Bundle Branch Blocks and Fragmented QRS Complex in Iranian Patients with Systemic Sclerosis
Background: Cardiac involvement, as one of the life-threatening manifestations of systemic sclerosis (SSc), is chiefly caused by collagen fiber deposition in the myocardium, which subsequently leads to conduction abnormalities. In the present study, we aimed to investigate the prevalence and clinical significance of bundle branch blocks (BBBs) and the fragmented QRS complex (fQRS) in Iranian patients with SSc.
Methods: Forty-one patients with SSc were enrolled from the outpatient SSc clinic of Shariati Hospital, Tehran University of Medical Sciences, between October 2016 and February 2017. Twelve-lead ECG was obtained and interpreted for BBBs and the fQRS. To adjust for the confounding effects of non–SSc-related cardiovascular risk factors, we calculated the Framingham risk score to estimate the risk of cardiovascular diseases. The associations between the studied conduction abnormalities and SSc cutaneous subtypes; disease duration; and the Medsger SSc severity scale of cutaneous, pulmonary, and vascular involvements were also analyzed.
Results: The study population consisted of 41 Iranian patients with SSc at a mean age of 47.48±11.57 years (82.9% female). The prevalence of BBBs and the fQRS was 26.8% and 36.6%, respectively. The fQRS was associated with the limited cutaneous SSc subtype (OR: 0.100, 95%CI: 0.018–0.553, and P=0.028). BBBs and the fQRS were not associated with either the Framingham risk score or the rest of the clinicodemographic variables.
Conclusion: BBBs and the fQRS were more prevalent in our patients with SSc, without any association with the involvement of the other organs. These findings may suggest the independent pathophysiology of cardiac involvement in SSc.
Vacca A, Meune C, Gordon J, Chung L, Proudman S, Assassi S, et al. Cardiac arrhythmias and conduction defects in systemic sclerosis. Rheumatology (Oxford). 2014;53(7):1172-7.
Tyndall AJ, Bannert B, Vonk M, Airo P, Cozzi F, Carreira PE, et al. Causes and risk factors for death in systemic sclerosis: a study from the EULAR Scleroderma Trials and Research (EUSTAR) database. Ann Rheum Dis. 2010;69(10):1809-15.
Assassi S, Del Junco D, Sutter K, McNearney TA, Reveille JD, Karnavas A, et al. Clinical and genetic factors predictive of mortality in early systemic sclerosis. Arthritis Rheum. 2009;61(10):1403-11.
Das MK, Suradi H, Maskoun W, Michael MA, Shen C, Peng J, et al. Fragmented wide QRS on a 12-lead ECG: a sign of myocardial scar and poor prognosis. Circ Arrhythm Electrophysiol. 2008;1(4):258-68.
van den Hoogen F, Khanna D, Fransen J, Johnson SR, Baron M, Tyndall A, et al. 2013 classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis Rheum. 2013;65(11):2737-47.
Medsger TA, Jr., Bombardieri S, Czirjak L, Scorza R, Della Rossa A, Bencivelli W. Assessment of disease severity and prognosis. Clin Exp Rheumatol. 2003;21(3 Suppl 29):S42-6.
Furst DE, Clements PJ, Steen VD, Medsger TA, Jr., Masi AT, D'Angelo WA, et al. The modified Rodnan skin score is an accurate reflection of skin biopsy thickness in systemic sclerosis. J Rheumatol. 1998;25(1):84-8.
D'Agostino RB, Sr., Pencina MJ, Massaro JM, Coady S. Cardiovascular Disease Risk Assessment: Insights from Framingham. Glob Heart. 2013;8(1):11-23.
Lambova S. Cardiac manifestations in systemic sclerosis. World J Cardiol. 2014;6(9):993-1005.
Terho HK, Tikkanen JT, Junttila JM, Anttonen O, Kentta TV, Aro AL, et al. Prevalence and prognostic significance of fragmented QRS complex in middle-aged subjects with and without clinical or electrocardiographic evidence of cardiac disease. Am J Cardiol. 2014;114(1):141-7.
Tigen K, Sunbul M, Ozen G, Durmus E, Kivrak T, Cincin A, et al. Regional myocardial dysfunction assessed by two-dimensional speckle tracking echocardiography in systemic sclerosis patients with fragmented QRS complexes. J Electrocardiol. 2014;47(5):677-83.
Bayar N, Cay HF, Erkal Z, Sezer I, Arslan S, Cagirci G, et al. The importance of fragmented QRS in the early detection of cardiac involvement in patients with systemic sclerosis. Anatol J Cardiol. 2015;15(3):209-12.
Sano M, Satoh H, Suwa K, Nobuhara M, Saitoh T, Saotome M, et al. Characteristics and clinical relevance of late gadolinium enhancement in cardiac magnetic resonance in patients with systemic sclerosis. Heart Vessels. 2015;30(6):779-88.
Perlini S, Salinaro F, Cappelli F, Perfetto F, Bergesio F, Alogna A, et al. Prognostic value of fragmented QRS in cardiac AL amyloidosis. Int J Cardiol. 2013;167(5):2156-61.
Homsi M, Alsayed L, Safadi B, Mahenthiran J, Das MK. Fragmented QRS complexes on 12-lead ECG: a marker of cardiac sarcoidosis as detected by gadolinium cardiac magnetic resonance imaging. Ann Noninvasive Electrocardiol. 2009;14(4):319-26.
Sayin MR, Akpinar I, Gursoy YC, Kiran S, Gudul NE, Karabag T, et al. Assessment of QRS duration and presence of fragmented QRS in patients with Behcet's disease. Coron Artery Dis. 2013;24(5):398-403.
Yano K, Peskoe SM, Rhoads GG, Moore JO, Kagan A. Left axis deviation and left anterior hemiblock among 8,000 Japanese-American men. Am J Cardiol. 1975;35(6):809-15.
Hingorani P, Natekar M, Deshmukh S, Karnad DR, Kothari S, Narula D, et al. Morphological abnormalities in baseline ECGs in healthy normal volunteers participating in phase I studies. Indian J Med Res. 2012;135:322-30.
Poormoghim H, Poorkarim MA, Lakeh MM, Heshmati BN, Almasi S, Hakim M. Preliminary study of cardiovascular manifestations and cardiac severity scale in 58 patients with systemic sclerosis in iran using the medsger scale. J Tehran Heart Cent. 2010;5(1):14-8.
Follansbee WP, Curtiss EI, Rahko PS, Medsger TA, Jr., Lavine SJ, Owens GR, et al. The electrocardiogram in systemic sclerosis (scleroderma). Study of 102 consecutive cases with functional correlations and review of the literature. Am J Med. 1985;79(2):183-92.
Roberts NK, Cabeen WR, Jr., Moss J, Clements PJ, Furst DE. The prevalence of conduction defects and cardiac arrhythmias in progressive systemic sclerosis. Ann Intern Med. 1981;94(1):38-40.
Bussink BE, Holst AG, Jespersen L, Deckers JW, Jensen GB, Prescott E. Right bundle branch block: prevalence, risk factors, and outcome in the general population: results from the Copenhagen City Heart Study. Eur Heart J. 2013;34(2):138-46.
Draeger HT, Assassi S, Sharif R, Gonzalez EB, Harper BE, Arnett FC, et al. Right bundle branch block: a predictor of mortality in early systemic sclerosis. PLoS One. 2013;8(10):e78808.