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Table of Contents
RESEARCH ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 10-14

High voltage J-waves as a predictor of death in acute ST-Segment elevated myocardial infarction in hospital


Department of Cardiology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shanxi, China

Date of Web Publication28-Mar-2019

Correspondence Address:
Gang Tian
Department of Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shanxi 710061
China
Yue Wu
Department of Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shanxi 710061
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cp.cp_32_18

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  Abstract 

Aims: Stratification of the risk of malignant arrhythmias in patients with coronary artery disease remains a challenge. This study evaluated the potential of high voltage J-waves in patients with acute ST-segment elevated myocardial infarction (STEMI) to predict the risk of malignant arrhythmias during hospitalization. Methods: A total of 128 consecutive STEMI patients with J-waves were enrolled within 48 h after the onset of the STEMI in this prospective study. The mean age was 62.97 ± 12.1 years, and 108 patients were male. Both 12-lead electrocardiograms (ECGs) and right-sided chest lead ECGs were recorded simultaneously within 10 min of admission to the hospital. Continuous ECG monitoring was administered from admission until discharge. Clinical characteristics and ECG parameters were compared between patients who survived and those who died during hospitalization. Results: Malignant ventricular arrhythmias (MVAs) were seen with J-waves more frequently in STEMI patients who subsequently died (P < 0.05). J-wave voltage, QTDc, Tp-e, and the Tp-e/QT ratio increased significantly in patients who died (P < 0.05). Multivariate logistic regression analysis revealed that J-wave voltage (odds ratio [OR], 89.09; 95% confidence interval [CI], 2.606-3045.108; P < 0.05) and MVAs (OR, 4.296; 95% CI, 1.348–13.693; P < 0.05) were associated with the occurrence of sudden death in patients with STEMI during hospitalization. Conclusions: High voltage J-waves are a potential ECG parameter for predicting sudden death in patients with STEMI during hospitalization.

Keywords: High voltage J-waves, malignant ventricular arrhythmias, myocardial infarction


How to cite this article:
Li H, Li H, Song Y, Wang D, Shu J, Cui C, Han F, Wu Y, Tian G. High voltage J-waves as a predictor of death in acute ST-Segment elevated myocardial infarction in hospital. Cardiol Plus 2019;4:10-4

How to cite this URL:
Li H, Li H, Song Y, Wang D, Shu J, Cui C, Han F, Wu Y, Tian G. High voltage J-waves as a predictor of death in acute ST-Segment elevated myocardial infarction in hospital. Cardiol Plus [serial online] 2019 [cited 2019 Apr 19];4:10-4. Available from: http://www.cardiologyplus.org/text.asp?2019/4/1/10/255074


  Introduction Top


Coronary artery disease (CAD) and its sequelae represent the vast majority of sudden cardiac death (SCD). Ventricular arrhythmias are a well-recognized complication in the setting of acute myocardial infarction (AMI) and are responsible for about 50% of SCD in patients with CAD. Identifying patients at high risk of ST-segment elevated myocardial infarction (STEMI) SCD could lead to improve the prognosis in the population. Therefore, novel tools to stratify the risk of SCD in CAD patients are needed.[1] Prominent J-waves may be observed in cases of early repolarization syndrome, Brugada syndrome, and idiopathic ventricular fibrillation (VF).[2],[3],[4],[5] Recent studies provided sound evidence regarding the scientific basis for J-wave's predictive capacity of ventricular arrhythmias and SCD in the setting of CAD.[6],[7],[8],[9],[10] The purpose of this study was to determine the prognostic efficacy of high voltage J-waves in predicting SCD susceptibility in Chinese in patients with acute STEMI.


  Methods Top


Subjects

A total of 128 STEMI patients with J-waves were enrolled within 48 h after the onset of the STEMI in this study admitted to the Cardiology Department of The First Affiliated Hospital of Xi'an Jiaotong University. Patients with bundle branch block, atrial fibrillation, preexcitation syndrome, renal failure, hypothermia, electrolyte imbalance, or prior admission to hospital with any form of acute coronary syndrome or previous coronary revascularization were excluded from the analysis. Informed consents were obtained from all subjects. Of these patients, 108 were male and 20 were female. During hospitalization, 21 patients died and 107 survived to hospital discharge.

The diagnosis of AMI was based on the electrocardiogram (ECG), elevated creatine kinase, or troponin levels and symptoms of ischemia. A STEMI was defined as an AMI with new ST elevation at the J point in 2 contiguous leads with the following cutoff points: ≥0.2 mV in men or ≥0.15 mV in women in leads V2–V3 and/or ≥0.1 mV in the other leads.[11]

Electrocardiogram measurements

12-lead simultaneous ECGs were obtained from all patients with STEMI within 10 min after admission to the hospital, and right-sided chest leads were recorded in routine resting ECG. The J-waves were classified as either notched or slurred [Figure 1] and were considered to be present when the J point was ≥0.1 mV above the isoelectric line in two or more contiguous leads.[6],[12] Continuous ECG monitoring was performed for all patients from admission until discharge. Types of malignant ventricular arrhythmias (MVAs) include the following: frequent premature ventricular contractions, premature ventricular bigeminy, bursts of premature ventricular contraction, multi-derived premature ventricular contractions, ventricular tachycardia, and VF.
Figure 1: Electrocardiograms from a patient with anterior ST-segment elevated myocardial infarction who had ventricular tachycardia. Prominent J-waves following the QRS (prominent notching in V4, and slurring in V5 and V6) are noted

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Two ECG analysts were blinded to measure the parameters of the ECG for STEMI patients with J-waves in 5-fold magnified ECG recordings. The QT intervals in all 12 leads were measured from the onset of the QRS complexes to the end of the T-waves. The QT interval was corrected for heart rate using Bazett's formula (QTc = QT/square root of RR interval in s). The QTc dispersion (QTDc) was measured as the difference between the maximum and the minimum QTc intervals on the 12-lead ECGs. If the height or depth of the T-wave was <1.5 mm, its lead was excluded from the analysis.[13] The T-wave peak was defined as the point of highest amplitude of the T-wave deflection. The T-wave end was defined as the point where the tangent of the descending limb of the T-wave intersects the isoelectric line. The Tp-e interval and the Tp-e/QT ratio were calculated using standard tangential methods.[14]

Data and statistical analyses

All categorical variables were expressed as frequencies and percentages. Continuous variables were expressed as mean ± Standard deviation and were compared using independent sample t-tests. The categorical variables were compared using the Chi-squared test or Fisher's Exact Test. Nonparametric data such as Killip class on admission was investigated using the Mann–Whitney U-test. A logistic regression analysis (Forward Stepwise) was performed to detect any significant independent predictors by adjusting multivariables (reported as odds ratios [OR] with 95% confidence intervals [CIs]). All analyses were performed using the PASW 18.0 software package (SPSS, Chicago, IL, USA). P < 0.05 was considered statistically significant.


  Results Top


Clinical characteristics of ST-segment elevated myocardial infarction patients with J-waves

A total of 73 patients suffered from AMI with inferior localization; 15 patients suffered from AMI with inferior and right ventricular localization, and three patients suffered from AMI with right ventricular localization. Among these patients, 13 died from MVAs including VF and torsades de pointes, and one from cardiogenic shock.

In total, 37 patients suffered AMI involving anterior localization (excluding inferior localization). Of these patients, three died from VF, and four died of cardiogenic shock. [Figure 1] shows the ECG of a patient with J-waves involving anterior STEMI who had ventricular tachycardia.

Among STEMI patients with J-waves, there were no significant differences in the demographic and clinical characteristics of patients who survived and those who did not [Table 1].
Table 1: Demographic and clinical characteristics of ST-segment elevated myocardial infarction patients with J-waves

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Electrocardiograms analysis of ST-segment elevated myocardial infarction patients with J-waves

[Table 2] shows the differences in ECG variables between the groups. Dead patients who suffered from STEMI with J-waves had a significantly greater J-wave voltage (0.419 vs. 0.248 mV; P = 0.013), QTDc (64.95 vs. 51.63 ms; P = 0.031), Tp-e (142.38 vs. 120.28 ms; P = 0.006), and Tp-e/QT ratio (0.37 vs. 0.316; P = 0.007). No statistically significant differences were observed in QTcmin, QTcmax, and RR interval.
Table 2: ECG parameters for ST-segment elevated myocardial infarction patients with J-waves

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A total of 52 patients suffered from MVAs. Of these patients, 16 patients died during hospitalization. The incidence of MVAs in death STEMI patients with J-waves was significantly higher than in the group that survived (P = 0.001) [Table 3].
Table 3: Difference in mortality between the malignant ventricular arrhythmias group and the group without malignant ventricular arrhythmias

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Predictors of death in ST-segment elevated myocardial infarction patients with J-waves

A multivariate logistic regression analysis revealed that J-wave voltage (OR, 89.09; 95% CI, 2.606–3045.108; P < 0.05) and MVA (OR, 4.296; 95% CI, 1.348–13.693; P < 0.05) were associated with the occurrence of death during STEMI with J-waves while QTDc and Tp-e/QT ratio were not associated with the occurrence of death [Table 4].
Table 4: Multivariate logistic regression analysis of the occurrence of death in ST-segment elevated myocardial infarction patients with J-waves

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  Discussion Top


In this study, we demonstrated that high voltage J-wave could be an important ECG parameter for predicting SCD in patients with STEMI during hospitalization.

The study showed that MVAs were more common in the patients suffering from SCD, and J-wave voltage, QTDc, Tp-e, and the Tp-e/QT ratio increased significantly in this group. J-wave voltage and MVAs were associated with the occurrence of SCD among STEMI patients with J-waves.

The ischemic J-wave is a transient phenomenon, and it appears during the early acute myocardial ischemia. Our previous study had found that the ischemic J-wave was observed during the early myocardial infarction (MI), especially within 48 h after the onset of the STEMI.[15] Myocardial ischemia in STEMI can lead to an increased transmural dispersion of repolarization (TDR).[16] ECG parameters such as J-wave voltage, QTDc, Tp-e, and the Tp-e/QT ratio can reflect TDR and predict the risk of malignant arrhythmias and SCD.[1],[6],[7],[14],[17],[18],[19],[20] In our study, the Tp-e/QT ratio and QTDc were not associated with the occurrence of SCD during STEMI with J-waves, which are not consistent with previous studies. J-wave voltage (OR, 89.09) was strongly associated with the occurrence of SCD among STEMI patients with J-waves. The J-wave voltage in the SCD group was higher than in the survival group (0.419 vs. 0.248 mV), suggesting that high voltage J-waves are an important ECG parameter for predicting SCD in patients with STEMI during hospitalization.

Transmural differences in early phases of the action potential are responsible for the inscription of the electrocardiographic J wave. The ventricular epicardium commonly displays action potentials with a prominent Ito-mediated notch or spike and dome, which in ventricular epicardium but not endocardium produces a transmural voltage gradient during early ventricular repolarization that registers as a J wave on the ECG.[9],[20] We found that MVAs were a risk factor for the occurrence of SCD in STEMI patients with J-waves. The ischemia-related changes in membrane currents can lead to the loss of the AP dome in the epicardium, in which Ito is prominent. Loss of the Ito-mediated epicardial dome, with a relatively maintained plateau phase and action potential duration in the endocardium, can generate a transmural voltage gradient. This is more likely to manifest in the ECG as a high voltage J-wave, with slurring of the terminal part of the QRS and mild ST-segment elevation.[16] Complete loss of the prominent AP dome occurs in the acute ischemia myocardial region but not in the perfused side of the ischemic border, leading to marked heterogeneity in epicardial AP dome loss that facilitates the development of phase 2 re-entry. This, in turn, is likely to be responsible for R-on-T extrasystole on the ECG, which can trigger MVAs such as torsades de pointes, VF, and SCD.[4],[8],[16]

TDR threshold which induces phase 2 re-entry is relatively lower in J-Wave Syndromes than long QT syndrome, so Paroxysmal ventricular tachycardia (PVT) or torsades de pointes (TdP) and SCD occur in J-Wave Syndromes easily, especially in the acute phase of STEMI.[10] Therefore, the prevention of STEMI-induced SCD is the most urgent issue. The presence of high voltage J-waves in the ECG of STEMI should act as a warning sign of increased probability of VT/VF and SCD. By successfully recognizing the presence of high voltage J-waves on the ECG, the treating physician can anticipate an adverse outcome and provide alternative patient care to decrease the likelihood of STEMI induced SCD.

Study limitations

There are several limitations to our study. First, the small sample size limits our statistical power, which is reflected in the broad CIs, most notably in the adjusted statistical analyses. Second, ECGs before the MI were not generally available. As a result, whether the patients had J-waves before the MI is unknown. Third, although we checked for a number of key variables associated with the occurrence of death in STEMI patients with J-waves, other potential contributors to death, including accurate AMI time and medication, especially antiarrhythmic medication, were not recorded. This could have impacted the results of this study. Therefore, further prospective studies with a larger sample size, a long-term follow-up, and the participation of many hospitals are necessary to resolve these limitations and ensure and enhance our results.


  Conclusions Top


High voltage J-waves are an important ECG parameter for predicting SCD in patients with STEMI during hospitalization.

Financial support and sponsorship

This work was funded by the Nature Science Foundation of China (No. 30570733).

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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