , diastolic 90-99 90-99 mm.Hg.mm.Hg.)) - - moderate HBP moderate HBP ((systolicsystolic 160-179 160-179 mm.Hg. mm.Hg., , diastolicdiastolic 100-109 100-109 mm.Hg. mm.Hg.)) - - severe HBP severe HBP ((systolic more thansystolic more than 180 180 mm.Hg. mm.Hg., , diastolic more than diastolic more than 110110 mm.Hg. mm.Hg.))

History of AMIHistory of AMIHistory of strokeHistory of stroke

Investigated PopulationInvestigated Population Inclusion and Exclusion CriteriaInclusion and Exclusion Criteria

Inclusion criteriaInclusion criteriaAFAFHBPHBPStable chronic angina, FCStable chronic angina, FC I-IIII-IIIEndocarditis, myocarditis, pericarditisEndocarditis, myocarditis, pericarditisValve diseasesValve diseasesExstrasystoleExstrasystoleConduction disordersConduction disordersHFHF (FC I-III(FC I-III))

Exclusion criteriaExclusion criteriaStable chronic angina, FCStable chronic angina, FC IVIV Acute coronary syndromeAcute coronary syndromeHF FC HF FC IVIV

Equipment Used and Parameters Equipment Used and Parameters EvaluatedEvaluated

Computer electrocardiograph “Computer electrocardiograph “CardiolabCardiolab++””Parameters evaluatedParameters evaluated:: HR (bpm)HR (bpm) QRS duration (ms)QRS duration (ms)

Echocardiograph “Echocardiograph “SIM SIM 50005000 plus” plus”Parameters evaluatedParameters evaluated: : LV ejection fraction (LV ejection fraction (%%))

Blood pressure cuffBlood pressure cuffParameters evaluatedParameters evaluated: : Systolic blood pressure in mm.HgSystolic blood pressure in mm.Hg Diastolic blood pressure in mm.HgDiastolic blood pressure in mm.Hg

Measurement of QRS DurationMeasurement of QRS Duration

QRS duration was measured in 3 QRS duration was measured in 3 consecutive complexes in leads consecutive complexes in leads IIII, , VV1, 1, VV5, 5, VV6 6

Among the measured complexes, the one Among the measured complexes, the one with the longest duration was chosenwith the longest duration was chosen

Classification of QRS according to Classification of QRS according to DurationDuration

Classification of QRS according to Classification of QRS according to duration:duration:

- - narrow narrow ((less than less than 60 ms60 ms)) - - normalnormal ( (from from 6060 to to 100 100 ms)ms) - - prolonged prolonged ((longer than longer than 100 ms100 ms))

Statistical AnalysisStatistical Analysis

Data base in Data base in Microsoft ExcelMicrosoft Excel

Statistical analysis with parametric Statistical analysis with parametric methodsmethods

Construction of graphs on the duration of Construction of graphs on the duration of QRS in different rangesQRS in different ranges

Distribution of QRS Duration in all the PatientsDistribution of QRS Duration in all the Patients

The distribution is asymmetrical, shifted to lower values.

The QRS duration of most patients is within the range of 91 to 100 ms.

No narrow complexes are observed (of less than 60 ms). Most patients had prolonged complexes.

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Relationship between Gender and QRS DurationRelationship between Gender and QRS Duration

The ratio between women (dark violet bars) and men (light violet bars) was 2:1.

The distribution of QRS duration in all the patients was similar to the one in each group separately.

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мужчины

женщины

Relationship between Age and QRS DurationRelationship between Age and QRS Duration

Adults

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2

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6

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80 90 100 110 120 130 140

QRS, мс

мужчины 45-60 лет

женщины 45-55лет

Older adults

0

1

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8

70 80 90 100 110 120 130 140 150 160

QRS, мс

мужчины 61-74 года

женщины 56-74 года

Elderly

00,5

11,5

22,5

33,5

44,5

90 100 110 120 130 140 150 160 170 180 190

QRS, мс

мужчины 75-87 лет

женщины 75-87 лет

The greatest range of QRS duration dispersion was observed in the subset of elderly patients, the smallest in the adults subset.

In the subsets of adults and elderly patients, most individuals are men, in the subset of older adults the ratio of men to women is 1:1.

Relationship between AF Forms and QRS DurationRelationship between AF Forms and QRS Duration

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персистирующая ипароксизмальная ФП

постоянная ФП

The ratio between the patients with paroxysmal or persistent AF (light violet bars) and chronic AF (dark violet bars) was 1:2.

An asymmetrical distribution is observed, shifted to the lower values. For the chronic AF subset, the distribution is similar to the normal one. The patients with persistent or paroxysmal AF are in the range within 91 to 100 ms.

Relationship between HR and QRS DurationRelationship between HR and QRS Duration

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тахи

нормо

бради

The ratio between the subsets with bradycardic (white bars), normal (dark violet bars) and tachycardic (light violet bars) AF was 1:6:5 respectively.

The greatest range of QRS duration was for “normal” AF (between 70 and 190 ms), the smallest for bradycardic AF (between 100 and 170 ms).

For normal and tachycardic AF, an asymmetrical distribution is observed, shifted to the lower values; for bradycardia, the distribution is more even throughout the range.

Relationship between the Time of Evolution of AF Relationship between the Time of Evolution of AF and QRS Durationand QRS Duration

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менее 10 лет

10 лет и более

The ratio between the patients with AF of less than 10 years (light violet bars) and of more than 10 years (dark violet bars) of evolution was 4:1.

In the subset of less than 10 years of evolution, the range of QRS dispersion was broader, in the subset of more than 10 years, narrower.

The distribution in both subsets was asymmetrical, shifted to the lower values.

Relationship between the Functional Class of HR Relationship between the Functional Class of HR and QRS Durationand QRS Duration

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СН І ФК

СН ІІ ФК

СН ІІІ ФК

The ratio between the patients with FC I (light violet bars), FC II (dark violet bars) and FC III (white bars) HR was 1:3:2, respectively.

While the FC advances, QRS duration increases (the maximal QRS duration increases from 140 to 190 ms).

The distributions in all subsets are asymmetrical, shifted to the lower values.

Relationship between the LV Ejection Fraction and Relationship between the LV Ejection Fraction and QRS DurationQRS Duration

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20-43%

44-66 %

67-88 %

The ratio between the patients with ejection fraction of 20-43%, 44-66%, and 67-88% was 1:4:2, respectively.As QRS duration increases, the ejection fraction decreases.The maximal QRS duration was observed in the subset with the ejection fraction of 44-66%.The distributions in all subsets are asymmetrical with a shift to lower values.

Relationship between Functional Class of Stable Relationship between Functional Class of Stable Chronic Angina and QRS DurationChronic Angina and QRS Duration

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І ФК

ІІ ФК

ІІІ ФК

The ratio between patients with FC I, FC II, and FC III was 1:3:4, respectively. While the FC increases, QRS duration increases (its maximal values increase from 120 to 180 ms).

The distributions in all subsets are asymmetrical with a shift to lower values.

Relationship between Blood Pressure and QRS DurationRelationship between Blood Pressure and QRS Duration

Systolic BP

02468

1012141618

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нормальное САД

мягкая АГ

умеренная АГ

тяжелая АГ

The ratio between patients without HBP (light violet bars) and with a mild (dark violet bars), moderate (white bars), and severe increase (light blue bars) of systolic BP was 5:3:2:1, respectively.The ratio between patients without HBP and with mild, moderate, and severe increase of diastolic BP was 5:2:2:1.

The maximal duration of QRS is observed in patients with moderate and severe HBP, according to their systolic BP, and moderate HBP, according to their diastolic BP.

The distributions of systolic and diastolic BP are asymmetrical with a shift to lower values.

Diastolic BP

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нормальное ДАД

мягкая АГ

умеренная АГ

тяжелая АГ

Relationship between History of AMI and QRS Relationship between History of AMI and QRS DurationDuration

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с ИМ

без ИМ

The ratio between the patients with history of AMI (light violet bars) and without it (dark violet bars) was 1:8.

The distributions in all the subsets are asymmetrical with a shift to lower values.

Relationship between History of Stroke and QRS Relationship between History of Stroke and QRS DurationDuration

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с инсультом

без инсульта

The relationship between the patients with history of stroke (light violet bars) and without it (dark violet bars) was 1:8.

The distributions in all subsets are asymmetrical with a shift to lower values.

Conclusions Conclusions

In the patients studied, the dispersion of the QRS duration range was In the patients studied, the dispersion of the QRS duration range was between 65 and 190 ms.between 65 and 190 ms.No narrow complexes were seen, while in turn, broad complexes were No narrow complexes were seen, while in turn, broad complexes were found in half of the patientsfound in half of the patients..The distributions of QRS duration were asymmetrical with a shift to lower The distributions of QRS duration were asymmetrical with a shift to lower valuesvalues.The greatest variability of QRS duration was observed in the following The greatest variability of QRS duration was observed in the following subsets: men, elderly patients, persistent and paroxysmal AF, “normal” AF, subsets: men, elderly patients, persistent and paroxysmal AF, “normal” AF, AF with no more than 10 years of evolution, FC III of heart failure, LV AF with no more than 10 years of evolution, FC III of heart failure, LV ejection fraction of 44-66%, FC III of stable chronic angina, moderate HBP, ejection fraction of 44-66%, FC III of stable chronic angina, moderate HBP, no history of AMI or strokeno history of AMI or stroke.The greatest variability of QRS duration was observed in the following subsets: women, older adults, chronic AF, bradycardic AF, AF of more than 10 years of evolution, FC I of heart failure, LV ejection fraction of 67-88%, FC I of stable chronic angina, mild HBP with history of AMI without stroke.While QRS duration increases, the FC of heart failure and the severity of HBP increase, and the LV ejection fraction decreases.It is important to consider the QRS duration in AF diagnosis.. QRS duration changes may reflect the effectiveness of therapeutic stepsQRS duration changes may reflect the effectiveness of therapeutic steps..