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QRS fragmentation in standard ECG as a diagnostic marker of arrhythmogenic right ventricular dysplasia–cardiomyopathy
Abstract
Background Epsilon potentials in right precordial leads are reliable diagnostic electrocardiographic (ECG) criteria of arrhythmogenic right ventricular dysplasia-cardiomyopathy (ARVD/C). Sensitivity of epsilon potentials can be enhanced by highly amplified and modified ECG recording technique. Nevertheless, in many cases the definition of epsilon potentials remains difficult.Objective To overcome these limitations, the value of QRS fragmentation in a standard 12-lead ECG was analyzed in 360 patients with ARVD/C (176 men, mean age 47.3 +/- 13.7 years).Methods Analysis of QRS fragmentation of the whole collective of patients was compared with the detection of epsilon potentials in highly amplified right precordial and modified limb leads in a subgroup of 207 patients. Fifty-two phenotypically and genotypically nonaffected subjects from systematic family screening in 10 families with known plakophilin-2 and desmoplakin mutations served as a control group.Results QRS fragmentation could be found in a total of 306 of 360 patients (85%); 2.09 +/- 1.8 fragmented QRS complexes (range 1 to 7) could be found per patient. Fragmented QRS complexes in only 1 right precordial lead were found in 106 cases. In 190 cases, QRS fragmentation was present in more than 1 lead, including all 12 standard leads. Epsilon potentials in highly amplified right precordial and modified limb leads could be found in a total of 159 cases (77%). Typical epsilon potentials in highly amplified right precordial leads could be found in 97 cases (47%).Conclusion QRS fragmentation in ARVD/C has a high diagnostic value similar to epsilon potentials by a highly amplified and modified recording technique.
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“QRS fragmentation in patients with arrhythmogenic right ventricular dysplasia was shown to have a high diagnostic value similar to epsilon potentials by a highly amplified and modified recording technique.48”
From The Year of 2008 in Electrocardiology (2010) · cites this paper as [48]
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“Clinically, fQRS has been associated with an increased mortality risk in patients with acute myocardial infarction,(9) higher rates of spontaneous ventricular fibrillation among patients with Brugada syndrome,(10) and to be of comparable prognostic value as epsilon potentials among patients with arrhythmogenic right v…”
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MethodAblation of Ventricular Arrhythmias in Arrhythmogenic Right Ventricular Dysplasia
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“This can cause QRS complex fragmentation or prolongation and could predispose to the trigger of ventricular arrhythmias (61, 62).”
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“All rights rese respectively, of patients with ARVC [17,29].”
BackgroundElectrocardiographic abnormalities in patients with cardiomyopathies
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“…a ti on w it h L G E p r e s e n ce [ 102 ] AC M F i b r o -f a tt y r e p l ace m e n t i n t h e s ub e p i ca r d i a l r e g i on o f t h e R V fr ee w a ll 85 % [ 103 ] Q R S fr a g m e n t a ti on : h i gh e r r i s k o f V T , V F , a nd a pp r op r i a t e I C D d i s c h a r g e s [ 78 ] .”
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Fragmented QRS complex is a diagnostic tool in patients with left ventricular diastolic dysfunction
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“The fQRS is also a diagnostic marker of arrhythmogenic right ventricular cardiomyopathy and Brugada syndrome [7, 8].”
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“syndrome,(17) it also has been defined as a marker of arrhythmogenic right ventricular cardiomyopathy (ARVC).(18) However, no data is available regarding fQRS in patients with LVNC.”
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“Inferior fQRS has also been observed in other RV afflicted pathologies including arrhythmogenic right ventricular dysplasia/cardiomyopathy [25] and ostium secundum atrial septal defect [26].”
BackgroundQRS Fragmentation Is Not Associated with Poor Response to Cardiac Resynchronization Therapy
Rickard, J., Zardkoohi, O., Popović, Z., Verhaert, D., Sraow, D. I., Baranowski, B. J., Martin, D. O., Grimm, R. A., Chung, M. K., TCHOU, P. J., et al. (2011) · Annals of Noninvasive Electrocardiology · doi:10.1111/j.1542-474x.2011.00424.x · Cited by 23
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“There were many reports using fQRS as an index to detect various cardiac structural abnormalities such as the arrhythmogenic right ventricular dysplasia (ARVD) (Peters et al., 2008; Das and El Masry, 2010; Zhou et al., 2011).”
MethodAn unusual case of cardiac glycoside toxicity
Kassop, D., Donovan, M. S., Cohee, B. M., Mabe, D. L., Wedam, E. F., & Atwood, J. E. (2013) · International Journal of Cardiology · doi:10.1016/j.ijcard.2013.11.019 · Cited by 21
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An overlap of Brugada syndrome and arrhythmogenic right ventricular cardiomyopathy/dysplasia
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“…end-diastolic volume (index), LVESV(I)¼ left ventricular end-systolic volume(index), QTc¼corrected QT interval, RMS40¼root-mean-square voltage of terminal 40 ms, RV¼right ventricle, RVEF¼right ventricular ejection fraction, RVEDV(I)¼right ventricular end-diastolic volume(index), RVESV(I)¼right…”
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Epsilon waves: Milestones in the discovery and progress
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“reported fQRS in 59% of ACM patients [8,9].”
BackgroundMethodResultInfluentialHumanized Dsp ACM Mouse Model Displays Stress-Induced Cardiac Electrical and Structural Phenotypes
Stevens, T. L., Manring, H. R., Wallace, M. J., Argall, A. D., Dew, T., Papaioannou, P., Antwi-Boasiako, S., Xu, X., Campbell, S. G., Akar, F. G., et al. (2022) · Cells · doi:10.3390/cells11193049 · Cited by 18
“Importantly, fQRS has been linked to prolonged QT, and both fQRS and inverted T waves are considered diagnostic parameters for both myocardial scarring and ACM [44,45].”
BackgroundFragmented QRS Can Predict Severity of Aortic Stenosis
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Fragmented QRS Complexes—A Novel but Underutilized Electrocardiograhic Marker of Heart Disease
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The fragmented QRS: does it really indicate a ventricular abnormality?
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Baranchuk, A. M., Femenía, F., Diez, J. C. L., Muratore, C. A., Valentino, M., Retyk, E., Galizio, N. O., Toro, D. D., Alonso, K., Hopman, W. M., et al. (2013) · Annals of Noninvasive Electrocardiology · doi:10.1111/anec.12077 · Cited by 17
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Self-citationClinical importance of lead aVR in arrhythmogenic cardiomyopathy
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“ECG changes in lead aVR are additional markers of arrhythmogenic cardiomyopathy in association with other ECG criteria like epsilon waves, Twave inversions [6], localised rightprecordialQRSprolongation [7] and QRS fragmentation [8].”
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“[1] Since then, this ECG sign, a novel marker of ventricular depolarization abnormalities, has also been studied in patients with other heart diseases including arrhythmogenic right ventricular cardiomyopathy,[2] nonischemic dilated cardiomyopathy,[3] rheumatic valve disease,[4] and Brugada syndrome.”
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“On the other hand, fQRS is not specific for coronary artery disease and has also been observed in other myocardial diseases associated with arrhythmias, such as dilated cardiomyopathy (16, 17), Chagas’ disease (18), ion channel disease such as Brugada (19) and long QT syndrome (20), some congenital heart diseases such…”
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Fontaine, G. H. (2011) · European Heart Journal · doi:10.1093/eurheartj/ehr088 · Cited by 15
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“QRS fragmentation has been proposed as an alternative to high-amplification ECG-detected epsilon waves as a marker of depolarization abnormalities in ‘RV-dominant’ ACM.(8) QRS fragmentation may be useful in LV-dominant ACM, particularly in DSP-related ACM, in which it could be a marker of arrhythmogenic fibrosis invol…”
BackgroundInfluentialElectrocardiographic Smoke Signals of Fragmented QRS Complex
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“2007), arrhythmogenic right ventricular dysplasia/cardiomyopathy (Peters et al. 2008) and Brugada syndrome (Morita et al.”
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Gender differences in prevalence and prognostic value of fragmented QRS complex
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“However, the fQRS is not specific marker for CAD as it is commonly seen in nonischemic cardiac diseases aswell [9,10].”
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Self-citationElectrocardiographic Markers of Sudden Cardiac Death (Including Left Ventricular Hypertrophy)
Pérez‐Riera, A. R., Barbosa‐Barros, R., & Shenasa, M. (2017) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2017.07.011 · Cited by 13
“fQRS in ARVC/D has a high diagnostic value, similar to epsilonwavepotentials by ahighly amplified and modified recording technique.(57) Idiopathic dilated cardiomyopathy: In idiopathic dilated cardiomyopathy, approximately 30% of cases have a genetic background and, like HCM, fQRS plays an important marker in identify…”
MethodBatchvarov, V. N., Bastiaenen, R., Postema, P. G., Clark, E., Macfarlane, P. W., Wilde, A. A. M., & Behr, E. R. (2015) · EP Europace · doi:10.1093/europace/euv379 · Cited by 12
“This is in concert with a previous study describing QRS abnormalities (epsilon potentials, QRS fragmentation) in both peripheral and precordial leads in ARVC patients.(12) The inclusion of T wave negativity as the only repolarizationrelated diagnostic sign(1) for ARVC is an oversimplification that ignores Figure 3 Pre…”
ResultPrognostic Significance of Fragmented QRS in Patients with Hypertrophic Cardiomyopathy
Lu, X., Wang, W., Zhu, L., Wang, Y., Sun, K., Zou, Y., Tian, T., Hui, R., Wang, J., Kang, L., et al. (2017) · Cardiology · doi:10.1159/000471845 · Cited by 12
Epsilon Waves Aid in the Prognosis and Risk Stratification of Patients With ARVC/D
Marcus, G. M. (2015) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.12775 · Cited by 11
Kommata, V., Elshafie, M., Sciaraffia, E., Perez, M. D., Augustine, R., & Blomström‐Lundqvist, C. (2021) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.14295 · Cited by 11
The Impact of Obesity on Sudden Cardiac Death Risk
Margolis, G., Elbaz‐Greener, G., Ruskin, J. N., Roguin, A., Amir, O., & Rozen, G. (2022) · Current Cardiology Reports · doi:10.1007/s11886-022-01671-y · Cited by 12
Bae, M. H., Jang, S. Y., Choi, W. S., Kim, K. H., Park, S. H., Lee, J. H., Kim, H.-K., Yang, D. H., Huh, S., Park, H. S., et al. (2013) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2013.02.066 · Cited by 11
Betensky, B. P., Deyell, M. W., Tzou, W. S., Zado, E. S., & Marchlinski, F. E. (2012) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-012-9709-y · Cited by 11
Seong, C. S., Gwag, H. B., Hwang, J. K., Park, S., Park, K., Kim, J. S., & On, Y. K. (2018) · PLoS ONE · doi:10.1371/journal.pone.0194363 · Cited by 11
Ren, L., Liu, Z., Jia, Y., Fang, P., Pu, J., & Zhang, S. (2014) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.12463 · Cited by 10
Fragmented QRS: A simple electrocardiographic prognostic marker in cardiovascular disease
Mittal, S. (2016) · Journal of Clinical and Preventive Cardiology · doi:10.4103/2250-3528.191100 · Cited by 10
Barman, H. A., Durmaz, E., Atıcı, A., Kahyaoğlu, S., Asoğlu, R., Şahin, İ., & İkitimur, B. (2019) · Annals of Noninvasive Electrocardiology · doi:10.1111/anec.12671 · Cited by 11
“Also, increased levels of Galectin‐3 are clearly associated with increased myocardial fibrosis and cardiac arrhythmias (Hiroshi et al., 2008; Peters et al., 2008; Sha et al., 2011).”
BackgroundResultIacoviello, M. (2014) · World Journal of Cardiology · doi:10.4330/wjc.v6.i7.562 · Cited by 8
Peters, S. (2012) · International Journal of Cardiology · doi:10.1016/j.ijcard.2012.04.080 · Cited by 9
Self-citationQRS fragmentation: its role in sherlocking the arrhythmogenic heart
Virk, H. U. H., Farooq, S., Ghani, A. R., & Arora, S. (2016) · Journal of Community Hospital Internal Medicine Perspectives · doi:10.3402/jchimp.v6.31235 · Cited by 9
“modified limb leads in a subgroup of 207 patients (24).”
BackgroundMethodFragmented QRS and ejection fraction in heart failure patients admitted to the hospital
Alattar, F. T., Imran, N., & Shamoon, F. E. (2015) · IJC Heart & Vasculature · doi:10.1016/j.ijcha.2015.07.003 · Cited by 9
“FQRS has also been reported in a variety of cardiac conditions such as ischemic and dilated cardiomyopathy, sarcoidosis, myocarditis, arrhythmogenic ventricular dysplasia [3], and Brugada syndrome.”
BackgroundAlonso, P., Andrés, A., Rueda, J., Fuentes, F. B., Igual, B., Serrano, M. R., Osa, A., Arnau, M. Á., & Salvador, A. (2014) · Revista Española de Cardiología (English Edition) · doi:10.1016/j.rec.2014.04.019 · Cited by 9
“…can take the form of a primary cardiac disorder (such as left ventricular hypertrophy, 12 an acute coronary syndrome, 14 or arrhythmogenic RV dysplasia 15 ), or a secondary disorder, in the context of systemic disease (such as amyloidosis, 15 rheumatoid arthritis, 16 or pulmonary sarcoidosis 17 ).”
BackgroundMethodEmkanjoo, Z., Mollazadeh, R., Alizadeh, A., Kheirkhah, J., Mohammadi, Z., Khalili, M., Azhari, A., & Shahrzad, S. (2014) · Indian Heart Journal · doi:10.1016/j.ihj.2014.12.003 · Cited by 9
“Stefan Peters et al 11,12 described the prevalence and sig-nificance of localized indices of QRS prolongation in ARVC/D patients compared to general population.”
BackgroundConduction abnormalities in arrhythmogenic right ventricular cardiomyopathy
Peters, S. (2013) · International Journal of Cardiology · doi:10.1016/j.ijcard.2013.07.093 · Cited by 9
Self-citationÖzkan, G., Ulusoy, Ş., Bektas, H., Kırış, A., Fidan, M., & Celik, S. (2014) · The Anatolian Journal of Cardiology · doi:10.5152/akd.2014.4886 · Cited by 9
“This association is thought to stem from myocardial scarring, ventricular arrhythmia and structural cardiac defects (7-11).”
BackgroundUlusoy, Ş., Özkan, G., Adar, A., Bektaş, H., Kırış, A., & Çelik, Ş. (2014) · Progress in Transplantation · doi:10.7182/pit2014200 · Cited by 8
Tikkanen, J. T. (2013) · Cited by 7
Ueda, N., Nagase, S., Kataoka, N., Nakajima, K., Kamakura, T., Wada, M., Yamagata, K., Ishibashi, K., Inoue, Y. Y., Miyamoto, K., et al. (2021) · Journal of Arrhythmia · doi:10.1002/joa3.12628 · Cited by 7
Importance of Electrocardiographic Markers in Predicting Cardiac Events in Children
Karadeniz, C. (2020) · Biomarkers in Medicine · doi:10.2217/bmm-2020-0391 · Cited by 6
Roukoz, H., Shah, M. M., Jesuraj, M. L., Thachil, A., Jayakumar, P. K., Benditt, D. G., & Narasimhan, C. (2015) · Indian Heart Journal · doi:10.1016/j.ihj.2015.03.012 · Cited by 6
“It is also associated with increased mortality and arrhythmic events in non-ischemic cardiomyopathyandmoreprevalent in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients.(18,19) In one study, fQRS was associated with cardiac involvement in patients with sarcoidosis.”
BackgroundBae, M. H., Choi, W. S., Kim, K. H., Park, S. H., Kim, H. W., Lee, J. H., Lee, S., Yang, D. H., Park, H. S., Cho, Y., et al. (2012) · International Journal of Cardiology · doi:10.1016/j.ijcard.2012.03.002 · Cited by 6
Alonso, P., Andrés, A., Rueda, J., Fuentes, F. B., Igual, B., Serrano, M. R., Osa, A., Arnau, M. Á., & Salvador, A. (2014) · Revista Española de Cardiología · doi:10.1016/j.recesp.2014.04.021 · Cited by 6
Peters, S. (2016) · International Journal of Cardiology · doi:10.1016/j.ijcard.2016.03.115 · Cited by 6
Self-citationSteger, A., Sinnecker, D., Berkefeld, A., Müller, A., Gebhardt, J., Dommasch, M., Huster, K. M., Barthel, P., & Schmidt, G. P. (2015) · Herzschrittmachertherapie + Elektrophysiologie · doi:10.1007/s00399-015-0390-6 · Cited by 6
The International Criteria for Electrocardiogram Interpretation in Athletes
Petek, B. J., Drezner, J. A., & Churchill, T. W. (2024) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2023.09.006 · Cited by 5
Ay, N. K., Enhoş, A., Ay, Y., Bakhshaliyev, N., Nadir, A., Karaçöp, E., Çelikkale, İ., Uluganyan, M., Ozdemir, R., & Göktekín, Ö. (2018) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2018.07.015 · Cited by 5
QRS COMPLEX FRAGMENTATION — AN IMPORTANT MARKER OF ABNORMAL DEPOLARIZATION
Пармон, Е. В., Gordeeva, M. S., T, T. A. K., & Робертович, Б. Э. (2017) · Russian Journal of Cardiology · doi:10.15829/1560-4071-2017-8-90-95 · Cited by 5
Metadata
- Authors
- Peters, S., Trümmel, M., & Koehler, B.
- Corresponding author
- Peters, Stefan
- ORCID
- Peters, Stefan
- Venue
- Heart Rhythm
- Publisher
- Elsevier BV
- Published
- 2008-10
- Volume
- 5
- Issue
- 10
- Pages
- 1417-1421
- ISSN
- 1547-5271 (ISSN-L)
- OpenAlex
- W1963847400
- Cited by
- 155
- References
- 9
- Citations by year
- 2026: 3 · 2025: 1 · 2024: 4 · 2023: 7 · 2022: 8 · 2021: 7 · 2020: 6 · 2019: 3 · 2018: 9 · 2017: 9 · 2016: 11 · 2015: 15 · 2014: 21 · 2013: 15 · 2012: 18
- FWCI
- 4.37
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Heart Rhythm (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiomyopathy and Myosin Studies
- Keywords
- QRS fragmentation, arrhythmogenic right ventricular cardiomyopathy, electrocardiographic diagnosis, right precordial leads, family screening
- MeSH terms
- Adult, Electrocardiography, Female, Humans, Male, Middle Aged, Biomarkers, Arrhythmogenic Right Ventricular Dysplasia
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