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such as the QT interval&#44; the QTc &#40;same interval&#44; but corrected to take into account its natural variation with the heart rhythm&#41; or the Tp-e &#40;interval from T-wave peak to T-wave end&#41; can be measured manually by a cardiologist on the ECG tracing&#44; with the help of a ruler&#44; or using a computer to magnify the tracing on digitised recordings&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Ventricular repolarisation can also be characterised by other features not directly available by visual inspection of the ECG tracings&#46; Moreover&#44; the variation over time of the repolarisation features&#44; and their spatial distribution have been shown to convey useful information on the physiology of repolarization&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> Of particular interest is the response of these features to changes in heart rate &#40;HR&#41;&#46; These indices&#44; usually driven by electrophysiological observations&#44; must be obtained by computerised methods&#44; where signal processing plays a crucial role&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the current issue of <span class="elsevierStyleItalic">Revista Cl&#237;nica Espa&#241;ola</span>&#44; Demirta&#351; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> assessed in an interesting case-control study the values of some repolarisation indices quantifying repolarisation dispersion in patients with coeliac disease &#40;CD&#41;&#46; In particular&#44; Tp-e interval and the ratios Tp-e&#47;QT and Tp-e&#47;QTc were manually measured from the 12-lead ECG in 38 patients with CD and 38 age- and sex-matched controls&#46; Their results showed significantly higher values of the three indices in the CD patients with respect to the control population&#44; suggesting that CD might be associated with an increase in ventricular repolarisation dispersion&#46; 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Since a Holter recording typically includes a wide range of HR&#44; including periods with stationary HR as well as abrupt accelerations and decelerations of HR&#44; computerised analysis of Holter recordings can be used to achieve good characterisation of the repolarisation dynamics&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Non-linear models including memory have been proposed<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> to characterise the memory of different ECG parameters with respect to the HR in the previous beats&#46; Results have shown that the duration and profile of the QT dependence with HR &#40;QT&#47;RR hysteresis&#41; is highly individual-dependent while&#44; on average&#44; RR intervals of the past 150 beats &#40;approximately 2&#46;5<span class="elsevierStyleHsp" style=""></span>min&#41; are required to accurately model the QT response&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">8&#44;9</span></a> The residual of the model&#44; i&#46;e&#46; the portion of QT variation that cannot be explained by the model&#44; was also a significant risk stratifier in patients under amiodarone&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> The Tp-e was also shown to be dependent on the previous RR intervals&#44; but with a shorter memory than the QT interval&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The relative amount of change in the Tpe &#40;measured in different stable conditions&#41; with respect to the change in the RR interval &#40;denoted as &#916;&#945;&#41; has been related to the dispersion of action potential duration restitution slopes in the ventricular cells&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> This non-invasive parameter&#44; measurable in regular ambulatory recordings&#44; has been shown to discriminate between SCD victims during the four-year follow-up from survivors in a population of chronic heart failure &#40;CHF&#41; patients&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> and to be predictive of arrhythmic risk induced by sotalol&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> Interestingly&#44; &#916;<span class="elsevierStyleItalic">&#945;</span> was also able to identify differentially the CHF patients predisposed to death from the progression of the disease &#40;pump failure death &#91;PFD&#93;&#41;&#58; while values of &#916;<span class="elsevierStyleItalic">&#945;</span> in the higher range where predictive of SCD&#44; values of &#916;<span class="elsevierStyleItalic">&#945;</span> in the lower range were suggestive of PFD&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In a recent work&#44; we hypothesised that increased dispersion of repolarisation restitution should be better reflected in the overall morphology of the T-wave and its variation with HR&#46; A novel index called T-wave morphology restitution &#40;TMR&#41; was quantified by measuring the T-wave morphological variation between two T waves that were representative of different HR&#44; and normalised by per RR increment&#46; In the previously cited CHF population&#44; TMR was significantly higher in SCD victims than in the remaining patients&#44; with Cox analysis revealing that increased TMR was strongly associated with SCD&#44; independently of other clinical and ECG-derived variables&#46; However&#44; no association was found between this index and PFD&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The research described in the previous paragraphs was performed as a collaborative effort between clinical and engineering research groups&#46; We believe that these types of collaborations will be crucial in years to come to make advances in the management of clinical decisions based on non-invasive data&#46;</p></span>"
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Editorial
Measuring ventricular repolarisation dynamics from ambulatory electrocardiography as non-invasive cardiac risk indices
Medición de la dinámica de repolarización ventricular mediante electrocardiografía ambulatoria, como índices de riesgo cardiaco no invasivos
J.P. Martíneza,b,
Autor para correspondencia
, P. Lagunaa,b
a Instituto de Investigación en Ingeniería de Aragón, IIS-Aragón, Universidad de Zaragoza, Zaragoza, Aragón, Spain
b Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Spain
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such as the QT interval&#44; the QTc &#40;same interval&#44; but corrected to take into account its natural variation with the heart rhythm&#41; or the Tp-e &#40;interval from T-wave peak to T-wave end&#41; can be measured manually by a cardiologist on the ECG tracing&#44; with the help of a ruler&#44; or using a computer to magnify the tracing on digitised recordings&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Ventricular repolarisation can also be characterised by other features not directly available by visual inspection of the ECG tracings&#46; Moreover&#44; the variation over time of the repolarisation features&#44; and their spatial distribution have been shown to convey useful information on the physiology of repolarization&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> Of particular interest is the response of these features to changes in heart rate &#40;HR&#41;&#46; These indices&#44; usually driven by electrophysiological observations&#44; must be obtained by computerised methods&#44; where signal processing plays a crucial role&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the current issue of <span class="elsevierStyleItalic">Revista Cl&#237;nica Espa&#241;ola</span>&#44; Demirta&#351; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> assessed in an interesting case-control study the values of some repolarisation indices quantifying repolarisation dispersion in patients with coeliac disease &#40;CD&#41;&#46; In particular&#44; Tp-e interval and the ratios Tp-e&#47;QT and Tp-e&#47;QTc were manually measured from the 12-lead ECG in 38 patients with CD and 38 age- and sex-matched controls&#46; Their results showed significantly higher values of the three indices in the CD patients with respect to the control population&#44; suggesting that CD might be associated with an increase in ventricular repolarisation dispersion&#46; Interestingly&#44; the Tp-e&#47;QTc ratio also showed a significant positive correlation with the duration of CD and the erythrocyte sedimentation rate&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">From these data&#44; together with the fact that increased prevalence of cardiac dysfunction&#44; such as idiopathic congestive heart failure and myocarditis&#44; have been observed in CD&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">4&#44;5</span></a> authors suggest that patients with CD would have an increased incidence of ventricular arrhythmia&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> An important limitation of the study is the lack of follow-up in the CD population&#44; which would have enabled it to be established whether differences in repolarisation features are indeed related to an increased risk of arrhythmic events&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study presents repolarisation dispersion indices as instantaneous measurements&#46; However&#44; it is well known that repolarisation features on the ECG are quite dependent on the HR&#44; which introduces an extra ingredient of inter-patient variability if not taken into account&#46; Although there are some corrections for HR&#44; such as the well-known Bazett formula&#44; to get the HR-corrected QTc&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">6&#44;7</span></a> these corrections do not account for the inter-patient differences in the HR dependence of the repolarisation&#46; Moreover&#44; correction formulae do not consider the fact that the QT interval does not depend on the last RR interval alone&#44; but also on the RR intervals of the preceding beats &#40;typically&#44; those of the previous 2&#8211;3<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; This phenomenon&#44; termed QT&#47;RR memory or hysteresis&#44; has been shown to be relevant for risk stratification&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> In this editorial comment we aim to recall some recent results showing the potential value of the dynamic analysis of the repolarisation parameters&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">One simple way to take those effects into account without the need for designing a specific protocol is by analysing 24-h Holter recordings&#46; Since a Holter recording typically includes a wide range of HR&#44; including periods with stationary HR as well as abrupt accelerations and decelerations of HR&#44; computerised analysis of Holter recordings can be used to achieve good characterisation of the repolarisation dynamics&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Non-linear models including memory have been proposed<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> to characterise the memory of different ECG parameters with respect to the HR in the previous beats&#46; Results have shown that the duration and profile of the QT dependence with HR &#40;QT&#47;RR hysteresis&#41; is highly individual-dependent while&#44; on average&#44; RR intervals of the past 150 beats &#40;approximately 2&#46;5<span class="elsevierStyleHsp" style=""></span>min&#41; are required to accurately model the QT response&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">8&#44;9</span></a> The residual of the model&#44; i&#46;e&#46; the portion of QT variation that cannot be explained by the model&#44; was also a significant risk stratifier in patients under amiodarone&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> The Tp-e was also shown to be dependent on the previous RR intervals&#44; but with a shorter memory than the QT interval&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The relative amount of change in the Tpe &#40;measured in different stable conditions&#41; with respect to the change in the RR interval &#40;denoted as &#916;&#945;&#41; has been related to the dispersion of action potential duration restitution slopes in the ventricular cells&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> This non-invasive parameter&#44; measurable in regular ambulatory recordings&#44; has been shown to discriminate between SCD victims during the four-year follow-up from survivors in a population of chronic heart failure &#40;CHF&#41; patients&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> and to be predictive of arrhythmic risk induced by sotalol&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> Interestingly&#44; &#916;<span class="elsevierStyleItalic">&#945;</span> was also able to identify differentially the CHF patients predisposed to death from the progression of the disease &#40;pump failure death &#91;PFD&#93;&#41;&#58; while values of &#916;<span class="elsevierStyleItalic">&#945;</span> in the higher range where predictive of SCD&#44; values of &#916;<span class="elsevierStyleItalic">&#945;</span> in the lower range were suggestive of PFD&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In a recent work&#44; we hypothesised that increased dispersion of repolarisation restitution should be better reflected in the overall morphology of the T-wave and its variation with HR&#46; A novel index called T-wave morphology restitution &#40;TMR&#41; was quantified by measuring the T-wave morphological variation between two T waves that were representative of different HR&#44; and normalised by per RR increment&#46; In the previously cited CHF population&#44; TMR was significantly higher in SCD victims than in the remaining patients&#44; with Cox analysis revealing that increased TMR was strongly associated with SCD&#44; independently of other clinical and ECG-derived variables&#46; However&#44; no association was found between this index and PFD&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The research described in the previous paragraphs was performed as a collaborative effort between clinical and engineering research groups&#46; We believe that these types of collaborations will be crucial in years to come to make advances in the management of clinical decisions based on non-invasive data&#46;</p></span>"
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ISSN: 00142565
Idioma original: Inglés
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