Annals of the Russian academy of medical sciencesAnnals of the Russian academy of medical sciencesВестник Российской академии медицинских наук0869-60472414-3545"Paediatrician" Publishers LLC147810.15690/vramn1478CARDIOLOGY AND CARDIOVASCULAR SURGERY: CURRENT ISSUESАКТУАЛЬНЫЕ ВОПРОСЫ КАРДИОЛОГИИ И СЕРДЕЧНО-СОСУДИСТОЙ ХИРУРГИИResearch ArticleQRS-Fragmentation: Perspectives for Use in Clinical PracticeФрагментация QRS-комплексов — перспективы использования в клинической практикеhttps://orcid.org/0000-0003-4040-29712764-7250FedulaevYuri N.ФедулаевЮрий Николаевич
Russian Federation

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

доктор медицинских наук, профессор, заведующий кафедрой факультетской терапии педиатрического факультета

kuwert@yandex.ruhttps://orcid.org/0000-0001-5127-1300ABE-1969-20203525-1775MakarovaIrina V.МакароваИрина Владимировна
Russian Federation

assistant, Department of Faculty Therapy

ассистент кафедры факультетской терапии педиатрического факультета

irina-makarova93@mail.ruhttps://orcid.org/0000-0002-7877-44071940-2017PinchukTatiana V.ПинчукТатьяна Витальевна
Russian Federation

MD, PhD, Department of Faculty Therapy

кандидат медицинских наук, доцент кафедры факультетской терапии

doktor2000@inbox.ruhttps://orcid.org/0000-0002-4503-62801333-2511ChuvarayanGrigoriy A.ЧувараянГригорий Асватурович
Russian Federation

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

кандидат медицинских наук, доцент кафедры факультетской терапии педиатрического факультета; заведующий отделением рентгенэндоваскулярных методов диагностики и лечения

grigoriy.chuvarayan@gmail.comPirogov Russian National Research Medical UniversityРоссийский национальный исследовательский медицинский университет имени Н.И. ПироговаCity Clinical Hospital №13Городская клиническая больница № 13030920217632792861311202030062021Copyright ©; 2021, "Paediatrician" Publishers LLCCopyright ©; 2021, Издательство "Педиатръ"2021"Paediatrician" Publishers LLCИздательство "Педиатръ"https://vestnikramn.spr-journal.ru/jour/about/submissionshttps://vestnikramn.spr-journal.ru/jour/article/view/1478

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.

Представлен первый русскоязычный обзор основных публикаций, посвященных возможностям и перспективам оценки нового ЭКГ-параметра — фрагментации QRS-комплексов (fQRS) — у пациентов с различными формами ишемической болезни сердца. Приводятся диагностические критерии fQRS, освещаются результаты сравнительного и корреляционного анализа fQRS с ключевыми электрокардиографическими (патологические зубцы Q), эхокардиографическими и ангиографическими параметрами, подчеркивается негативное прогностическое значение показателя при стабильной ишемической болезни сердца и в случае развития острого инфаркта миокарда. Наличие fQRS в целом ассоциируется с осложненным течением ИБС, высоким риском развития жизнеугрожающих аритмий, повторных сердечно-сосудистых катастроф, ростом общей и сердечно-сосудистой смертности как в краткосрочной перспективе, так и в отдаленном периоде. Авторы считают необходимым обратить внимание на перспективность внедрения метода оценки fQRS в реальную клиническую практику. Определение показателя проводится на основании стандартной ЭКГ, что не требует дополнительных материальных ресурсов и оборудования и в то же время позволяет улучшить неинвазивную диагностику и стратификацию риска у пациентов с атеросклеротическим поражением коронарных артерий на амбулаторном и стационарном этапах.

electrocardiographycoronary diseasemyocardial infarctionprognosisэлектрокардиографияишемическая болезнь сердцаинфаркт миокардапрогнозBaldassarre 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/ijerph17144975Reichlin 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.2016.14303Knuuti 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/ehz425Стабильная 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.pdfМангушева 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: 10.32000/2072-1757-2019-2-15-20Ari 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/s00380-011-0121-9Attachaipanich 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.12593Das 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.2007.06.024El-Sherif N. The rsR’ pattern in left surface leads in ventricular aneurysm. Heart. 1970;32:440–448. doi: https://doi.org/10.1136/hrt.32.4.440Varriale 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-FDas 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.107.763284Dabbagh 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.a2014.0242Das 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.105.595892Das 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.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.2016.12.008Jain 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/10.2174/1573403x10666140514103451Supreeth 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.2019.12.005Bonakdar 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.2015.5887Wang 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.xCarey 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.2010.02.011Tusun 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.12289Korkmaz 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.2017.01.005Yilmaz 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.2013.0181Hung 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/s12350-018-01546-2Yan 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.2012.01.007Allatar 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.2015.07.003Torigoe 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.2011.09.003Xu 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/s00059-014-4155-5Das 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.2009.07.046Lorgis 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.2013.11.026Hizal 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.12011Daszyk 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.a2015.0251Akgul 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.12179Bekler 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.2014.79438Bozbeyoğlu 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.12314Güngör 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.12357Guo 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/s00059-012-3603-3Redfors 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.2017.10.051Uslu 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.12180Sheng 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.B1300091Stavileci 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.12133Yildirim 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.890201Zhao 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).20170903ATanriverdi 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.12265Pietrasik 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.