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Qtc Dispersion and Complex Ventricular Arrhythmias in Untreated Newly Presenting Hypertensive Patients

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Qtc Dispersion and Complex Ventricular Arrhythmias in Untreated Newly Presenting Hypertensive Patients Journal of Human Hypertension (1999) 13, 665–669 1999 Stockton Press. All rights reserved 0950-9240/99 $15.00 http://www.stockton-press.co.uk/jhh ORIGINAL ARTICLE QTc dispersion and complex ventricular arrhythmias in untreated newly presenting hypertensive patients AM Saadeh1, SJ Evans2, MA James2 and JV Jones2 2Department of Medical Cardiology, Bristol Royal Infirmary, Bristol, BS2 8HW, UK; 1Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan Increased dispersion of ventricular repolarisation arrhythmias (Lown’s score у3) were found in 43% of the (increased QT dispersion) is believed to predispose to patients. The QTc dispersion was strongly correlated arrhythmias associated with sudden death in certain with the Lown’s classification of arrhythmia and the age cardiac diseases. Hypertension is also associated with of the patients. Patients with more severe ectopy increased risk of sudden death, particularly in those (Lown’s score у3) were significantly older (57.4 ؎ 10.3 ؎ with left ventricular hypertrophy (LVH). Therefore, the years) compared to those with score р2 (48.3 and had a significantly greater (0.0067 ؍ first aim of this study is to look into the possible patho- 12.6 years) (P ;genic role of QT dispersion on the ventricular arrhyth- QTc dispersion (69.9 ؎ 22.5 ms vs 55.2 ؎ 18.8 ms Presence of electrocardiographic strain did .(0.002 ؍ mias occurring in a group of never-treated hypertensive P patients. The second aim is to look at other possible not affect the severity of arrhythmia, as 29% of the determinants of QT dispersion (ie, level of blood press- patients with LVH and strain had grade у3 Lown’s score ure, hypokalaemia, electrocardiographic LVH and pres- compared to 39% in the group with LVH but without ence or absence of strain pattern) in hypertensive strain. In the presence of relative hypokalaemia, hyper- patients, and their relevance to complex ventricular tensive patients with LVH showed more QTc dispersion arrhythmias. (85.7 ؎ 15.5 ms) and a greater tendency for complex QTc (corrected QT) was measured in 70 newly ventricular arrhythmias (100% grade у3 Lown’s score) presenting (never-treated) hypertensive patients (47 compared to those with LVH and normal serum potass- male, 23 female, mean age 51.9 ؎ 12.5 years) from a ium levels (64.1 ؎ 22.6 ms and 35%, QTc dispersion and The level of .(0.05 ؍ standard 12-lead surface electrocardiogram (ECG). Lown’s score у3, respectively P Blood pressure measurements and 24-h ECG holter rec- blood pressure had no effect on either the QTc dispersion ordings were performed in all patients. Serum potass- or the prevalence of complex ventricular arrhythmias. ium level was measured in 51 of the patients. Ventricular Prevalence of complex ventricular arrhythmias in arrhythmias were classified using a modified Lown’s hypertensive patients is strongly correlated with QTc scoring system. dispersion and age. When hypertensive patients with Maximum QTc, minimum QTc and QTc dispersion for LVH have low potassium levels the risk of developing all patients were 442 ؎ 30.3 ms, 380 ؎ 26.7 ms and complex ventricular arrhythmias is significantly .ms respectively. High grade ventricular increased 21.6 ؎ 61.5 Keywords: QTc dispersion; arrhythmia; hypertension Introduction arrhythmias, others6 found no correlation between these arrhythmias and diuretic induced hypokalae- Hypertension is a major cardiovascular risk factor. mia. There have only been three studies on the Although the incidence of sudden cardiac death is prevalence of ventricular arrhythmias in newly diag- increased in hypertensive patients, particularly in 1–3 nosed, never treated essential hypertensive subjects. those with left ventricular hypertrophy (LVH), the Schillaci et al7 found a positive correlation between exact pathogenesis and mechanisms are not fully frequent and complex ventricular arrhythmias and clear. LVH. Such a positive correlation was not found by The fact that the majority of such deaths in hyper- James and Jones8 nor by Mayet et al.9 tensive patients occurred in those with LVH has led Inhomogeneous recovery of excitability of cardiac to the theory that ventricular arrhythmia is the likely 4,5 muscle has long been claimed to be responsible for responsible cause. While some studies, incrimi- ventricular arrhythmias. As early as 1964 Han and nate diuretic therapy as the primary cause of these Moe,10 in studies on animals, demonstrated the link between increased dispersion of repolarisation of the ventricular myocardium and complex ventricu- Correspondence: Professor JV Jones, Department of Medical Car- lar arrhythmias. diology, Bristol Royal Infirmary, Bristol, BS2 8HW, UK Increased dispersion of ventricular recovery time Received 28 October 1998; revised and accepted 14 June 1999 is believed to be the cause of many arrhythmias QTc dispersion, arrhythmia and hypertension AM Saadeh et al 666 associated with certain cardiac diseases including rected (QTc) according to Bazett’s formula the long QT syndrome,11 dilated cardiomyopathy,12 (QTc = measured QT/√R-R intervals).19 The QTc dis- chronic heart failure,13 post-myocardial infarction14 persion was defined as the difference between the and hypertrophic cardiomyopathy.15 maximum and minimum QTc interval occurring in As far as we are aware, there have been no studies any of the 12 ECG leads. on the possible pathogenic role of QT dispersion on Fourteen (20%) of the ECGs were randomly selec- ventricular arrhythmias occurring in never-treated ted and measured twice by another observer to study hypertensive patients. the inter- and within-observer variability of QT However, QT interval dispersion changes have measurements. Within and inter-observer variability been described in treated hypertensive patients16,17 were 15% and 6% respectively. (Neither were stat- and in one study of LVH in hypertension.18 There- istically significant). fore the aim of this study is to look into the different determinants of QTc dispersion in newly Electrocardiographic measurement of left presenting, but untreated hypertensive patients and ventricular hypertrophy their relevance to development of complex ventricu- lar arrhythmias in these same patients. We have used the precordial leads criteria of Soko- low to measure LVH.20 Left ventricular hypertrophy Subjects and methods and strain was defined as being present when there was ST segment depression and T wave inversion The study group consisted of 70 consecutive in leads I, aVL, V5 and V6 in the presence of voltage presenting subjects with essential hypertension (47 criteria for LVH. males and 23 females; mean age 51.9 Ϯ 12.5 years) in whom the high blood pressure was untreated and Twenty-four hours ambulatory newly discovered. Patients with a history or evi- electrocardiography dence on examination of cardiac or systemic dis- eases were excluded, as were patients with a history Ambulatory electrocardiography was performed of palpitations or 12-lead ECG evidence of arrhyth- using Reynolds-Tracker recorders and a pathfinder mia, ischaemic changes without accompanying LVH III P31 analyser. Semi-automated, visually assisted or bundle branch block. analysis was performed by trained cardiology tech- During ECG analysis an additional four patients nicians and quality control was maintained by ran- were excluded. Two because of bundle branch dom checking of 24-h tapes by one investigator. block, one because of ECG evidence of myocardial Results were analysed by total ectopic counts and infarction (absent history of MI) and one because of by the use of a modified Lown’s score.21 sinus arrhythmia. Hypertensive patients were only included in the Serum potassium study if they had never received antihypertensive treatment at the time of presentation and their mean Serum potassium was measured by flame emission diastolic blood pressure was у95 mm Hg estab- photometry (chemispeck). lished from several readings taken during two separ- ate visits. Statistical methods All patients gave informed consent to participate in the study which was approved by the hospital When two groups of data were compared, the ethics committee. unpaired Student’s t-test was used for the normally distributed data. One-way analysis of variance (ANOVA) was used to test for overall differences Electrocardiography among the groups. Linear regression analysis was Standard 12-lead electrocardiograms were recorded used to assess correlations between groups. Values on a three-channel ECG recorder at a paper speed of are expressed as means Ϯ s.d. and a P value of р0.05 25 mm/s and standardisation of 1 mV/cm. All leads was taken as the level of significance. were recorded simultaneously. Results Electrocardiographic measurement of QTc The mean age of the patients was 51.9 Ϯ 12.5 years dispersion with no significant difference between the males QT intervals were measured manually by one (51.3 Ϯ 12.3) and females (53.0 Ϯ 13.0) (P = 0.299). blinded observer. For each lead, wherever possible, A mean of 10.7 Ϯ 1.2 electrocardiographic leads three consecutive cycles were measured and the were measured in each patient. Twenty-nine percent mean of the three values was calculated. of the patients had 12 measurable leads, 41% had The QT interval was taken from the onset of the 11, 13% had 10, 6% had nine and 11% had eight QRS to the end of the T wave, that is, return to the measurable leads. Maximum QTc intervals were T-P baseline. When U waves were present the QT observed mostly in the precordial leads, V4 and V5 interval was measured to
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