12-Lead electrocardiogram as a predictor of sudden cardiac death: from epidemiology to clinical practice

Figures & data

Figure 1. A schematic illustration presenting lead V6 of an ECG with delayed intrinsicoid deflection (time from the onset of the QRS complex to R-wave peak in lead V5 or V6 ≥ 0.05s). The paper speed is 50 mm/s.

Figure 2. An ECG of a 41-year-old male who hadn’t been diagnosed with cardiac disease showing an ER pattern in the inferior and lateral leads. The subject died of SCD after 25 years of follow-up. The paper speed is 50 mm/s.

Table 1. Examples of studies assessing the SCD risk associated with electrocardiographic abnormalities in the general population.

Authors	Study population, follow-up	ECG parameter studied	Adjusted HR (95%CI) for SCD
Jouven et al. [20]	5713 men (42–53y); follow-up 23 years	Resting heart rate >75bpm	3.46 (1.60–7.44)
Aro et al. [8]	10,899 subjects (52% men, mean age 44 ± 8 y); follow-up 30 ± 11y	QRS ≥110ms	2.14 (1.38–3.33)
		IVCD (QRS ≥110ms without bundle-branch block)	3.11 (1.74–5.54)
		LBBB	2.71 (1.20–6.11)
Kurl et al. [9]	2049 men (age 42–60y); follow-up 19y	QRS >110ms	2.50 (1.38–4.55)
Aro et al. [21]	10,815 subjects (52% men, mean age 44 ± 8 y); follow-up 30 ± 11y	Delayed frontal QRS transition zone	1.89 (1.18–3.03)
Tikkanen et al. [17]	10,864 subjects (52% men, mean age 44 ± 8 y); follow-up 30 ± 11y	Inferior ER ≥0.1mV	1.43 (1.06–1.94)
		Inferior ER >0.2mV	2.92 (1.45–5.89)
		LVH (Sokolow-Lyon)	1.16 (1.05–1.27)^a
Aro et al. [8]	10,713 subjects (52% men, mean age 44 ± 8 y); follow-up 30 ± 11y	QRS-T angle ≥100°	2.26 (1.59–3.21)
Aro et al. [8]	10,899 subjects (52% men, mean age 44 ± 8 y); follow-up 30 ± 11y	Inferior/lateral T-wave inversions	3.16 (1.86–5.36)
Straus et al. [13]	7983 subjects (61% women, age ≥55y)	Prolonged QTc (>450ms in men, >470ms in women)	2.5 (1.3–4.7)

^a Cardiac death.

Figure 3. A schematic illustration showing a heartbeat with different JT intervals. The J-point to T peak interval is short in SQTS (red curve, 110 ms) but close to normal in subjects with short-QT interval without the syndrome (black curve, 180 ms).

Figure 4. A schematic illustration showing a heartbeat with multiple abnormalities that are associated with increased SCD risk. These include (1) the fragmentation of the QRS complex, (2) the notched ER pattern with a downsloping ST segment, (3) the T-wave inversion directed to the opposite direction from the QRS complex, (4) the wide QRS complex (110 ms), (5) the long-QT interval (500 ms), and (6) the long T-peak to T-end interval (105 ms). The paper speed is 50 mm/s.

Jouven X, Empana J-P, Schwartz PJ, et al. Heart-rate profile during exercise as a predictor of sudden death. N Engl J Med. 2005;352:1951–1958.

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Aro AL, Huikuri HV. Electrocardiographic predictors of sudden cardiac death from a large Finnish general population cohort. J Electrocardiol. 2013;46:434–438.

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Kurl S, Mäkikallio TH, Rautaharju P, et al. The duration of QRS complex in resting electrocardiogram is a predictor of sudden cardiac death in men. Circulation. 2012;125:2588–2594.

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Aro AL, Eranti A, Anttonen O, et al. Delayed QRS transition in the precordial leads of an electrocardiogram as a predictor of sudden cardiac death in the general population. Heart Rhythm. 2014;11:2254–2260.

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Tikkanen JT, Huikuri HV. Characteristics of "malignant" vs "benign" electrocardiographic patterns of early repolarization. J Electrocardiol. 2015;48:390–394.

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Straus SMJM, Kors JA, De Bruin ML, et al. Prolonged QTc interval and risk of sudden cardiac death in a population of older adults. J Am Coll Cardiol. 2006;47:362–367.

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