QRS-Fragmentation: Perspectives for Use in Clinical Practice

Cover Page

Cite item

Full Text

Open Access Open Access
Restricted Access Access granted
Restricted Access Subscription or Fee Access


The current article provides a detail review of foreign publications, discussing the opportunities and the benefits of evaluation of the QRS-fragmentation (fQRS) — a new electrocardiographic (ECG) parameter in patients with coronary artery disease (CAD). Diagnostic criteria for narrow and wide QRS-complexes are defined. Main results of the comparative and correlation analysis, evaluating fQRS and electrocardiographic (pathologic Q-waves), echocardiographic (left ventricular ejection fraction), angiographic settings are described. There is a discussion of the prognostic role of fQRS in stable CAD as well as in patients presented with acute myocardial infarction. fQRS is an available ECG-marker of local myocardial fibrosis. It seems to be a useful negative predictor in individuals with CAD, indicating an increased risk of life-threatening ventricular arrhythmias and recurrent cardiac events. The presence of fragmented QRS-complexes is associated with an increased in-hospital and long term (overall as well as cardiovascular) mortality. Routine evaluation of fQRS in standard ECG leads does not require additional resources, and will contribute to an improvement in diagnostics and risk stratification of stable CAD as well as myocardial infarction. Assessment of fQRS can be included in noninvasive diagnostic algorithm concerning CAD.

Full Text

Restricted Access

About the authors

Yuri N. Fedulaev

Pirogov Russian National Research Medical University

Email: kuwert@yandex.ru
ORCID iD: 0000-0003-4040-2971
SPIN-code: 2764-7250

MD, PhD, Professor, Head of the Department of Faculty Therapy

Russian Federation, 1 Ostrovitianov street, Moscow, 117997

Irina V. Makarova

Pirogov Russian National Research Medical University

Author for correspondence.
Email: irina-makarova93@mail.ru
ORCID iD: 0000-0001-5127-1300
SPIN-code: 3525-1775
ResearcherId: ABE-1969-2020

assistant, Department of Faculty Therapy

Russian Federation, 1 Ostrovitianov street, Moscow, 117997

Tatiana V. Pinchuk

Pirogov Russian National Research Medical University

Email: doktor2000@inbox.ru
ORCID iD: 0000-0002-7877-4407
SPIN-code: 1940-2017

MD, PhD, Department of Faculty Therapy

Russian Federation, 1 Ostrovitianov street, Moscow, 117997

Grigoriy A. Chuvarayan

Pirogov Russian National Research Medical University; City Clinical Hospital №13

Email: grigoriy.chuvarayan@gmail.com
ORCID iD: 0000-0002-4503-6280
SPIN-code: 1333-2511

MD, PhD; Head of Department of X-ray endovascular diagnosis and treatment

Russian Federation, 1 Ostrovitianov street, Moscow, 117997; 1/1 Velozavodskaja street, Moscow, 115280


  1. Baldassarre A, Mucci N, Padovan M, et al. The Role of Electrocardiography in Occupational Medicine, from Einthoven’s Invention to the Digital Era of Wearable Devices. Int J Environ Res Public Health. 2020;17(14):4975. doi: https://doi.org/10.3390/ijerph17144975
  2. Reichlin T, Abächerli R, Twerenbold R, et al. Advanced ECG in 2016: is there more than just a tracing? Swiss Med Wkly. 2016;146:w14303. doi: https://doi.org/10.4414/smw.2016.14303
  3. Knuuti J, Wijns W, Achenbach S, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407–477. doi: https://doi.org/10.1093/eurheartj/ehz425
  4. Стабильная ишемическая болезнь сердца: клинические рекомендации. Минздрав России, 2020. [Stabil’naja ishemicheskaja bolezn’ serdca: Klinicheskie rekomendacii. Ministerstvo zdravoohranenija Rossijskoj Federacii, 2020. (In Russ.)] Available from: https://scardio.ru/content/Guidelines/2020/Clinic_rekom_IBS.pdf
  5. Мангушева М.М., Маянская С.Д., Исхакова Г.Г. К вопросу о трудностях ЭКГ диагностики инфаркта миокарда // Практическая медицина. — 2019. — Т. 17. — № 2. — С. 15–20. [Mangusheva MM, Majanskaja SD, Ishakova GG. The question of the difficulties of ECG diagnosis of myocardial infarction. Practical Medicine. 2019;17(2):15–20. (In Russ.)] doi: 10.32000/2072-1757-2019-2-15-20
  6. Ari H, Cetinkaya S, Ari S, et al. The prognostic significance of a fragmented QRS complex after primary percutaneous coronary intervention. Heart Vessels. 2012;27(1):20–28. doi: https://doi.org/10.1007/s00380-011-0121-9
  7. Attachaipanich T, Krittayaphong R. Fragmented QRS as a predictor of in-hospital life-threatening arrhythmic complications in ST-elevation myocardial infarction patients. Ann Noninvasive Electrocardiol. 2019;24(1):e12593. doi: https://doi.org/10.1111/anec.12593
  8. Das MK, Saha C, El Masry H, et al. Fragmented QRS on a 12-lead ECG: A predictor of mortality and cardiac events in patients with coronary artery disease. Heart Rhythm. 2007;4:1385–1392. doi: https://doi.org/10.1016/j.hrthm.2007.06.024
  9. El-Sherif N. The rsR’ pattern in left surface leads in ventricular aneurysm. Heart. 1970;32:440–448. doi: https://doi.org/10.1136/hrt.32.4.440
  10. Varriale P, Chryssos BE. The RSR′ complex not related to right bundle branch block: Diagnostic value as a sign of myocardial infarction scar. Am Heart J. 1992;123(2):369–376. doi: https://doi.org/10.1016/0002-8703(92)90648-F
  11. Das MK, Suradi H, Maskoun W, et al. Fragmented wide QRS on a 12-lead ECG: a sign of myocardial scar and poor prognosis. Circulation. Arrhythmia and Electrophysiology. 2008;1(4):258–268. doi: https://doi.org/10.1161/CIRCEP.107.763284
  12. Dabbagh Kakhki VR, Ayati N, Zakavi SR, et al. Comparison between fragmented QRS versus Q wave in myocardial scar detection using myocardial perfusion single photon emission computed tomography. Kardiol Pol. 2015;73:437–444. doi: https://doi.org/10.5603/KP.a2014.0242
  13. Das MK, Khan B, Jacob S, et al. Significance of a fragmented QRS complex versus a Q wave in patients with coronary artery disease. Circulation. 2006;113(21):2495–2501. doi: https://doi.org/10.1161/CIRCULATIONAHA.105.595892
  14. Das MK, Saha C, El Masry H, et al. Fragmented QRS on a 12-lead ECG: A predictor of mortality and cardiac events in patients with coronary artery disease. Heart Rhythm. 2007;4:1385–1392. doi: https://doi.org/10.1016/j.hrthm.2007.06.024.
  15. Illescas-González E, Araiza-Garaygordobil D, Sierra Lara JD, et al. QRS-fragmentation: Case report and review of the literature. Arch Cardiol Mex. 2018;88(2):124–128. doi: https://doi.org/10.1016/j.acmx.2016.12.008
  16. Jain R, Singh R, Yamini S, Das MK. Fragmented ECG as a Risk Marker in Cardiovascular Diseases. Current Cardiology Reviews. 2014;10(3):277–286. doi: https://doi.org/10.2174/1573403x10666140514103451
  17. Supreeth RN, Francis J. Fragmented QRS — Its significance. Indian Pacing and Electrophysiology Journal. 2020;20(1):27–32. doi: https://doi.org/10.1016/j.ipej.2019.12.005
  18. Bonakdar H, Moladoust H, Kheirkhah J, et al. Significance of a fragmented QRS complex in patients with chronic total occlusion of coronary artery without prior myocardial infarction. Anatol J Cardiol. 2016;16(2):106–112. doi: https://doi.org/10.5152/akd.2015.5887
  19. Wang DD, Buerkel DM, Corbett JR, Gurm HS. Fragmented QRS complex has poor sensitivity in detecting myocardial scar. Ann Noninvasive Electrocardiol. 2010;4(15):308–314. doi: https://doi.org/10.1111/j.1542-474X.2010.00385.x
  20. Carey MG, Luisi AJ, Baldwa S, et al. The Selvester QRS Score is more accurate than Q waves and fragmented QRS complexes using the Mason-Likar configuration in estimating infarct volume in patients with ischemic cardiomyopathy. J Electrocardiol. 2010;(43):318–325. doi: https://doi.org/10.1016/j.jelectrocard.2010.02.011
  21. Tusun E, Ilter A, Besli F, et al. Fragmented QRS Is Associated with Improved Predictive Value of Exercise Treadmill Testing in Patients with Intermediate Pretest Likelihood of Significant Coronary Artery Disease. Ann Noninvasive Electrocardiol. 2016;2(21):196–201. doi: https://doi.org/10.1111/anec.12289
  22. Korkmaz A, Yildiz A, Demir M, et al. The relationship between fragmented QRS and functional significance of coronary lesions. J Electrocardiol. 2017;3(50):282–286. doi: https://doi.org/10.1016/j.jelectrocard.2017.01.005
  23. Yilmaz H, Gungor B, Kemaloglu T, et al. The presence of fragmented QRS on 12-lead ECG in patients with coronary slow flow. Kardiol Pol. 2014;72(1):14–19. doi: https://doi.org/10.5603/KP.2013.0181
  24. Hung CL, Verma A, Uno H, Shin SH, et al. Longitudinal and circumferential strain rate, left ventricular remodeling, and prognosis after myocardial infarction. J Am Coll Cardiol. 2010;56(22):1812–1822. doi: https://doi.org/10.10 07/s12350-018-01546-2
  25. Yan GH, Wang M, Yiu KH, et al. Subclinical left ventricular dysfunction revealed by circumferential 2D strain imaging in patients with coronary artery disease and fragmented QRS complex. Heart Rhythm. 2012;9(6):928–935. doi: https://doi.org/10.1016/j.hrthm.2012.01.007
  26. Allatar F, Imran N, Shamoon F. Fragmented QRS and ejection fraction in heart failure patients admitted to the hospital. IJC Heart and Vasculature. 2015;9:11–14. doi: https://doi.org/10.1016/j.ijcha.2015.07.003
  27. Torigoe K, Tamura A, Kawano Y, et al. The number of leads with fragmented QRS is independently associated with cardiac death or hospitalization for heart failure in patients with prior myocardial infarction. J Cardiol. 2012;1(59):36–41. doi: https://doi.org/10.1016/j.jjcc.2011.09.003
  28. Xu Y, Qiu Z, Xu Y, et al. The role of fQRS in coronary artery disease. A meta-analysis of observational studies. Herz. 2015;40(Suppl1):8–15. doi: https://doi.org/10.1007/s00059-014-4155-5
  29. Das MK, Michael MA, Suradi H, et al. Usefulness of fragmented QRS on a 12-lead electrocardiogram in acute coronary syndrome for predicting mortality. Am J Cardiol. 2009;104(12):1631–1637. doi: https://doi.org/10.1016/j.amjcard.2009.07.046
  30. Lorgis L, Cochet A, Chevallier O, et al. Relationship between fragmented QRS and no-reflow, infarct size, and peri-infarct zone assessed using cardiac magnetic resonance in patients with myocardial infarction. Can J Cardiol. 2014;2(30):204–210. doi: https://doi.org/10.1016/j.cjca.2013.11.026
  31. Hizal Erdem F, Tavil Y, Yazici H, et al. Association of fragmented QRS complex with myocardial reperfusion in acute ST-elevated myocardial infarction. Ann Noninvasive Electrocardiol. 2013;18(1):69–74. doi: https://doi.org/10.1111/anec.12011
  32. Daszyk AM, Zygmund K, Mitrȩga KA, et al. Fragmentation of the QRS complex in patients with acute coronary syndrome treated invasively. Kardiol Pol. 2016;7(74):644–649. doi: https://doi.org/10.5603/KP.a2015.0251
  33. Akgul O, Uyarel H, Pusuroglu H, et al. Predictive value of a fragmented QRS complex in patients undergoing primary angioplasty for ST elevation myocardial infarction. Ann Noninvasive Electrocardiol. 2015;20(3):263–272. doi: https://doi.org/10.1111/anec.12179
  34. Bekler A, Gazi E, Erbağ G, et al. ST yükselmesiz miyokart enfarktüslü hastalarda başvurudaki 12-derivasyonlu elektrokardiyografide fragmente QRS varliği ile uzun dönem mortalite arasindaki ilişki [Relationship between presence of fragmented QRS on 12-lead electrocardiogram on admission and long-term mortality in patients with non-ST elevated myocardial infarction. (In Turkish)]. Turk Kardiyol Dern Ars. 2014;42(8):726–732. doi: https://doi.org/10.5543/tkda.2014.79438
  35. Bozbeyoğlu E, Yıldırımtürk Ö, Yazıcı S, et al. Fragmented QRS on Admission Electrocardiography Predicts Long-Term Mortality in Patients with Non-ST-Segment Elevation Myocardial Infarction. Ann Noninvasive Electrocardiol. 2016;21(4):352–357. doi: https://doi.org/10.1111/anec.12314
  36. Güngör B, Özcan KS, Karataş MB, et al. Prognostic Value of QRS Fragmentation in Patients with Acute Myocardial Infarction: A Meta-Analysis. Ann Noninvasive Electrocardiol. 2016;21(6):604–612. doi: https://doi.org/10.1111/anec.12357
  37. Guo R, Zhang J, Li Y, et al. Prognostic significance of fragmented QRS in patients with non-ST elevation myocardial infarction: results of a 1-year, single-center follow-up. Herz. 2012;37(7):789–795. doi: https://doi.org/10.1007/s00059-012-3603-3
  38. Redfors B, Kosmidou I, Crowley A, et al. Prognostic significance of QRS fragmentation and correlation with infarct size in patients with anterior ST-segment elevation myocardial infarction treated with percutaneous coronary intervention: Insights from the INFUSE-AMI trial. Int J Cardiol. 2018;253:20–24. doi: https://doi.org/10.1016/j.ijcard.2017.10.051
  39. Uslu N, Gul M, Cakmak HA, et al. The assessment of relationship between fragmented QRS complex and left ventricular wall motion score index in patients with ST elevation myocardial infarction who underwent primary percutaneous coronary intervention. Ann Noninvasive Electrocardiol. 2015;20(2):148–157. doi: https://doi.org/10.1111/anec.12180
  40. Sheng QH, Hsu CC, Li JP, et al. Correlation between fragmented QRS and the short-term prognosis of patients with acute myocardial infarction. J Zhejiang Univ Sci B. 2014;15(1):67–74. doi: https://doi.org/10.1631/jzus.B1300091
  41. Stavileci B, Cimci M, Ikitimur B, et al. Significance and usefulness of narrow fragmented QRS complex on 12-lead electrocardiogram in acute ST-segment elevation myocardial infarction for prediction of early mortality and morbidity. Ann Noninvasive Electrocardiol. 2014;19(4):338–344. doi: https://doi.org/10.1111/anec.12133
  42. Yildirim E, Karaçimen D, Özcan KS, et al. The relationship between fragmentation on electrocardiography and in-hospital prognosis of patients with acute myocardial infarction. Med Sci Monit. 2014;20:913–919. doi: https://doi.org/10.12659/MSM.890201
  43. Zhao Q, Zhang R, Hou J, Yu B. Relationship between Fragmented QRS and NT-proBNP in Patients with ST Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention. Acta Cardiol Sin. 2018;34(1):13–22. doi: https://doi.org/10.6515/ACS.201801_34(1).20170903A
  44. Tanriverdi Z, Dursun H, Simsek MA, et al. The Predictive Value of Fragmented QRS and QRS Distortion for High-Risk Patients with STEMI and for the Reperfusion Success. Ann Noninvasive Electrocardiol. 2015;20(6):578–585. doi: https://doi.org/10.1111/anec.12265
  45. Pietrasik G, Goldenberg I, Zdzienicka J, et al. Prognostic significance of fragmented QRS complex for predicting the risk of recurrent cardiac events in patients with Q-wave myocardial infarction. Am J Cardiol. 2007;100(4):583–586. doi: https://doi.org/10.1016/j.amjcard.2007.03.063.

Supplementary files

Supplementary Files
1. Fig. 1. Variants of fragmented narrow (A – B) and wide (D) QRS complexes

Download (55KB)
2. Fig. 2. Fragmentation of QRS complexes along the lower wall of the left ventricle (QRS complexes of the RSR´ type in standard lead III, split R waves - in lead aVF)

Download (613KB)
3. Fig. 3. Fragmented QRS complexes in the chest leads in a patient with multivessel coronary artery disease: V4 - S-wave notch; V5-6 - R-wave splitting; writing speed - 50 mm / s

Download (626KB)

Copyright (c) 2021 "Paediatrician" Publishers LLC

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies