Raphael Rosso1, Arnon Adler1, Boris Strasberg1, Milton E Guevara-Valdivia1, Riyaz Somani1, Adrian Baranchuk1, Amir Halkin1, Manlio F Márquez1, Melvin Scheinman1, Arie Steinvil1, Bernard Belhassen1, Mark Kazatsker1, Amos Katz1, Sami Viskin2. 1. From the Tel Aviv Sourasky Medical Center (R.R., A.A., A.H., A.S., B.B., S.V.) and Rabin Medical Center, Petah-Tikva (B.S.), Sackler School of Medicine, Tel Aviv University, Israel; UMAE Hospital de Especialidades Dr. Antonio Fraga Mouret, CMN La Raza IMSS, Mexico (M.E.G.-V.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.F.M.); Kingston General Hospital, Queen's University, Kingston, ON, Canada (R.S., A.B.); University of California San Francisco (M.S.); Hillel Yaffe Medical Center, Hedera, Israel (M.K.); and Barzilai Medical Center, Ashkelon, Ben-Gurion University, Beersheba, Israel (A.K.). 2. From the Tel Aviv Sourasky Medical Center (R.R., A.A., A.H., A.S., B.B., S.V.) and Rabin Medical Center, Petah-Tikva (B.S.), Sackler School of Medicine, Tel Aviv University, Israel; UMAE Hospital de Especialidades Dr. Antonio Fraga Mouret, CMN La Raza IMSS, Mexico (M.E.G.-V.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.F.M.); Kingston General Hospital, Queen's University, Kingston, ON, Canada (R.S., A.B.); University of California San Francisco (M.S.); Hillel Yaffe Medical Center, Hedera, Israel (M.K.); and Barzilai Medical Center, Ashkelon, Ben-Gurion University, Beersheba, Israel (A.K.). samiviskin@gmail.com.
Abstract
BACKGROUND: The magnitude of QT prolongation in response to bradycardia, rather than the bradycardia per se, determines the risk for torsade de pointes during atrioventricular block (AVB). However, we do not know why some patients develop more QT prolongation than others, despite similar bradycardia. We hypothesized that in patients who develop significant QRS vector changes during AVB, the effects of cardiac memory lead to excessive QT prolongation. METHODS AND RESULTS: We studied 91 patients who presented with AVB and who also had an ECG predating the bradyarrhythmia for comparison. We correlated changes in QRS morphology and axis taking place during AVB with the bradycardia-induced QT prolongation. Patients with and without QRS morphology changes at the time of AVB were of similar age and sex. Moreover, despite similar R-R interval during AVB, cases with a QRS morphology change had significantly longer QT (648 ± 84 versus 561 ± 84; P<0.001) than those without. Patients who developed a change in QRS morphology at the time of AVB had a 7-fold higher risk of developing long QT. This risk nearly doubled when the change in QRS morphology was accompanied by a change in QRS axis. CONCLUSIONS: Cardiac memory resulting from a change in QRS morphology during AVB is independently associated with QT prolongation and may be arrhythmogenic during AVB.
BACKGROUND: The magnitude of QT prolongation in response to bradycardia, rather than the bradycardia per se, determines the risk for torsade de pointes during atrioventricular block (AVB). However, we do not know why some patients develop more QT prolongation than others, despite similar bradycardia. We hypothesized that in patients who develop significant QRS vector changes during AVB, the effects of cardiac memory lead to excessive QT prolongation. METHODS AND RESULTS: We studied 91 patients who presented with AVB and who also had an ECG predating the bradyarrhythmia for comparison. We correlated changes in QRS morphology and axis taking place during AVB with the bradycardia-induced QT prolongation. Patients with and without QRS morphology changes at the time of AVB were of similar age and sex. Moreover, despite similar R-R interval during AVB, cases with a QRS morphology change had significantly longer QT (648 ± 84 versus 561 ± 84; P<0.001) than those without. Patients who developed a change in QRS morphology at the time of AVB had a 7-fold higher risk of developing long QT. This risk nearly doubled when the change in QRS morphology was accompanied by a change in QRS axis. CONCLUSIONS: Cardiac memory resulting from a change in QRS morphology during AVB is independently associated with QT prolongation and may be arrhythmogenic during AVB.