Elsevier

American Heart Journal

Volume 152, Issue 2, August 2006, Pages 355-361
American Heart Journal

Clinical Investigation
Congestive Heart Failure
Low voltage on the electrocardiogram is a marker of disease severity and a risk factor for adverse outcomes in patients with heart failure due to systolic dysfunction

https://doi.org/10.1016/j.ahj.2005.12.021Get rights and content

Background

The prognostic implications of low QRS voltage on the electrocardiogram (ECG) in heart failure (HF) are not well characterized.

Methods

We manually measured and summed the QRS voltage in all 12 leads of the ECG (∑QRS) in two cohorts: (1) 415 patients with a low left ventricular ejection fraction followed up in a HF clinic (“clinic cohort”) and (2) 100 subjects with advanced HF who had an ECG within 1 year preceding cardiac transplantation (“pretransplant cohort”). Low voltage was defined as the lowest quartile of the clinic cohort (∑QRS <12 mV) and its prevalence was compared in the two cohorts. The associations of low voltage with 1-year outcomes were assessed in the clinic cohort.

Results

In the clinic cohort, the frequency of low voltage was higher in New York Heart Association class 4 versus class 1-3 patients (34% vs 22% respectively, P = .04). The frequency of low voltage in the pretransplant cohort (47%) was twice that of the clinic cohort (24%, P < .001). After 1 year of follow-up in the clinic cohort, low ECG voltage was associated with a higher rate of death (14% vs 5%, P = .008) and the composite end point of death or HF hospitalization (35% vs 20%, P = .004). These associations persisted in multivariable analyses adjusting for important confounders.

Conclusions

Low ECG voltage is a marker of the severity of HF and is a risk factor for adverse outcomes in patients with systolic HF at 1 year.

Section snippets

Patient populations

This is a retrospective study. From a consecutive series of patients (N = 551) evaluated in the Parkland Memorial Hospital CHF clinic7, 8 (“clinic cohort”) between June 1998 and June 2002, we included all patients (n = 415) who had a qualitatively reduced left ventricular ejection at the time of clinic referral and had an ECG within 6 months of their initial clinic visit. Patients with a paced rhythm (n = 11) were excluded.

A second cohort was gathered from the UT Southwestern cardiac transplant

Distribution and correlation of ECG voltages

Total ECG voltages in the clinic cohort ranged from 4.6 to 45 mV with a median (25th, 75th percentiles) of 15 (12, 20) mV. In the pretransplant cohort, ECG voltages ranged from 3.4 to 27 mV with a median (25th, 75th percentiles) of 12 (9.5, 16) mV. In the clinic cohort, there were significant correlations between total ECG voltage and total limb voltage (r = 0.76), total ECG voltage and total precordial voltage (r = 0.93), and total limb and total precordial voltages (r = 0.48) (P < .001 for

Discussion

We propose new criteria for defining low ECG voltage (∑QRS <12 mV) in patients with HF due to systolic dysfunction. Using these criteria in a contemporary cohort of HF patients, low voltage was a marker of disease severity, being more common in NYHA class 4 than class 1-3 patients. The prevalence of low voltage was further increased in patients with advanced HF as defined by referral for cardiac transplantation. Further, low ECG voltage was associated with an increased risk of adverse outcomes

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