ABSTRACT Background-Rationale of the Study: Among several invasive and non-invasive tests for risk stratification of acute coronary syndromes (ACS), fewer markers can be utilized in clinical practice. Our rationale is to validate use of QRS-fragmentation as a promising bed-side test for assessment of prognosis in those patients. Methods and Results: Collection of two-hundred and twenty patients with ACS was done during two years (from January 2011 till January 2013). Significant organic vaLVe disease and QRS duration ≥120 ms as well as patients with permanent pacemakers were excluded. Patients were subjected to full clinical examination, ECG and Echocardiography in the first day of admission followed by diagnostic coronary angiography before discharge and a nuclear study was done for Randomized sample from each group. 12-leads ECG revealed fragmentation of QRS in 74 patients and 146 patients with no QRS fragmentation. Localization of the infarct site revealed NS difference between percentages in both groups. Echocardiography revealed a significant deterioration of LV functions in group-A than group-B. Also, MR jet area was significantly higher in group-A. Coronary angiography revealed severer lesions in group-A more than group-B. Nuclear study revealed higher percentages of irreversible scars in group-A (30%) and higher reversibility in group-B (80%). In-hospital Occurrence of complications from ACS revealed a significant higher incidence of MACE in group-A. Conclusion: Presence of fragmented QRS in surface ECG during ACS represents myocardial scar or fibrosis and reflects the severity of coronary lesions and a correlation between fQRS and depression of LVfunction is established. Indeed, occurrence of MACE is suspected.
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T. Abdelrahman, "QRS Fragmentation as a Prognostic Test in Acute Coronary Syndrome," World Journal of Cardiovascular Surgery, Vol. 3 No. 2, 2013, pp. 42-51. doi: 10.4236/wjcs.2013.32008.
 N. C. Flowers, L. G. Horan, J. R. Thomas and W. J. Tolleson, “The Anatomic Basis for High-Frequency Components in the Electrocardiogram,” Circulation, Vol. 39, No. 4, 1969, pp. 531-539. doi:10.1161/01.CIR.39.4.531
 P. L. Friedman, J. J. Fenoglio and A. L. Wit, “Time Course for Reversal of Electrophysiological and Ultrastructural Abnormalities in Subendocardial Purkinje Fibers Surviving Extensive Myocardial Infarction in Dogs,” Circulation Research, Vol. 36, No. 1, 1975, pp. 127-144.
 P. Varriale and B. E. Chryssos, “The RSR’ Complex Not Related to Right Bundle Branch Block: Diagnostic Value as a Sign of Myocardial Infarction Scar,” American Heart Journal, Vol. 123, No. 2, 1992, pp. 369-376.
 A. Bayes de Luna, “Electrographic Patterns of Ischemia, Injury and Necrosis,” In: A. Bayes de Luna, Ed., Clinical Electrocardiography: A Textbook, 2nd Edition, Futura Publishing Company, Inc., Armonk, 1998, pp. 141-142.
 M. K. Das, B. Khan, S. Jacob, A. Kumar and J. Mahenthiran, “Significance of a Fragmented QRS Complex Versus a Q Wave in Patients with Coronary Artery Disease,” Circulation, Vol. 113, No. 21, 2006, pp. 2495-2501.
 M. K. Das, C. Saha, H. El Masry, et al., “Fragmented QRS on a 12-Lead ECG: A Predictor of Mortality and Cardiac Events in Patients with Coronary Artery Disease,” Heart Rhythm, Vol. 4, No. 11, 2007, pp. 1385-1392. doi:10.1016/j.hrthm.2007.06.024
 M. Yuce, V. Davutoglu, B. Ozbala, et al., “Fragmented QRS Is Predictive of Myocardial Dysfunction, Pulmonary Hypertension and Severity in Mitral Stenosis,” The Tohoku Journal of Experimental Medicine, Vol. 220, 2010, pp. 279-283. doi:10.1620/tjem.220.279
 A. Cheema, A. Khalid, A. Wimmer, et al., “Fragmented QRS and Mortality Risk in Patients with Left Ventricular Dysfunction,” Circulation: Arrhythmia and Electrophysiology, Vol. 3, 2010, pp. 339-344.
 G. Breithardt, M. E. Cain, N. el-Sherif, et al., “Standards for Analysis of Ventricular Late Potentials Using High-Resolution or Signal-Averaged Electrocardiography. A Statement by a Task Force Committee of the European Society of Cardiology, the American Heart Association, and the American College of Cardiology,” Circulation, Vol. 83, No. 4, 1991, pp. 1481-1488.
 J. A. Gomes, M. E. Cain, A. E. Buxton, M. E. Josephson, K. L. Lee and G. E. Hafley, “Prediction of Long Term Outcomes by Signal-Averaged Electrocardiography in Patients with Unsustained Ventricular Tachycardia, Coronary Artery Disease, and Left Ventricular Dysfunction,” Circulation, Vol. 104, 2001, pp. 436-441.
 H. Morita, K. F. Kusano, D. Miura, et al., “Fragmented QRS as a Marker of Conduction Abnormality and a Predictor of Prognosis of Brugada Syndrome,” Circulation, Vol. 118, No. 17, 2008, pp. 1697-1704.
 M. K. Das, H. Suradi, W. Maskoun, M. A. Michael, C. Shen, J. Peng, et al., “Fragmented Wide QRS on a 12-Lead ECG: A Sign of Myocardial Scar and Poor Prognosis,” Circulation: Arrhythmia and Electrophysiology, Vol. 1, 2008, pp. 258-268. doi:10.1161/CIRCEP.107.763284
 P. I. Gardner, P. C. Ursell, J. J. Fenoglio Jr. and A. L. Wit, “Electrophysiologic and Anatomic Basis for Fractionated Electrograms Recorded from Healed Myocardial Infarcts,” Circulation, Vol. 72, No. 3, 1985, pp. 596-611.
 I. Wiener, B. Mindich and R. Pitchon, “Determinants of Ventricular Tachycardia in Patients with Ventricular Aneurysms: Results of Intraoperative Epicardial and Endocardial Mapping,” Circulation, Vol. 65, 1982, pp. 856-861. doi:10.1161/01.CIR.65.5.856
 I. Wiener, B. Mindich and R. Pitchon, “Fragmented Endocardial Electrical Activity in Patients with Ventricular Tachycardia: A New Guide to Surgical Therapy,” American Heart Journal, Vol. 107, 1984, pp. 86-90.
 M. K. Das, H. Suradi, W. Maskoun, et al., “Fragmented wide QRS on a 12-Lead ECG: A Sign of Myocardial Scar and Poor Prognosis,” Circulation: Arrhythmia and Electrophysiology, Vol. 1, No. 4, 2008, pp. 258-268.
 M. K. Das, W. Maskoun, C. Shen, M. A. Michael, H. Suradi, M. Desai, et al., “Fragmented QRS on Twelve-Lead Electrocardiogram Predicts Arrhythmic Events in Patients with Ischemic and Nonischemic Cardiomyopathy,” Heart Rhythm, Vol. 7, No. 1, 2010, pp. 74-80.
 M. Homsi, L. Alsayed, B. Safadi, J. Mahenthiran and M. K. Das, “Fragmented QRS Complexes on 12-Lead ECG: A Marker of Cardiac Sarcoidosis as Detected by Gadolinium Cardiac Magnetic Resonance Imaging,” Annals of Noninvasive Electrocardiology, Vol. 14, No. 4, 2009, pp. 319-326. doi:10.1111/j.1542-474X.2009.00320.x
 S. Peters, M. Trümmel and B. Koehler, “QRS Fragmentation in Standard ECG as a Diagnostic Marker of Arrhythmogenic Right Ventricular Dysplasia-Cardiomyopathy,” Heart Rhythm, Vol. 5, No. 10, 2008, pp. 1417-1421.
 M. Takagi, Y. Yokoyama, K. Aonuma, N. Aihara and M. Hiraoka, “Clinical Characteristics and Risk Stratification in Symptomatic and Asymptomatic Patients with Brugada Syndrome: Multicenter Study in Japan,” Journal of Cardiovascular Electrophysiology, Vol. 18, No. 12, 2007, pp. 1244-1251. doi:10.1111/j.1540-8167.2007.00971.x
 S. G. Priori, M. Gasparini, C. Napolitano, et al., “Risk Stratification in Brugada Syndrome: Results of the Prelude (Programmed ELectrical Stimulation Predictive Value) Registry,” Journal of the American College of Cardiology, Vol. 59, No. 1, 2012, pp. 37-45.
 C. Antzelevitch, “Role of Transmural Dispersion of Repolarization in the Genesis of Druginduced Torsades de Pointes,” Heart Rhythm, Vol. 2, No. 11, 2005, pp. S9-S15. doi:10.1016/j.hrthm.2004.09.011
 K. Haraoka, H. Morita, Y. Saito, et al., “Fragmented QRS Is Associated with Torsades de Pointes in Patients with Acquired Long QT Syndrome,” Heart Rhythm, Vol. 7, No. 12, 2010, pp. 1808-1814.
 S. J. Park, Y. K. On, J. S. Kim, et al., “Relation of Fragmented QRS Complex to Right Ventricular Fibrosis Detected by Late Gadolinium Enhancement Cardiac Magnetic Resonance in Adults with Repaired Tetralogy of Fallot,” American Journal of Cardiology, Vol. 109, No. 1, 2012, pp. 110-115. doi:10.1016/j.amjcard.2011.07.070
 H. Kadi, A. Inanir, A. Habiboglu, et al., “Frequency of Fragmented QRS on ECG Is Increased in Patients with Rheumatoid Arthritis without Cardiovascular Disease: A Pilot Study,” Modern Rheumatology, 2011.
 G. Pietrasik and W. Zareba, “QRS Fragmentation: Diagnostic and Prognostic Significance,” Cardiology Journal, Vol. 19, No. 2, 2012, pp. 114-121.
 C. V. Reddy, K. Cheriparambill, B. Saul, et al., “Fragmented Left Sided QRS in Absence of Bundle Branch Block: Sign of Left Ventricular Aneurysm,” Annals of Noninvasive Electrocardiology, Vol. 11, 2006, pp. 132-138.
 D. D. Wang, D. M. Buerkel, J. R. Corbett and H. S. Gurm, “Fragmented QRS Complex Has Poor Sensitivity in Detecting Myocardial Scar,” Annals of Noninvasive Electrocardiology, Vol. 15, No. 4, 2010, pp. 308-314.
 Y. Take and H. Morita, Indian Pacing and Electrophysiology Journal, Vol. 12, No. 5, 2012, pp. 213-225.
 G. H. Yan, M. Wang, K. H. Yiu, et al., “Subclinical Left Ventricular Dysfunction Revealed by Circumferential 2D Strain Imaging in Patients with Coronary Artery Disease and Fragmented QRS Complex,” Heart Rhythm, Vol. 9, No. 6, 2012, pp. 928-935.
 P. Korhonen, T. Husa, T. Konttila, et al., “Fragmented QRS in Prediction of Cardiac Deaths and Heart Failure Hospitalizations after Myocardial Infarction,” Annals of Noninvasive Electrocardiology, Vol. 15, No. 2, 2010, pp. 130-137. doi:10.1111/j.1542-474X.2010.00353.x
 K. Torigoe, A. Tamura, Y. Kawano, K. Shinozaki, M. Kotoku and J. Kadota, “The Number of Leads with Fragmented QRS Is Independently Associated with Cardiac Death or Hospitalization for Heart Failure in Patients with Prior Myocardial Infarction,” Journal of Cardiology, Vol. 59, No. 2, 2012, pp. 36-41.
 T. Erdogan, M. Cetin, S. A. Kocaman, et al., “Relationship of Fragmented QRS with Prognostic Markers and In-Hospital MACE in Patients Undergoing CABG,” Scandinavian Cardiovascular Journal, Vol. 46, No. 2, 2012, pp. 107-113. doi:10.3109/14017431.2011.651485
 G. M. Pietrasik, S. Polonsky, A. J. Moss and W. Zareba, “Presence of Fragmented Wide-QRS Complex and the Risk of Death and Sudden Cardiac Death among MA-DIT-II Patients with Left Bundle Branch Block,” ACC Poster, Atlanta, 2010.
 A. J. Brenyo, G. Pietrasik, S. McNitt and W. Zareba, “QRS Fragmentation: Lack of Association with Cardiac Events in Patients with a Normal QRS Duration,” Denver, Co., 2010.
 G. B. Forleo, D. G. Della Rocca, L. P. Papavasileiou, et al., “Predictive Value of Fragmented QRS in Primary Prevention Implantable Cardioverter Defibrillator Recipients with Left Ventricular Dysfunction,” Journal of Cardiovascular Medicine (Hagerstown), Vol. 12, No. 11, 2011, pp. 779-784. doi:10.2459/JCM.0b013e32834ae458