Incremental diagnostic and prognostic value of the QRS-T angle, a 12-lead ECG marker quantifying heterogeneity of depolarization and repolarization, in patients with suspected non-ST-elevation myocardial infarction.

Strebel, Ivo; Twerenbold, Raphael; Wussler, Desiree; Boeddinghaus, Jasper; Nestelberger, Thomas; du Fay de Lavallaz, Jeanne; Abächerli, Roger; Maechler, Patrick; Mannhart, Diego; Kozhuharov, Nikola; Rubini Giménez, Maria; Wildi, Karin; Sazgary, Lorraine; Sabti, Zaid; Puelacher, Christian; Badertscher, Patrick; Keller, Dagmar I; Miró, Òscar; Fuenzalida, Carolina; Calderón, Sofia; ... (2019). Incremental diagnostic and prognostic value of the QRS-T angle, a 12-lead ECG marker quantifying heterogeneity of depolarization and repolarization, in patients with suspected non-ST-elevation myocardial infarction. International journal of cardiology, 277, pp. 8-15. Elsevier 10.1016/j.ijcard.2018.09.040

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BACKGROUND

The value of the 12-lead ECG in the diagnosis of non-ST-elevation myocardial infarction (NSTEMI) is limited due to insufficient sensitivity and specificity of standard ECG criteria. The QRS-T angle reflects depolarization-repolarization heterogeneity and might assist in detecting patients with a NSTEMI (diagnosis) as well as predicting patients with an increased mortality risk (prognosis).

METHODS

We prospectively enrolled 2705 consecutive patients with symptoms suggestive of NSTEMI. The QRS-T angle was automatically derived from the standard 10 s 12-lead ECG recorded at presentation to the ED. Patients were followed up for all-cause mortality for 2 years.

RESULTS

NSTEMI was the final diagnosis in 15% (n = 412) of patients. QRS-T angles were significantly greater in patients with NSTEMI compared to those without (p < 0.001). The use of the QRS-T angle in addition to standard ECG criteria indicative of ischemia improved the diagnostic accuracy for NSTEMI as quantified by the area under the ROC curve from 0.68 to 0.72 (p < 0.001). An algorithm for the combined use of standard ECG criteria and the QRS-T angle improved the sensitivity of the ECG for NSTEMI from 45% to 78% and the specificity from 86% to 91% (p < 0.001 for both comparisons). The 2-year survival rates were 98%, 97% and 87% according to QRS-T angle tertiles (p < 0.001).

CONCLUSION

In patients with suspected NSTEMI, the QRS-T angle derived from the standard 12-lead ECG provides incremental diagnostic accuracy on top of standard ECG criteria indicative of ischemia, and independently predicts all-cause mortality during 2 years of follow-up.

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